EPI director: Command Center response can be improved
Ramona Antone-Nez, the Navajo Epidemiology Center director, told the Council’s health committee last week that when COVID-19 struck the Navajo Nation, no one foresaw the magnitude.
“I think we’re doing the best we can with the resources we have,” said an emotional Antone-Nez. “This is a really aggressive, acute illness. I want to encourage our people to wear their masks and do their best and stay patient.” She acknowledged that understaffing is one of the many issues at the Navajo COVID-19 Health Command Operations Center that can impede its responses.
With regard to incoming “213” requests, which are pleas for help, she said this is an area with room for improvement. She said the Navajo EPI team have asked for additional support from entities like the CDC, which they have received. “There’s a lot of moving parts,” said Antone-Nez. “We’ve had to adjust.” Antone-Nez said since the first case emerged on March 17, Navajo has been in competition with the entire United States for access to Personal Protective Equipment due to poor national preparedness.
“We do have our challenges, but there is great strength in our language and the people we are working with,” said Antone-Nez. “I think we can do better, but we’re also doing the best we can.” Recently, the Command Center enter entered into a Unified Coordination Group, a collaboration between the Navajo Department of Health, the BIA, Navajo Area Indian Health Service and tribal health facilities, she said.“As the spread of COVID-19 becomes more complex, the need for a unified command is critical in reducing the spread of COVID-19,” states a March 15 press release from the center.
Antone-Nez said the protocol for sending COVID-19 positive or exposed individuals home to self-isolate was ineffective because whole households were infected. The added is risk is that many homes are multigenerational.
“It’s important that we separate individuals to protect the households,” said Antone-Nez. Initially, individual contact tracing and case management protocols did not take that into full consideration, but now they are looking at adopting a method that is being used at the Shiprock Medical Center called “Families Under Investigation,” which Antone-Nez would like to see implemented across Navajo.
“They understand they need to address the entire family,” she said. She said the Alternative Care Sites (in Shiprock, Gallup, Chinle) have started to open and hotels are being used where people can quarantine/self-isolate without exposing others. Antone-Nez believes ACS facilities have been underutilized and part of the issue is finding adequate personnel to staff them.
Now, with over 4,000 COVID-19 cases on the Nation, Antone-Nez said a team is being assembled to streamline contact tracing protocols, which is going live this week. Within the Command Center, contact tracing efforts are being led by EPI team members Brenette Pine and Jill Moses who currently have a team of approximately 70 in training, said Antone-Nez.
To date, she said, most of those functions were conducted by Navajo Area IHS units and tribal health organizations where the testing is done. “We need to build a team of 600 (contact tracers) overall for the Nation,” said Antone-Nez, which would break down to about five to six per chapter. Antone-Nez asks that people cooperate when they get a call from a contact tracer. “When a person is identified as positive for COVID-19 we want to know where that person may have been possibly exposing others,” she said.
Navajo Area Chief Medical Officer Dr. Loretta Christensen said approximately 120 people are helping epidemiology and tracing activities on the Nation, but 250 are needed to cover the current case load. Christensen said they are training people and volunteers can contact Navajo Area IHS or the Navajo Epidemiology Center.
Delegate Pernell Halona told Antone-Nez he sent in a 213 request to the Command Center requesting contact tracing assistance, but never got a response. “It could be that we took care of it or maybe we didn’t take care of it,” said Antone-Nez, who offered to follow up. “Perhaps overall our response is slow to all these calls that are coming in.”
She said that as far as she knew there was no policy in place on how to address a COVID-19 positive individual who is not complying with guidelines such as self-isolation. “When you hear it from community members and their relatives that they are positive, how do we make sure they are sheltering in place and not out in public?” she said.
Antone-Nez suggested the health and Law and Order committees might want to evaluate laws relating to containing and enforcing these types of situations. “It is my understanding that the Nation does not have enforcement to this,” she said.
Antone-Nez said there is also concern over individuals who might be asymptomatic because the virus can be infectious before the onset of symptoms. “Is there a policy for mitigation of spread?” asked Vice Chair Carl Slater.
“Any analysis about which tactics have been most effective?” Chair Daniel Tso told Antone-Nez he had asked Incident Commander David Nez for chapter data weeks ago, but never heard back. Antone-Nez explained the policy of the Command Center is not to publicize chapter level data in order to protect the identity of individuals.
She did say 102 chapters have at least one or more positive cases. Antone-Nez confirmed that the numbers reported by the EPI team only include those Navajo who reside on the Nation, even though they are also tracking Navajo border town numbers separately. When asked when the peak might occur on Navajo, Antone-Nez responded, “I don’t even try to make those projections anymore.” “How can we get your center to share data with UNM metals research center?” asked Tso. “We want to make sure there are many other eyes on the numbers to help define new ways of addressing this pandemic.”
Slater said he is especially concerned about elders in rural areas who don’t have transportation. “For those who are isolated, up on the mesas or who don’t have children, what are we doing to help them?” he said. Antone-Nez deferred to Jill Jim and David Nez about “wrap-around services,” including mental health, child care, domestic violence, aging, and transportation. “I really want to get to where the households that are very rural are assisted in the response,” she said.
Slater asked if recoveries were being tracked. “We do need to make a better effort to improve the recovery reports,” responded Antone-Nez.
She explained that people have to wait three days after the last signs and symptoms of COVID-19 have passed and take two tests before they can be counted as recovered which can cause delays in tracking. Due to the shortage of tests, priority has been going to the “front end” – those who need to be tested, she said. Antone-Nez added that COVID-19 can be a persistent infection for up to 39 days. As of Tuesday, the total number of COVID-19 cases on Navajo had reached 4,153 with 144 deaths and an estimated 1,001 recoveries.
“We have a lot of issues, no doubt,” said Antone-Nez. “I will work to improve how I operate on a daily basis. The demands are high, but I’ve also been calling out for help.”