Going House to House: The Hopi Tribe's Community COVID-19 Surveillance Program, 2020

The Hopi Tribe, a sovereign nation in northeastern Arizona, has about 7,500 people in 12 rural villages. From April 11 to June 15, 2020, the Hopi Health Care Center (HHCC), an Indian Health Service facility, reported 136 COVID-19 cases among Hopi residents; 27 (20%) needed hospitalization.

Why a new program

Contact tracing found that people with symptoms were slow to seek care and testing, that masks and distancing were used inconsistently, and that many knew little about testing, isolation and quarantine. So the Hopi Tribe Department of Health and Human Services (DHHS), HHCC and CDC built a community-focused program to strengthen surveillance and bring systematic health messages to the villages.

It built on the Tribe's Community Health Representative Program, in which salaried staff with basic clinical training each look after 30–40 patients in one or two villages, with home visits and health education.

Door to door

In each test, community health representatives visited every household in a village and, for each member:

• screened for COVID-19 symptoms and exposures on a standard form — fever, chills, body aches, fatigue, headache, runny nose, congestion, sore throat, loss of smell or taste, cough, shortness of breath, chest pain, nausea or vomiting, diarrhea, abdominal pain;
• recommended testing where needed, referring people to HHCC;
• taught prevention, and how to stop spread within households, with culturally adapted materials — a laminated booklet on isolating and quarantining in small houses that may lack running water, a flyer on hand hygiene, masks and distancing, and the program's newsletter with contacts for tribal resources.

To stay safe, representatives wore protective equipment, interviewed outdoors, kept at least 6 feet away, and at homes with confirmed cases only educated healthy members from a distance.

Two field tests

Five two-person teams — a community health representative and a volunteer from the village, the Hopi DHHS or the CDC field team — covered each village in 5 hours. The four people who declined screening in Bacabi were children whose parents declined for them.

What it showed

• Feasible: 10 staff screened 141 people in under 10 hours, in a rural, low-resource setting.
• Accepted: only 5% of households refused — likely helped by using representatives who are known and trusted in the villages.
• To improve: work more with village leaders to find occupied homes and times when people are in; streamline the interview; hand out masks.

After positive feedback from the villages, the representatives, HHCC and Hopi leadership, every Hopi village was canvassed at least once from July to October 31, 2020, and resources were being sought to visit more often. If expanded, the program was to be evaluated after a year for its effect on case detection and community knowledge and practices.

Sources

Based on Jenkins R, Burke RM, Hamilton J, et al., "Notes from the Field: Development of an Enhanced Community-Focused COVID-19 Surveillance Program — Hopi Tribe, June–July 2020," MMWR Morbidity and Mortality Weekly Report, volume 69, Centers for Disease Control and Prevention; a work of the United States government in the public domain.