COVID-19 Strategic Action Framework: Community Testing

Page updated on Sep 4, 2020 at 10:58 AM

The following analysis summarizes the Alexandria’s current testing situation, and the background, implementation, resource requirements, and results of the three recent COVID-19 community testing events. The analysis has informed a Strategic Action Framework to increase targeted community testing opportunities.

Testing Landscape

Prior to the community testing events, Alexandria Health Department (AHD) has dedicated significant resources to expanding testing capacity and accessibility in Alexandria.

Medical Practices, Urgent Cares, Inova Alexandria Hospital, Neighborhood Health

Since commercial testing first became available, AHD has focused resources on recruiting and supporting all interested Alexandria medical practices, urgent care centers, Inova Alexandria Hospital, and Neighborhood Health to expand COVID-19 testing. AHD has used multiple outreach methods (email, conference calls, blast-faxes, site visits) and has provided information (e.g. about federal reimbursement for testing patients without insurance), technical specimen-collection guidance, laboratory contacts, and training (including fit-testing for proper seals of respirators). Many healthcare providers stated that their inability to obtain personal protective equipment (PPE) had been a barrier to testing, as CDC recommendations and best practices require the proper use of PPE in order to prevent the transmission of the coronavirus from patients to healthcare providers.
In response to this stated barrier, AHD acquired PPE through multiple sources: Virginia Department of Health, Virginia Department of Emergency, Strategic National Stockpile, H1N1 Cache, and private donations. AHD distributed, through May 2020, the following quantities of PPE to Alexandria healthcare providers willing to conduct COVID-19 testing and to be publicly listed as doing so:

N95 Respirators: 9,300

Face Shields/ Goggles: 1,262

Surgical Masks: 7,950

Gloves: 737

Isolation Gowns: 4,560

 

As of May 28, there are 11 testing sites within the City limits of Alexandria willing to be listed in a public format, available in four languages and updated every two weeks. (Note: there are additional practices that provide testing for their current patients; they have requested not to be listed publicly, as they do not have capacity to accept and test new patients). Among the publicly listed sites, more than half provide free testing for eligible patients. Additionally, there are two practices “just over the City border” at which Alexandrians obtain services and both of those practices provide free testing for those who are eligible.

Providing Information to the Public on Testing Availability

Alexandria Health Department, working with the City’s Joint Information System, has developed numerous materials in different languages and formats highlighting where people can access testing on an ongoing basis. These materials have been distributed to other City agencies, Alexandria City Public Schools, faith-based organizations, and community partners. AHD and the JIS have also placed these materials across the City through signage, delivered information to every household through the mail, and distributed content directly to the most vulnerable residents through meal bags for low-income families. Community partners and residents have been encouraged to call the COVID-19 Hotline (703.746.4988) for assistance in locating a testing facility. 

Coordinating and Facilitating Targeted Testing

AHD has coordinated and facilitated testing in both targeted facility and neighborhood settings.

The facility settings—long-term care facilities (LTCFs), including both skilled nursing facilities and assisted living facilities, and group homes—are home to many of Alexandria’s most-at-risk for severe disease from COVID-19. These populations are most likely to need hospitalization, most likely to need an intensive care bed with a ventilator, and most likely to die due to their advanced age and/or underlying medical conditions. AHD has coordinated, facilitated and followed through with technical assistance a point prevalence survey (PPS) at all eight Alexandria LTCFs interested (one facility has declined). AHD has also conducted and facilitated testing at multiple. AHD’s focus on those most-at-risk for severe disease is congruent with a public health justice perspective.

To reach specific neighborhood settings, AHD and the City of Alexandria signed a Memorandum of Understanding with Neighborhood Health, a federally qualified health center and primary care home, to provide testing events across the City. This initiative is meant to reach people based on 1. Those who have underlying medical conditions, 2. Those experiencing social conditions that makes exposure more likely such as crowded housing or a job without sick leave, and 3. Epidemiological trends such as ZIP code positivity rates. As of September 2, there have been 7 events across Alexandria, serving around 100 people per event. Many of the participants have been uninsured residents who may not otherwise have been able to access free testing. AHD works with community partners to select and coordinate the testing site where Neighborhood Health and Medical Reserve Corps volunteers implement the tests.

Testing Results

Alexandria has a high rate of testing per 1,000 population (both before and after the 5/25 community testing events). The table below presents the testing per capita rate in the Northern Virginia jurisdictions. Alexandria has consistently had the second highest testing rate per capita in the region.

 

Alexandria

Arlington

Fairfax

Prince William

Loudoun

5/24

39.1

34.1

32.0

45.8

24.6

6/4

58.8

45.8

43.9

64.5

38.6

9/2 189.1 180.6 159.4 205.5 161.1

* Per 1,000 population (Sources: vdh.virginia.gov/coronavirus and census.gov/quickfacts)

Thus, Alexandrians are being tested at a comparable, or higher, rate than residents in other Northern Virginia jurisdictions through its existing medical infrastructure (medical practices, hospital and community health center).

Alexandria Memorial Day COVID-19 Testing Events 

Background

On May 15, AHD was informed of a “turn-key” community testing opportunity through a Virginia Department of Emergency Management (VDEM) contract with MAKO laboratories. This VDEM-MAKO contract was available throughout the State, and other Northern Virginia health districts were offered the same opportunity during the first week of the contract implementation. AHD opted to conduct both of its community testing events on the same day in order to serve two different targeted communities simultaneously.

The purpose of the Alexandria Memorial Day testing events was to provide testing—and information for ongoing testing sources and community resources—to Alexandrians who might not have been able to access such services. Other Northern Virginia jurisdictions with open, community-wide testing from 10:00 am to 6:00 pm, experienced full capacity sometime 1:00-4:00 pm. This did not happen in either of Alexandria’s two events (neither at Landmark nor at Cora Kelly).

Results-Data

The below table summarizes the 5/25 Memorial Day testing events results

 

Landmark

Cora Kelly

Totals for Both Events*

Total Tests

1,996

957

2,953*

Indeterminate Residence

92 (4.6%)

58 (6.1%)

150 (5.1%)

Non-Alexandria Residence**

768 (38.5%)

259 (27.1%)

1,027 (34.8%)

Alexandria Residence**

1,136 (56.9%)

640 (66.9%)

1,776 (60.1%)

Positive Test Results

176 (8.8%)

60 (6.3%)

236 (8.0%)

Positives who are Alexandrians

43 (24.4%)

26 (43.3%)

69 (29.2%)

 * The contractor MAKO reported on May 25 that they had collected 2,980 tests but later corrected that to 2,953.

** ZIP Codes 22311 and 22312 are shared with Fairfax County. There were 296 attendees from these ZIP Codes at Landmark and 19 at Cora Kelly; based on AHD’s experience of approximately 50% of these ZIP Codes’ reportable diseases being Alexandrians, 148 of the Landmark attendees from 22311 and 22312 were assigned as Alexandrians and 10 of the Cora Kelly attendees from 22311 and 22312 were assigned as Alexandrians.

Results – Summary and Analysis

Of the 2,953 attendees at both events, less than two-thirds were Alexandrians; there was a higher percentage of attendees who were Alexandrians at the walk-in only event at Cora Kelly (67%) compared to the drive-in/walk-in event at Landmark (57%). Of the 236 who tested positive at both events, only 29% were Alexandrians; 43% of those who tested positive at the Cora Kelly event were Alexandrians while only 24% of the positives from the Landmark event were Alexandrians.

While the purpose of the Memorial Day testing events was to serve Alexandrians, more than one-third of participants were non-Alexandrians. This indicates a wide appeal by non-Alexandrians to attend Alexandria events. The low percentage of Alexandrians testing positive indicates that Alexandrians who have symptoms and desire testing are obtaining it through the Alexandria’s medical practices, urgent care centers, Inova Alexandria Hospital and Neighborhood Health.

Despite AHD’s repeated requests for demographic data collection and the inclusion of race, ethnicity, and symptom questions on the registration form, MAKO has not provided this information to AHD for analysis.

Limitations and Challenges of Community Testing Events

While community testing events can be helpful to communities where testing is not readily available, where there are limited healthcare providers and/or where there may be significant geographic distances to obtain care, they also have limitations and pose challenges, including:

1. These are “one-and-done” events

People receive test results for this specific point in time. However, they may be infected in between testing and receiving results, creating a false sense of security. Additionally, those without a doctor or medical home do not have the benefit of finding a regular source of care, which is essential for testing, and health conditions beyond COVID-19 issues.

2. A community event can say to the under-served that “this is important… for this one day”… but it does not demonstrate a commitment to assuring ongoing medical care

Care should be available when a person is ready, not when it is convenient for local government staff.

3. These can be sensational and interesting to the media and can attract the “worried well” to attend and artificially lower the positivity rate

Opportunities to be tested without symptoms can attract people who otherwise do have health insurance and medical home but “just want to know” if they have COVID-19. This may be a disservice to populations experiencing high positivity rates, specifically those living in crowded housing conditions or working in jobs without sick leave benefits.

4. Such community testing events are immensely resource-intensive and resource-diverging

During the 9 days from awareness to testing, AHD spent more than 400 hours in planning and preparation. This involved mostly 12 persons and the majority of the work fell on 5, who logged more than 50 hours each during the 9 days solely on this initiative (50-60-60-80-90 hours among the 5). The 12 carrying the greatest burden are in leadership roles in AHD’s ICS structure, as this work planning and preparation work for large events cannot be accomplished by others. During the community testing event preparation, AHD diverted resources from other community imperatives, and AHD did NOT conduct essential other functions, including recruitment, training and PPE deliver to physician practices, critical for Alexandria to maintain and enhance testing capacity; education, training and PPE delivery to LTCFs, where more than 50% of Alexandria’s COVID-19 related fatalities are occurring. Furthermore, following up on nearly 3,000 tests—most of which belong to other jurisdictions—is incredibly time consuming.

Additionally, the Alexandria Memorial Day testing events were incredibly time-consuming for the City of Alexandria’s Command Staff and Joint Information System teams, detracting from other COVID-19 response and recovery activities. 

Neighborhood Health’s 5/16 Testing Event

On May 16, Alexandria’s federally qualified health center, Neighborhood Health, conducted its first community testing event in Arlandria, a ZIP code with a test positivity rate of more than 50% at the time of the event. The purpose was to reach pre-symptomatic, symptomatic and asymptomatic low-income patients, many of whom experience crowded housing conditions. Alexandria Health Department supported this event by contacting and coordinating community partners, planning and liaising with the City’s Emergency Operations Center, provision of health education materials, and activating Medical Reserve Corps volunteers to support the event (e.g. pedestrian flow control, registration, translation).

Although there were up to 300 tests available for community members at the May 16 event, only 236 people were tested. This may be due to the extremely brief window that community partners (Tenants and Workers United, Casa Chirilagua, and Community Lodgings) had to recruit people for the appointment slots. However, there were also a number of no-shows for appointment slots, suggesting that demand is lower than previously expected.

While Neighborhood Health did not track how many attendees were Alexandria residents, their leadership estimate that “at least 80%” of attendees walked up to the event, indicating that they were Alexandria residents living in the neighborhood. Attendees who did not have an existing source of medical care had the option of immediately enrolling as Neighborhood Health patients on that day. Neighborhood Health followed up with all persons with positive test results to further ensure that everyone with COVID-19 would receive appropriate medical care. Alexandria Health Department followed up with persons with positive test results as well, as this is a reportable condition; AHD also followed up with persons with negative test results to explain the implications of the results.

There were several clear advantages of this targeted neighborhood strategy:

  • Reaches a target community of those:
    • In ZIP Codes with a high testing positivity rate
    • In areas with low-income, low-wealth, over-crowded housing
    • Who have higher risk of severe COVID-19 disease due to underlying medical conditions
  • Enables attendees who do not have an existing source of care to immediately enroll in a medical home
  • Allows for more focused outreach, attracting Alexandria residents versus larger scale communications that can bring in people from other jurisdictions

Key Summary Points

  • Alexandria has multiple sites available for COVID-19 testing
    • Many offer free testing for eligible individuals
  • Alexandria’s rate of testing is the 2nd highest in Northern Virginia
    • Despite not having any of the hospital/healthcare system supported drive-throughs
    • This was true both before and after Alexandria’s Memorial Day Testing events
  • At least six Alexandria testing sites offer free testing for Alexandrians in need
  • Community testing events are resource-intensive and resource-divergent from serving Alexandrians at-risk for severe disease and Alexandrians in need
  • Targeted testing – through point prevalence surveys in facilities and focused neighborhood testing –better serve Alexandrians, especially those at high risk and those in need of services, than open community events

AHD: Commitment to Testing

Based on COVID-19’s impact, AHD’s resources, Alexandria’s testing availability and needs for testing, Alexandria Health Department will continue to

  • Coordinate and facilitate point prevalence surveys for long-term care facilities and congregate settings (serving Alexandrians most at-risk for hospitalization, intensive care support, and death)
  • Support targeted, neighborhood testing strategies by medical homes (e.g. Neighborhood Health)

By focusing AHD and City resources on Alexandria’s most vulnerable populations, we aim to reduce the number of infections, hospitalizations, and deaths due to COVID-19 and directly address the health disparities in our community.


Strategic Action Framework

Mission

Support COVID-19 testing availability for all Alexandrians, especially for those at greatest risk for severe disease

Objectives

  • Reduce and eliminate infections, hospitalizations, and deaths due to COVID-19
  • Support medical practices and medical homes to expand their testing capacity, particularly for those without insurance
  • Inform all Alexandrians about availability of testing and care resources

Key Context

This is a living document and changes will be made based on updates in public health’s understanding of COVID-19, updated CDC and VDH guidance, and AHD resources and prioritizations.

The owners for each task are AHD staff with multiple responsibilities. Target dates for each task are subject to change based on COVID-19 circumstances and priorities.

Strategy/Tactics

1. Recruit and retain clinicians, urgent care centers and Neighborhood Health to conduct testing

TASK

STATUS/ UPDATES

Health advisories, updates, information and guidance

Initiated 1/16 and regular updates (#21) through August

Ongoing

Teleconferences specific for clinicians

Conducted 7 from January through March

Recruit medical practices, urgent care centers, Neighborhood Health, Inova Alexandria Hospital to conduct testing

Ongoing

Provision of technical assistance (e.g. lab contacts, testing methods and processes, donning & doffing PPE, etc) to support testing

Multiple contacts March through August
Ongoing

Advisement about federal resources to reimburse testing and treatment for patients without insurance

May
Ongoing

Provision of respirator fit-testing

Multiple, February through May; ongoing as needed

Provision of PPE

Multiple, February through May; ongoing

2. Coordinate and facilitate targeted community testing

TASK

STATUS/UPDATES

Conduct 2 community testing events on 5/25

Completed

Analyze 2 community testing events

Completed

Review NoVA community testing events with colleagues

Multiple discussions, May

Engage Neighborhood Health to conduct targeted community testing

Discussed with NH – April and May; 5/30; 6/5

Completed
City supported July
VDH MOA executed August

Coordinate weekly free testing with Neighborhood Health around the community

 Started mid-July. Conducted six events as of 9/1.

Analyze data for epidemiologic clusters

Ongoing since April

Engage select property managers, community leaders

Ongoing since May

3. Support long-term care and congregate living facilities as they test staff and residents; support the facilities as they act on results

TASK

STATUS/ UPDATES

Complete initial facility-wide point prevalence survey (PPS) testing

Completed in all 8 LTCFs interested – details in AHD LTCF Strategic Action

Engage and discuss with LTCFs serial testing models

Discussions during PPS facilitations – May
6/7
Ongoing

Seek VDH and other sources for funding and other resources to support serial testing

Multiple discussions – May

Completed – VDH supported serial testing for outbreaks; CMS serial testing

Assess and determine funding for staff testing

Completed (see above)

Support our skilled nursing facilities in meeting testing requirements related to the CMS Interim Final Rule CMS-3401-IFC

Ongoing

Support our LTCF and congregate living facilities to test around positive cases

Ongoing

4. Communicate with residents, community leaders and businesses about testing resources and medical homes

TASK

STATUS/ UPDATES

Create and disseminate resources through daily news releases, flyers posted in high-pedestrian areas, website content, emails and calls to community partners

Multiple occurrences (several times daily) and multiple platforms and venues January through August

Seek feedback from community on barriers to testing and care through discussions with community leaders, town halls with residents, and calls

Ongoing work, February-present

Launch community-wide survey on care experiences/barriers

Initiated 5/25, closing on 6/19

Update resources on testing locations and promote widely

Completed July 10

Create and distribute materials advertising targeted community testing when location/date/times are finalized

Target date: 72 hours before each targeted testing event

Revamp testing materials on City webpage to encourage testing of both symptomatic individuals and close contacts Early September

SWOT Analysis

Strengths:

Motivated AHD workforce

MRC volunteers

Weaknesses:

Testing, nationwide, started slowly, was not readily available in the first months of the pandemic

Testing is not universally available for people without symptoms (becoming more commonly available)

Opportunities:

Residents desire testing

Clinicians can receive reimbursement for testing persons without insurance

Threats:

There are many tests on the market (e.g. for serology antibody testing) that are not FDA-approved, creating confusion for the public and policy-makers

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