COVID-19 Contact Tracing in Navajo NationJI LL MOSES , MD, MPH

DI RECTOR, D I V I S ION OF PUBL I C HEA LTH

CHI NLE SERVI CE UNI T , NA VA JO A REA I NDIAN HEA LTH SERVI CE

IHS ECHOSEPTEMBER 3 , 2020

Acknowledgements and DisclaimersThe opinions expressed in this presentation do not necessarily reflect the official views and policies of the Department of Health and Human Services, and the Indian Health Service, nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Disclosures:

Dr. Moses serves as the HCOC Case Management Lead for Navajo Nation and is the Director of Public Health at the Chinle Service Unit, NAIHS

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ObjectivesTo share information on the Navajo Nation experience with the COVID-19 pandemic and the evolution of the public health response.

To provide an overview of the case management and contact tracing system established to contain COVID cases.

To demonstrate how contact tracing workforce measures can play a role in determining reopening readiness

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4https://navajo-nation-coronavirus-response-ndoh-nec.hub.arcgis.com/

Navajo Nation• 3 states (NM, AZ, UT)• 2 IHS regions (Navajo, ABQ)• 13 Navajo healthcare

organizations (federal and 638)

COVID Unified Command • NAIHS + 638 + Navajo DOH• Medical and PH branches• Close coordination with

Navajo Leadership (President Nez)

https://navajo-nation-coronavirus-response-ndoh-nec.hub.arcgis.com/

• Rapid epi responses at service unit/tribal health organizations

• Staff reassigned to COVID response

• Different data systems• Limited home support• Recruited key partners

Immediate Response

(March – April)

• Unified contact tracing data system

• Standard Operating Procedures

• Volunteer assistance for contact tracing

• FEMA & NGO’s assist with home support

Coordinated Efforts

(May – June)

• Aim for suppression• Gating Criteria & Standardized Metrics • Community of Practice - best practices• Workforce planning and sustainability

Unified StrategiesJuly - August

Navajo Nation Contact Tracing Response

Core elements of Navajo Nation COVID-19 Public Health Response

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Navajo Nation Health Command - Public Health Emergency Orders

Public Health Ops

Epidemiology Case ManagementPublic Health

MessagingCommunity Mitigation

Medical Ops

Isolation facilities

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Navajo Nation Case Management Strategies / Teams

https://time.com/5838271/utah-navajo-health-system-coronavirus/https://www.npr.org/sections/health-shots/2020/04/15/828084250/how-to-get-the-most-out-of-your-virtual-medical-appointmenthttps://www.abqjournal.com/1463859/navajo-community-health-reps-play-key-role-in-contact-tracing.htmlhttps://www.youtube.com/watch?v=9zB_wJIPJBE

PresenterPresentation NotesCase Management (TTSI)TestingCase investigation Contact tracingSupported isolation and quarantine

https://time.com/5838271/utah-navajo-health-system-coronavirus/https://www.abqjournal.com/1463859/navajo-community-health-reps-play-key-role-in-contact-tracing.html

Expanded Contact Tracing - Progress to date

Contact Tracing Volunteer program • Diné and regional public health

students • Training, certification, quality

assurance

Site support • Team integration on CommCare• Case Management huddles• Team / 1:1 check-ins

Transition to sustainable workforce • Certification & work study

opportunities• Paid workforce

Expanded Contact Tracing - Program Goals

Unified data and workforce

system

Flexible and

responsive team

Long-term public

health capacity in

Navajo Nation

Case Management Metrics

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Workforce

# of Contact Tracers is >5 per average new daily

case

Cases

90% of cases investigated and

instructed to isolate within 24

hours of dx

>80% of cases identified among contacts during

14-day quarantine.

Contacts

90% of close

contacts notified to quarantine within 24

hours of case investigation

Testing

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Gating Measures and Indicators

*Gating Threshold Ver 3.0. Analysis are completed over a 14 day period and there is a 3 week assessment time after each transition

Phase 0 Phase 1 Phase 2 Phase 3Cases

Downward trajectory Downward trajectory

Downward trajectory and no evidence of sustained

rebound

Downward trajectory and no evidence of sustained

reboundAverage daily number of new cases per 100000 population over the last 14 days ≥25 cases per 100K 10-24 cases per 100K 1-9 cases per 100K 10%

*Percentage of positive tests equal to or less than

7-10%.

*Percentage of positive tests equal to or less than

4-6%

*Percentage of positive tests equal to or less than

≤3%

Hospital CapacityInpatient or ICU beds

A1. Cases – Is there a 14 day downward trajectory ?

A3. Cases – Incidence

Navajo Nation has moved from 34th rank to 38th rank out of 51

Interpretation: The Navajo Nation COVID-19 7-day incidence rate in comparison to state-level rates across the United States. The Navajo Nation’s rate is 49.86/100,000 persons, which is 38th highest compared to states. State-level data were obtained from CDC on August 27, 2020 via: https://www.cdc.gov/covid-data-tracker/index.html#cases.

A3. Cases – Incidence

9 Average Daily Cases per 100000 population over the last 14 days

7 Average Daily Cases per 100000 population over the last 7 days

13 IHS-THOs and Gating Measures – Includes Border Towns

Risk level calculated as average daily cases per 100000 population over 14 days.

Numbers are too small to report

Risk Level

Service Unit Average daily new cases per 100K

population over 7 days

Average daily new cases per 100K

population over 14 days

30 Day Trend Decrease Percent Positive (14-day rolling average

of 3DCS)

Number of New Cases in 14-Day

Period

Ratio of Contact Tracers to Average

Daily Number of New Cases

SU1 0 0 0

SU2 3 9 YES 3% 36 8

SU3 1 3 YES 3% 14 6

SU4 11 16 NO 11% 35 10

SU5 5 11 YES 7% 47 8

SU6 2 4 YES 2% 5 10

SU7 0 0 YES 7% 0

SU8 1 4 YES 3% 6 5

SU9 4 8 YES 4% 50 5

SU10 11 11 2 11

SU11 4 9 YES 8% 47 4

SU12 3 10 YES 5% 6 4

SU13 3 12 YES 6% 16 8

Navajo Nation with Border Towns 4 10 YES 6% 278 6

Next StepsContact Tracing Community of Practice

◦ Communicate issues and needs◦ Share best practices

Fully implement contact tracing key performance indicators and use to drive system improvements

◦ Dashboard with SU/THO specific data

Use CARES Act and other funds to support core contact tracing workforce

Strengthen contact tracing critical incident and situational awareness reporting to inform community mitigation and public health messaging

Acknowledgements and DisclaimersThe opinions expressed in this presentation do not necessarily reflect the official views and policies of the Department of Health and Human Services, and the Indian Health Service, nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Disclosures:

Dr. Moses serves as the HCOC Case Management Lead for Navajo Nation and is the Director of Public Health at the Chinle Service Unit, NAIHS

Ahéhee’To all of our partners!

Jill Moses, MD, MPHDirector of Public Health Chinle Service Unit, Indian Health ServiceJill.moses@ihs.gov

COVID-19 Contact Tracing in Navajo NationAcknowledgements and DisclaimersObjectivesSlide Number 4Navajo Nation Contact Tracing ResponseCore elements of Navajo Nation �COVID-19 Public Health ResponseSlide Number 7Slide Number 8Slide Number 9Case Management MetricsSlide Number 11Gating Measures and IndicatorsA1. Cases – Is there a 14 day downward trajectory ?Slide Number 14Slide Number 1513 IHS-THOs and Gating Measures – Includes Border TownsNext StepsAcknowledgements and Disclaimers