Integrated COVID-19 Interventions in a Native American Community: Arizona, December 25, 2021–January 31, 2022

Abstract

COVID-19 has disproportionately affected Indigenous communities. The Whiteriver Service Unit (WRSU) took an integrated public health–health care system delivery approach in collaboration with the White Mountain Apache Tribe to decrease the case fatality rate (CFR). The WRSU performed daily data analyses identifying risk factors, expeditiously treating and proactively vaccinating people during at-home visits. The WRSU’s CFR was 0.3% lower than Arizona’s (P = .04). Among communities disproportionally affected, an integrated approach using data to drive real-time decision-making among a culturally competent workforce can contribute to decreased CFR. (Am J Public Health. 2023;113(10):1089–1092. https://doi.org/10.2105/AJPH.2023.307364)

During the December 2021–April 2022 COVID-19 surge, the Department of Preventative Medicine (DPM) of the Indian Health Service’s Whiteriver Service Unit (WRSU) built upon and strengthened existing local processes to coordinate care across various public health and clinical teams, importantly involving community members, to mitigate the impact of disease. Real-time, data-driven, and efficiently communicated decisions allowed a nimble response embedded in the community that streamlined case identification, individual patient risk assessment, and early linkage to care and vaccination.

INTERVENTION AND IMPLEMENTATION

After the first community COVID-19 case was detected on April 1, 2020, the WRSU’s DPM coordinated the response to COVID-19, developing the high-risk team, contact tracing, case investigation, COVID-19 vaccination program, and high-risk home visit teams. The WRSU used a single, integrated electronic health record system for the DPM, ambulatory and inpatient care, the emergency department (ED), and community outreach. The DPM comprises physicians, nurses, medical assistants, pharmacists, physical therapists, health technicians, dental hygienists, and community health representatives performing public health system roles.

During the COVID-19 omicron (B.1.1.529 and descendant lineages) surge that began in December 2021, the DPM daily obtained laboratory COVID-19 test results, performed analyses to create reports of all positive results, and identified persons at increased risk for progression to severe disease, based on age, underlying conditions, and vaccination status. These persons were monitored at home visits (history, ambulatory and resting pulse oximetry, physical exam) and remotely (self-monitored pulse oximetry). Those who met specific, locally developed criteria were referred to the WRSU’s ED for further evaluation.

The high-risk team reviewed the electronic health record of all patients who tested positive for COVID-19 to determine eligibility for early treatment with either monoclonal antibody or other antiviral medication (sotrovimab, combined casirivimab and imdevimab, and remdesivir) based on the Food and Drug Administration’s Emergency Use Authorization and locally defined criteria. The WRSU developed a specific scoring system (the COVID-19 Treatment Allocation Score), adapting external allocation systems (Monoclonal Allocation Screening Score and National Institutes of Health COVID-19 Treatment Guidelines Panel) based on local data and outcomes. These criteria were updated in real time through an Incident Command System, necessitated by the rapid influx of patients during the surge of cases. The COVID-19 Treatment Allocation Score was used to identify patients to contact for treatment, not to exclude patients from treatment; individual clinicians had independent authority to order treatments for patients based on individual, case-based, clinical discretion.

The WRSU engaged in aggressive, proactive COVID-19 vaccine efforts. Field team members, many of whom were from the community and spoke the local language, provided home vaccinations for persons at increased risk. Hospital-wide patient encounters were reviewed to identify opportunities to provide vaccination to prevent future surges.

PLACE, TIME, AND PERSONS

The WRSU serves approximately 18 000 members of the White Mountain Apache Tribe (WMAT) and other tribes on the reservation and surrounding areas across approximately 2600 square miles in remote and mountainous east-central Arizona. During January 2022, 97% of test samples for SARS-CoV-2 (the virus that causes COVID-19) sequenced in Arizona were BA.1 omicron variant.¹ The WRSU and WMAT faced the highest case rates of the entire pandemic among a high-risk population remote from intensive care unit–level care (180 miles from nearest tertiary care centers). On December 20, 2021, near the start of the state omicron surge, the COVID-19 Pandemic Vulnerability Index of Navajo County, Arizona (where WMAT is located) was higher than those of 97% of US counties, predictive of higher incidence and mortality risk.² Arizona experienced the highest weekly case count of the entire pandemic (2.4 times the previous highest weekly case count for the state) and less than 5% intensive care unit bed availability.^3,4

PURPOSE

Native American communities endured great morbidity and mortality from the COVID-19 pandemic; in Arizona, 13% of COVID-19 cases and 18% of deaths were among Native Americans, who make up only 5.3% of the state’s population.^3,5,6 To decrease the case fatality rate (CFR) and offer culturally competent care, the WRSU implemented a proactive COVID-19 risk management strategy, integrating public health, preventive medicine, and health care delivery.

EVALUATION AND ADVERSE EFFECTS

During the BA.1 omicron surge (December 25, 2021–January 31, 2022), the COVID-19 CFR in the WRSU was significantly lower than that in the rest of Arizona. Despite a 69% higher COVID-19 incidence (incidence rate ratio [IRR] = 1.69; P ≤ .001), the CFR in the WRSU (0.14%) was one third that in Arizona overall (0.44%).^7,8 These outcomes are notable; Indigenous communities have been disproportionately affected by COVID-19 with mortality rates consistently higher than the US average.⁹

A total of 2168 persons in the WRSU catchment area (12 044 per 100 000) received a positive SARS-CoV-2 test result (Table 1). Among these, 41 patients (1.9%) were hospitalized (228 per 100 000), and three patients (0.14%) died. Compared with Arizona, where the COVID-19 incidence was 7136 per 100 000, the WRSU incidence was significantly higher (IRR = 1.69) and correlates with the higher county COVID-19 Pandemic Vulnerability Index. The overall Arizona CFR (0.44%) was more than three times that of the WRSU (CFR difference = −0.3; P = .04). COVID-19–related mortality among WRSU patients (17 per 100 000) was 47% lower than that in Arizona overall (32 per 100 000), although the difference was not statistically significant (IRR = 0.53; P = .26).

TABLE 1—

COVID-19 Cases and Outcomes: Whiteriver Service Unit (WRSU) and Arizona, December 25, 2021–January 31, 2022

Characteristic	No. (Rate per 100 000)		IRR (95% CI)
	WRSUa	State of Arizonab
Cases of confirmed COVID-19	2 168 (12 044)	519 431 (7 139)	1.69 (1.62, 1.76)
COVID-19–related hospitalizations	41 (228)	16 245 (223)	1.02 (0.73, 1.39)
COVID-19–related deaths	3 (17)	2 294 (32)	0.53 (0.11, 1.55)
Case fatality rate, % (95% CI)c	0.14 (−0.02, 0.30)	0.44 (0.42, 0.46)	…

Note. CI = confidence interval; IRR = incidence rate ratio.

^a Rates per 100 000 were calculated for cases, hospitalizations, and deaths using the electronic health record (EHR) for WRSU population-level data. The Indian Health Service EHR, in conjunction with iCare, a population management software tool, and Resource and Patient Management System, were used for WRSU data collection for health care delivery and public health analyses and decision-making.

^b Trends in number of COVID-19 cases and deaths in the United States by state/territory, as reported to the Centers for Disease Control and Prevention (CDC), were accessed by data download from https://covid.cdc.gov/covid-data-tracker/#trends_dailycases, https://covid.cdc.gov/covid-data-tracker/#cases_totaldeaths, and https://covid.cdc.gov/covid-data-tracker/#new-hospital-admissions (accessed October 11, 2022). The CDC calculates the number of new cases or deaths each day either by using the information provided by states and territorial jurisdictions or by calculating the difference in cumulative counts reported by the state from the day before. Rates per 100 000 are calculated as total cases or deaths per 100 000 people using the US Census Bureau Population Estimates Program.

^c Case fatality rate difference between WRSU and Arizona was −0.30 percentage points (95% CI = −0.46, −0.14; P = .04).

Among 1616 persons aged 18 years or older with a positive SARS-CoV-2 test result, 528 (33%) received treatment, including 319 (20%), 186 (12%), and 23 (1%) who received sotrovimab, combined casirivimab and imdevimab, and a three-day outpatient course of remdesivir, respectively (Table 2). Of three WRSU deaths among patients with laboratory-confirmed COVID-19, none met Emergency Use Authorization criteria for outpatient treatment because of oxygen requirements or hospitalization at time of diagnosis. Among patients who received any outpatient treatment, no deaths occurred.

TABLE 2—

COVID-19 Treatment Outcomes Among Persons Aged ≥ 18 Years With a Positive SARS-CoV-2 Test Result: Whiteriver Service Unit, Arizona, December 25, 2021–January 31, 2022

Treatment Outcome	No. (%)
Total with positive SARS-CoV-2 test result	1616 (100)
Received outpatient treatmenta	528 (33)
Sotrovimab	319 (20)
Casirivimab/imdevimab	186 (12)
Remdesivir	23 (1)
Death	0
Did not receive outpatient treatment	1088 (67)
Met EUA criteria for outpatient treatmentb	1032 (64)
Did not meet EUA criteriac	56 (3)
Death	3 (0.2)

Note. EUA = Food and Drug Administration’s Emergency Use Authorization.

^a Treatment included sotrovimab, casirivimab/imdevimab, or remdesivir.

^b Patients categorized as high risk and who met EUA criteria for outpatient treatment.

^c Patients who required oxygen therapy because of COVID-19, were hospitalized because of COVID-19, or otherwise did not meet EUA criteria for outpatient treatment.

In a review of patient encounters to assess opportunities to deliver COVID-19 vaccine, it was found that 75% of patients seen in the ED in January 2022 were not up to date. ED-based vaccinations were initiated by pharmacists to avoid relying on ED staff to administer vaccines.

SUSTAINABILITY

The WRSU’s DPM, which coordinated and conducted the WRSU community COVID-19 response, has full-time staff and will continue to use the same strategy to respond to other diseases. The WRSU coordinates with tribal government agencies (e.g., the Emergency Operations Committee, the Public Health Department, community health representatives, and the WMAT Emergency Medical Services) to enhance sustainability.

PUBLIC HEALTH SIGNIFICANCE

The WRSU’s COVID-19 response demonstrates how an integrated, proactive approach using data to drive dynamic, real-time decision-making among a dedicated workforce that understands the local community context, can contribute to a decreased CFR.¹⁰ Clear and real-time communication was essential to the response, particularly in meeting time-frame goals for treatments.

Home outreach can require substantial investments of time and human resources; however, in this remote population with limited resources, including transportation, as well as limited or unavailable Internet and video capabilities, there were few other alternatives to reaching persons at highest risk for severe disease. In addition, seeing patients in their own environment and performing a physical examination provide more information than can be obtained through a telephone call, inform clinical decision-making, and enhance patient care. Early identification of patients at high risk, streamlining expedient treatment, and linking to ongoing care through home visits all contributed to improvements in outcomes. Preemptive planning of vaccination efforts while still in surge mitigation phase has the potential to reduce future morbidity and mortality.

A proactive risk management and health strategy, preventive measures, collaborative and integrative interventions involving health care and public health institutions from the community to hospital level, and an integrated data-driven response led to a COVID-19 CFR that was significantly lower than that of the rest of Arizona. Among communities disproportionally affected by COVID-19, an integrated approach using data to drive dynamic, real-time decision-making among a culturally competent workforce can contribute to decreased COVID-19 case fatality.