As America’s oldest city, St. Augustine, Florida, draws visitors from around the country. “Hospitality is the economy,” as city manager John Regan likes to say -- local businesses rely on an influx of tourists and spring breakers this time of year to survive.
So when Regan started canceling events that draw hundreds of thousands of people – and millions of dollars of revenue – to the town of 14,000, he drew the ire of his business community. Hospitality workers and tourism outfits wanted to know why, with only 20 confirmed coronavirus cases in the county at the time, Regan took such drastic measures.
“The very first question people ask is, ‘on what data do you base these decisions?’ And the answer is, 'the absence of data,'” Regan said. “So we're ruining businesses in this process to save lives. But how can you not default to the public health position?”
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Leaders across the country are struggling to make decisions with major public health and economic implications – often without solid information to guide them.
To help, Regan struck a deal with one company that claims to have an innovative way to help close the information gap.
Kinsa, a Silicon Valley-based health technology firm, says its internet-connected personal thermometers can provide real-time data that might be able to anticipate when and where the next coronavirus hot spot could happen – and help towns like St. Augustine prepare, though the company also acknowledges several caveats and limitations.
Regan bought 600 thermometers from Kinsa to hand out to St. Augustine families on Tuesday. The units are expected to arrive next month.
“The sad fact is that [public health officials] try to curb the spread of infectious illness with zero information about where and when the disease started,” said Inder Singh, Kinsa’s founder and chief executive. “How do you curb an outbreak before it becomes an epidemic or a pandemic if you don't know where it's starting?”
The thermometers, which are connected to a smartphone app, are designed to crowd-source unusual fever activity in real-time.
When users record their temperature, that data, stripped of personal information, is uploaded to the company’s database and reflected in an interactive map at the county level. The result is a literal heat map of potential trouble spots – an “early warning system,” as Singh calls it.
While fevers are one of the main symptoms associated with the coronavirus, many positive cases display no symptoms at all, presenting one of a number of limits to the thermometer’s ability to accurately track the spread of the virus.
Still, Regan believes the data will be useful.
“I'm not the only city that has to make decisions with no data,” he said. “Wouldn’t it be much better if we had data and we could communicate to people what they could expect as a result of the sacrifices that they’re making?”
Singh said Kinsa has more than one million thermometers in circulation. Most are sold on Amazon, but the company has also donated thermometers to low-income schools. In recent weeks, demand has outpaced supply and the devices are on back-order, he said.
Kinsa says its temperature data has allowed the company to track and predict flu patterns in recent years. During the coronavirus-era, deviations from their baseline flu projections highlight what they call “atypical illness,” – which could indicate a cluster of coronavirus cases, Singh and his advisers said.
Kinsa isn’t the only data-collector of its kind with implications on early tracking of the coronavirus. This week, researchers at Boston Children's Hospital launched covidnearyou.org, which provides similar coronavirus mapping data. The University of California San Francisco recently partnered with Oura, a startup whose vitals-tracking smart ring might be able to detect the early onset of coronavirus.
WHOOP, a fitness tracking app, also said its technology could “help predict who may have coronavirus before they show symptoms,” according to Will Ahmed, the company’s CEO. The WHOOP app, which connects to a wearable bracelet, allows users to self-report positive coronavirus diagnoses.
“We are starting to see meaningful differences in what it looks like to be healthy, versus reporting sick, versus even reporting COVID-19,” Ahmed said.
In theory, the data collected by Kinsa and others highlighting possible atypical-illness could pinpoint potential coronavirus clusters well before official testing and give public health officials a much-needed warning. In Florida, Kinsa’s mapping identified fever clusters days before the state emerged as a hot-bed of coronavirus transmissions, Singh said.
“Alerting all of the mayors in Florida to what's going on in their communities will cause them to take much more aggressive actions,” said Andy Slavitt, the former acting director of the Centers for Medicare and Medicaid Services, who said he's optimistic about the thermometer tech.
“The converse can also be true,” Slavitt continued. “If you're talking to [officials] in another city where the virus hasn't spread much yet, you could tell them that they could, in a cautious way, keep some of their businesses open.”
Slavitt’s words may come as a ray of light for local leaders eager to get their economy back on track, even as public health experts warn that doing so presents a risk to public health. In a town like St. Augustine, re-opening businesses might invite asymptomatic out-of-town guests to more easily spread the virus.
And Kinsa's platform is far from settled science. Since its data relies on having thermometers in use across the country, many rural areas are a statistical black hole – the combination of fewer people and smaller sample sizes diminishes the effectiveness of Kinsa’s data gathering.
For areas that are more saturated with smart-thermometers, the data gathered still relies on deviations from expected fever levels associated with seasonal influenza, making it difficult to draw concrete conclusions about the data.
“That basically means that the fidelity of the signal is dependent on a statistical probability of you catching people who have a fever,” Shah said.
Another concern raised by industry experts is that Kinsa, a for-profit company, publishes the coronavirus-related material to its interactive map without going through a scientific peer-review process. Singh said his decision to publish raw, non-vetted data reflected “a moral imperative” for awareness of the disease’s spread, even as his company is submitting its findings for peer review in parallel.
Dr. John Brownstein, chief innovation officer at Boston Children's Hospital and an ABC News contributor, described Kinsa’s data as “a double-edged sword.”
“On one hand, we are seeing unprecedented levels of people trying to share information, so that’s the amazing part of it,” Brownstein said. “But the other side of it, for those who have not undergone peer-reviews, we have to be especially critical of what we’re reading and be incredibly cautious.”
Kinsa has also faced scrutiny for its relationship with corporate sponsors. In 2018, the New York Times reported that Kinsa, as a for-profit company, shared data with Clorox, allowing the cleaning supply giant to target ads in area codes where Kinsa reported increased fevers.
“Since day one, we've been spending our time trying to think about privacy because ultimately we are a public health company. And if we don't have the trust of the public, we have nothing,” Singh said. “And we think we found the exact right equation to fully protect an individual's privacy while exposing data that is necessary for society and communities to respond to outbreaks.”
Federal health officials say they have hesitated to collaborate. Kinsa’s leadership expressed frustration with the Centers for Disease Control and Prevention's unwillingness to work with them despite making several overtures in recent years.
In response to an inquiry from ABC News, a spokesperson for the CDC confirmed it “is not working directly with this particular company,” but added that the “CDC appreciates the efforts of so many companies working across the private sector to address this new threat.”
Nirav Shah, the former commissioner of the New York State Department of Health and an advisor to Kinsa, said the CDC’s decision to keep companies like Kinsa at arms’ length does not surprise him.
“To work with startups, to work with a for-profit, to work with someone who's crowdsourcing data that isn't you know clinically validated lab tests based, it's asking a lot,” Shah said.
The Kinsa team is candid about its platform’s limitations too.
“If you think about the instruments on the dashboard of an airplane, they all work together to provide situational awareness -- no single instrument provides the full picture,” said Ben Dalziel, an Oregon State University professor and Kinsa’s academic collaborator.
“So I think that, at best, the kind of syndromic monitoring that Kinsa is doing can be a tool to help the formal health system get more situational awareness and more targeted assistance,” added Dalziel, who said Kinsa funds his lab’s research.
Regardless of the drawbacks, as state and local officials wade through uncharted territory, the high-tech thermometers might offer a start – something better than the “zero information,” Singh said.
With President Donald Trump hoping to have companies back in force by Easter and local leaders anxious to re-open businesses, Slavitt, the former top government official, said: “that level of intelligence may not be perfect, but it's going to help.”
“The past has been making decisions in the absence of data,” Regan said. “The future is making proactive decisions with data.”