Cities - try to predict superspreading hotspots for COVID-19 - Nature

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Cities - try to predict superspreading hotspots for COVID-19 - Nature
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                                                                                                                                                      EDGAR SU/REUTERS
A migrant worker outside a dormitory in Singapore — such high-rise sites have seen some of the city’s worst clusters of COVID-19.

Cities — try to predict superspreading
hotspots for COVID-19
Roland Bouffanais & Sun Sun Lim

                                                T
Tracking how people move                                 wo months ago in Singapore, walkers,      Superspreading sites — where transmission
                                                         joggers and cyclists in Bishan-Ang Mo     rates are particularly high — can seed tens or
around urban areas can                                   Kio Park got a surprise — a robotic dog   hundreds of cases in days.
pinpoint where disease might                             nipping at their heels. It ‘barked’ at       For example, last month in Beijing, more
                                                         them to stay metres away from others.     than 100 cases were tied to one central food
transmit fastest and farthest.                  No tactic seems too outlandish to deal with the    market. Cases have surged in apartment blocks
                                                COVID-19 pandemic, which has confined bil-         in Melbourne, Australia, triggering a fresh
                                                lions of people across the world to their homes.   lockdown. In May, more than 200 visitors to
                                                   Now, leaders face a conundrum. Reopen           Seoul’s Itaewon nightclub district became
                                                facilities too slowly and prolong hardship,        infected.
                                                or relax restrictions too quickly and ignite          Governments need tools to assess where the
                                                a fresh wave of infections. It’s a precarious      riskiest spots in the riskiest places — cities —
                                                balancing act. The spread of the SARS-CoV-2        might be. Big-data studies of human mobility
                                                virus can be lightning fast and surreptitious.     need to be combined with epidemiological

352 | Nature | Vol 583 | 16 July 2020
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Cities - try to predict superspreading hotspots for COVID-19 - Nature
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                                  models. And the demographic profiles of             SCHOOL NETWORKS
                                  people coming into contact at any particular        The movements of almost 6,000 schoolchildren across 33 schools tracked over one day
                                                                                      (12 July 2016) in Singapore reveal how the students mingled. They spent most of their time
                                  location need to be included.                       in close proximity to their classmates. But they also came into contact with many more
                                                                                      people on public transport, in shopping centres and at after-school activities.
                                  Close contact
                                                                                       Student (coloured by school)       Interaction
                                  Researchers understand reasonably well that
                                  the disease spreads in places where people
                                  spend a lot of time face-to-face, such as care
                                                                                                                                   Pupils at central
                                  homes, hospitals and restaurants1–3. Duration                                                    schools mingle
                                  of contact, physical proximity and environ-                                                      more than those
                                  mental conditions are the main factors. A fleet-                                                 at the periphery

                                  ing encounter with a passer-by on a path is less
                                  likely to result in infection than sitting inside
                                  next to a person for 20 minutes. Cramped and
                                  poorly ventilated indoor spaces are riskier
                                  than expansive outdoor ones.
                                     But many more factors have a role, and these
                                  are less understood. Some people do not com-
                                  ply with safety measures, for many reasons.
                                  Inebriated diners and excitable theme-park
                                  visitors, for example, are unlikely to stay
                                  metres apart. The degree of mixing differs. The
SOURCE: R. BOUFFANAIS/S. S. LIM

                                  same group of students might sit together in a
                                  classroom every day. But children in secondary
                                  school mingle with more students and teach-                    Even children
                                  ers than do those in preschools. And school-                   from distant
                                  children meet widely outside school hours,                     schools mix

                                  when commuting, playing sports or attending
                                  tutorials (see ‘School networks’).
                                     The details of such everyday interactions
                                  are documented too poorly to model risk fac-        skyrocketed to more than 40,000, or more                  building’ reforms across ventilation, drainage,
                                  tors accurately, as experiences with COVID-19       than 12% of that population, compared with                refuse and building maintenance4. Air purifi-
                                  show. Resorts, conferences, religious gath-         fewer than 2,600 infections elsewhere in the              cation systems were installed in hospitals. A
                                  erings and workplaces have all experienced          compact city-state of 5.3 million people.                 research programme looked into the impacts
                                  notable outbreaks. In late May, the South              On 18 June, 700 residents of a tower block             of the built environment on health. Studies
                                  Korean city of Bucheon saw hundreds of cases        in the German city of Göttingen were quaran-              showed that residents were affected by, for
                                  at an e-commerce distribution warehouse.            tined, with some 100 cases detected. Some                 example, the orientation of the building
                                  Meat-packing plants in the United States,           residents clashed with police as they tried               they lived in, the height of their apartment
                                  Canada, Germany, Spain, Ireland, Brazil and                                                                   above ground and their immediate outdoor
                                  Australia have seen surges. Some of the first       “Very little is known about                               environment4.
                                  superspreading events took place on cruise
                                  ships — more than 700 people on board the
                                                                                      how the disease spreads in                                Flows of people
                                  British-registered Diamond Princess tested          dynamic spaces.”                                          But people don’t stay put. Cities are bustling
                                  positive in February.                                                                                         places — open systems in which many people
                                     Care homes with many elderly or                                                                            from many different locations come and go.
                                  immune-compromised residents are especially         to flee. Hong Kong saw something similar in               An urbanite might cross paths with thousands
                                  vulnerable. Long-term care facilities have seen     2003, at the start of its epidemic of severe              of people each day, during long commutes in
                                  almost 60% of the COVID-19 deaths in Washing-       acute respiratory syndrome (SARS) — more                  packed trains and buses and in stations in rush
                                  ton state, 45% in Sweden and almost one-third       than 300 people living in block E of Amoy                 hour5,6. Even car drivers encounter lots of peo-
                                  in the United Kingdom. Health-care workers          Gardens became infected, almost overnight.                ple, at petrol stations or while running errands.
                                  are, of course, highly exposed, with more than        Indeed, many of the same factors that lie               Any of these interactions could expose them
                                  92,000 infections and more than 500 deaths          behind superspreading of COVID-19 today —                 to COVID-19. Yet very little is known about how
                                  among US health-care personnel alone.               high population densities, poor accommo-                  the disease spreads in dynamic spaces, such as
                                     Groups living in close proximity are at          dation and narrow streets — contributed to                airports, stations, bars, restaurants, cinemas
                                  risk. For example, almost 93% of Singapore’s        some of the worst pockets of past outbreaks,              and aeroplanes.
                                  COVID-19 cases in the first 48 days occurred in     including those of cholera, typhoid, tubercu-                It’s clear that long-distance travel extends
                                  dormitories for migrant workers (see ‘Hous-         losis and SARS (see ‘Cleaner cities’).                    the reach of an outbreak. Contact tracing
                                  ing risks’). Each block houses thousands of           Much stands to be learnt. For example, after            tied a nightclub visitor in Seoul’s Itaewon
                                  workers, sometimes 20 per room. Cases there         SARS in 2003, Hong Kong adopted ‘healthy                  district to a staggering 1,300 others — he had

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Cities - try to predict superspreading hotspots for COVID-19 - Nature
Comment
       travelled 42 kilometres to get there from the                    where tracing has not happened at scale. Con-
       city of Yongin, and visited other districts and                  tact-tracing apps and the data they generate
       provinces before testing positive. Air travel                    are potentially valuable, but surveillance
       spread COVID-19 quickly to the world’s most
       connected metropolises — from Wuhan to
                                                                        fears, among other concerns, have stymied
                                                                        their adoption.
                                                                                                                                Cleaner
       Singapore, Hong Kong, London and Milan, or
                                                                        Modelling flows
                                                                                                                                cities
       through Europe to New York and Boston.
          We don’t know how the virus was carried                       A model of disease spread can be built and              How changes to the built environment
       and which measures might have prevented or                       refined as data and knowledge improve on                have thwarted infection.
       slowed its transmission. For example, would                      human flows on the following three levels.
       more mask-wearing, social distancing or clean-                                                                           Underground sewers and pipes led to
       ing at airports have helped? Or was it the time                  City-wide. A base map is needed to represent            straighter and wider streets in London, after
       spent on the plane breathing in others’ air or                   the main flows of people throughout a city.             a severe cholera outbreak was linked to raw
       touching surfaces that was crucial? Or did the                   This should cover the numbers and timings               sewage in drinking water in the 1850s.
       disease spread in the streets and restaurants                    of people travelling between key sites, such                Wipe-down surfaces made homes easier
       after passengers had disembarked? We need                        as schools, shopping centres, train stations or         to clean after ‘germ theory’ arrived in the
       to learn more.                                                   care homes. Such data might be drawn from               nineteenth century. Dusty draperies made
          Likewise, little is known about how people                    anonymized mobile-phone records or infor-               way for tile and linoleum.
       move through cities. Some municipalities,                        mation about trips on public transport — local              Bright light and fresh air were
       including Paris, Singapore and Taipei, release                   authorities need to be encouraged to release            championed by modernist architects to
       real-time data on land transport, including pas-                 the information to researchers. Travel into and         promote health. People with tuberculosis
       senger volumes at stops or stations by origin                    out of the city should be estimated at major            were put in airy sanatoriums with
       and destination. These data sets are made avail-                 stations or airports, where a high volume of            whitewashed walls, large windows and
       able to companies, third-party developers and                    mixing occurs. The availability and quality of          balconies. Old tenements were torn down
       researchers to develop route-planning apps,                      data, as well as overcoming privacy concerns,           to avoid contagion. And green spaces,
       for example. But most cities don’t supply, and                   are the main limitations. Individuals in cars are       such as New York’s Central Park, were
       might not even collect, such data. They lack                     difficult to monitor, for example. The mod-             protected as urban ‘lungs’.
       the technology and regulatory frameworks                         elling frameworks are well established in the               Medicines such as vaccines, antibiotics
       needed to share sensitive personal informa-                      field of transportation and mobility research           and antiviral drugs now deflect attention
       tion on where and when someone has travelled.                    for planning and development purposes. For              from the state of our streets. Yet poor
       Privacy must be assured.                                         example, in 2016 in Singapore, a National               people in urban settings still experience
          Also, trip data cannot tell you how much                      Science Experiment tracked the movements                ill health in overcrowded and cramped
       time someone spent in a certain location, or                     of 43,000 students from 128 schools using a             housing. Diseases such as malaria are
       with whom or for how long. Little is known                       custom-built pocket sensor.                             spreading fast in rapidly developing urban
       about people entering or leaving a city, includ-                                                                         fringes in Africa. Severe acute respiratory
       ing tourists. And detailed information on the                    Bottlenecks. The mixing indoors at transport            syndrome (SARS) and COVID-19 highlight
       locations of COVID-19 cases is largely missing.                  hubs, airports, large shopping centres or               the risks of outbreaks in densely populated
       Some countries have comprehensive test and                       libraries should be added to the base map,              and high-throughput locations.
       trace systems; most do not. GPS data from                        for example by using Wi-Fi signals from smart
       mobile phones have been used in Singapore                        devices5. Locations can then be ranked accord-         destinations7. Typical flow patterns can be
       and South Korea as part of contact tracing,                      ing to the intensity of incoming and outgoing          extrapolated from previous studies. For exam-
       but not in countries such as the United States,                  flows and the diversity of journey origins and         ple, shopping centres and parks are known to
                                                                                                                               be busiest at weekends, train stations at rush
      HOUSING RISKS                                                                                                            hours on weekdays, schools at the beginning
      Almost 95% of Singapore’s cases of COVID-19 have occurred in dormitories that house migrant workers. So far,             and end of the day and airports during long
      more than 42,000 workers have been infected — 12.5% of the people living in these high-density blocks. In the
      rest of the population of around 5.3 million people, just 2,600 cases have been recorded.                                weekends. The proximities of people and the
                                                                                                                               durations of interaction can be estimated,
                                                                             Rest of Singapore (excluding migrant workers)     with assumptions such as geographer Waldo
                                                                             Dormitories (migrant workers and related cases)
                                                                                                                               Tobler’s ‘first law of geography’ — “everything
                           1,200
                                                                                                                               is related to everything else, but near things
                                                                                                                               are more related than distant things”. More
Number of COVID-19 cases

                                                                                                                               accurate data should then be sought at key
                                                                                                                               points of convergence, such as stadiums, bars,
                            800                                                                                                nightclubs and theatres, and the model refined
                                                                                                                               accordingly.
                                                                                                                                                                                   SOURCE: SINGAPORE MINISTRY OF HEALTH

                                                                                                                               Epidemiology. All known factors affecting
                                                                                                                               disease transmission, in terms of demo-
                            400                                                                                                graphics and human interactions, should be
                                                                                                                               included across a representative range of
                                                                                                                               human activities. For example, preschoolers
                                                                                                                               mingling in playgrounds, co-workers interact-
                                                                                                                               ing in factories and offices or elderly residents
                              0
                              1 April   8   15   22   29   6 May   13   20     27   3 June   10     17     24   1 July    8    shopping and socializing. Environmental fac-
                              2020                         2020                     2020                        2020           tors must also be considered, such as risk of

       354 | Nature | Vol 583 | 16 July 2020
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EDGAR SU/REUTERS

                   A robot dog reminds park users in Singapore to stay apart.

                   infection in an outdoor stadium versus gyms,          Wider sources of data on human mobility        residential blocks, such as those for migrant
                   hair salons and theatres. Such knowledge is        need to be tapped8. For example, ‘smart’ cities   workers, should be examined.
                   rapidly evolving for SARS-CoV-2. Where there       such as Singapore have networks of cameras           Longer term, the design and management of
                   are gaps, information on other viral diseases      on lamp posts to track traffic flows. These       cities should be altered to minimize the spread
                   with similar transmission modes (such as           could be reconfigured to track the density        of disease and the chance of future pandem-
                   rubella, SARS, pertussis, smallpox and influ-      and mixing of people (anonymously). Built-in      ics. Failing that, we’ll have to rely on packs of
                   enza) can inform preliminary strategies.           barometers in some smartphones could fol-         robotic dogs to shepherd us.
                     By combining all these insights, govern-         low vertical movement, such as the flows of
                   ments will be better able to anticipate super-     workers in office towers and the circulation
                   spreading locations and target precautionary       of people in high-rise shopping centres and       The authors
                   measures, such as delaying reopening busi-         residences. Data from geolocation and con-
                   nesses, quarantining arrivals, tightening          tact-tracing apps can provide insight into        Roland Bouffanais is an associate professor
                   crowd control and intensifying cleaning and        where people go, with whom they interact,         at Singapore University of Technology
                   disinfection in particular places.                 what they do and even how they feel9. For         and Design, Singapore. Sun Sun Lim is a
                                                                      instance, the GeoCoV19 study analysed 524         professor and head of humanities, arts and
                   Next steps                                         million geolocated tweets in 62 languages,        social sciences at Singapore University of
                   Funding agencies should support accelerated        posted over 90 days since 1 February to eval-     Technology and Design, Singapore.
                   studies of human movement and interac-             uate public sentiments, emergency needs,          e-mails: bouffanais@sutd.edu.sg;
                   tions in key superspreading locations such         knowledge gaps and misinformation trails10.       sunlim@sutd.edu.sg
                   as transport hubs. Scientists need to rank         Such data would have to be anonymized to
                   superspreading potential and compute the           protect privacy.
                   effect of measures such as social distancing          Governments should use these data and          1.    Manivannan, A., Yow, W. Q., Bouffanais, R. & Barrat, A.
                                                                                                                              EPJ Data Sci. 7, 34 (2018).
                   or mask-wearing. For example, might primary        models to hone their public-health strategies.    2.    Isella, L. et al. J. Theoret. Biol. 271, 166–180 (2011).
                   schools with a small catchment area reopen         More effective targeting of measures will help    3.    Stehlé, J. et al. PLoS ONE 6, e23176 (2011).
                   at full capacity if all students and educators     to avoid ‘virus fatigue’ among the public and     4.    Baldwin, A. N. Proc. Inst. Civil Eng. Municipal Eng. 159,
                                                                                                                              37–42 (2006).
                   wear a mask? What about secondary schools,         help education and the economy by allowing        5.    Del Valle, S. Y., Hyman, J. M., Hethcote, H. W. &
                   which have a more diverse student body that        places to minimize the risks of some kinds of           Eubank, S. G. Soc. Networks 29, 539–554 (2007).
                   is likely to engage in riskier behaviours, such    reopening.                                        6.    Jiang, L. et al. J. Hosp. Infect. 98, 404–411 (2018).
                                                                                                                        7.    Chin, W. C. B. & Bouffanais, R. Preprint at https://arxiv.org/
                   as dating or drug-taking?                             Urban planners should also re-examine                abs/2005.05063 (2020).
                      Urban analysts and modellers need to            disease spread in the built environment. For      8.    Willemse, E. J., Tunçer, B. & Bouffanais, R. Proc. 24th Int.
                                                                                                                              Conf. Assoc. Computer-Aided Architect. Design Res. Asia
                   understand the dynamics of face-to-face inter-     example, they might integrate safe-distancing
                                                                                                                              2, 805–814 (2019).
                   actions, networks and crowd mixing. Key ques-      measures into street and building designs.        9.    Ling, R., Fortunati, L., Goggin, G., Lim, S. S. & Li, Y. in The
                   tions include: how often are we in close contact   More walkways and vertical parks might sep-             Oxford Handbook of Mobile Communication and Society
                                                                                                                              (eds Ling, R., Fortunati, L., Goggin, G., Lim, S. S. & Li, Y.)
                   with people? For how long? What places in our      arate flows of people, as at the Kampung Admi-
                                                                                                                              3–12 (Oxford Univ. Press, 2020).
                   normal daily movements put us in close con-        ralty development in Singapore (see go.nature.    10.   Qazi, U., Imran, M. & Ofli, F. SIGSPATIAL Spec. 12, 6–15
                   tact with the greatest number of new people?       com/2z9pxmz). The health impacts of dense               (2020).

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