The Jefferson County Department of Health (JCDH) in Alabama, founded in 1917 on the heels of a typhoid outbreak, is a semi-autonomous health department, governed by the local Board of Health.  Jefferson County is the most populous county in the state, governed by the County Commission, and encompasses Alabama’s largest city - Birmingham.  The county has an estimated population of 658,573 per 2019 U.S. Census Bureau estimates.  The racial and ethnic breakdown of the population is: 53% white, 43% black, 2% Asian, 4% Hispanic (of any race).  About 53% of the population is female and 47% is male. The age breakdown is: 23% under 18 years of age, 61% 18 to 64 years of age, 16% age 65 and older.  Unfortunately, 16% of the population lives in poverty.

JCDH activated our Incident Command Structure for COVID-19 in January 2020, as more cases of COVID-19 were confirmed in the U.S.  By March, the Governor of Alabama declared a state public health emergency existed on recommendation of the State Health Officer and on the same day, JCDH reported the first confirmed case of COVID-19 in Jefferson County.  Soon thereafter, the Jefferson County Health Officer issued an order to limit public gatherings in response to a rapidly growing number of cases of COVID-19 detected in our county.  Law enforcement and first responders began to voice concerns about a potential exposure to COVID-19 after responding to a death in a facility.  Days later, JCDH confirmed the county’s first COVID-19 related death.  The County Health Officer issued additional orders temporarily closing nonessential businesses, services, and schools.   Hospital and long-term care facility visitations were limited and public gatherings were further limited.

Jefferson County Unified Command (JCUC) was established on March 28th with JCDH Health Officer and the Jefferson County Emergency Management Agency (EMA) Director as Unified Incident Commanders, respectively.  Under JCUC, a Public Safety Branch was created and charged with coordinating countywide public safety response efforts.  Also under JCUC, a Public Health Branch was created and charged with the goal of coordinating community testing efforts.

The Public Health Branch formulated a countywide Collaborative comprised of three separate groups of the community stakeholders to help inform the testing strategy and ensure equity.  Once the community testing strategy was finalized, the Public Health and Public Safety Branches, respectively, coordinated the first-ever countywide testing effort between different governmental public safety agencies.  Protocols and a standing order from JCDH’s Health Officer allows for nasal-self collection of PCR specimens under the observation of trained paramedics that are appointed by local mayors.  A local lab is used to ensure same-day results.  Health department employees are able to directly enter the order requisition in the laboratory information system.  Results are transmitted to public safety personnel via SMS test messaging and to the Health Officer’s designee.  All individuals with a positive result are contacted by the health department.  This collaborative effort has resulted in thousands of tests being performed allowing for timely contact tracing and mitigation of viral spread in the workplace.

Public safety personnel are at high-risk of SARS-CoV-2 exposure due to their close contact with the general public.  Early in the pandemic JCDH recognized a need for expedited testing with timely results in order to maintain critical and essential public safety functions.  At the time, the typical turnaround time for PCR test results took up to 5 days.  Finding time to go to a testing site presented challenges and testing providers were scattered throughout the county with varying days and hours of operation.

JCDH identified a local lab that could process specimens within twenty-four hours or less.  The lab’s FDA Emergency Use Authorization was confirmed and lab performance was validated by the state health department’s lab.  Since there were some public safety personnel that do not have insurance (e.g. volunteer firefighters) it was important that cost for testing would be covered.  The lab had enrolled in HRSA’s COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured Program.  JCDH executed an agreement with the lab and added a clause to the agreement stating the health department would cover the lab costs if HRSA program funds were exhausted.

On May 4, 2020, protocols and a standing order from JCDH’s Health Officer allowed for nasal-self collection of PCR specimens based on FEMA’s April 16, 2020 document Nasal Self-Swab Concept of Implementation that highlighted experiences at sites around the country.  The nasal self-collection technique was reviewed and modified by Alabama’s State Epidemiologist who currently serves as the President of the Council of State and Territorial Epidemiologists.  This modified technique involves manual external compression of the nares after insertion of the swab to ensure adequate specimen yield.  This was the first time the nasal self-collection method was used in the county.  After appointment by local mayors, a paramedic from each municipality was trained to pickup specimen kits, safely observe nasal self-collection, and package and drop of specimens the same day so that results were received typically in less than twenty-four hours.  Paramedics had been used during the 2009 novel H1N1 pandemic as vaccinators but had never been utilized in this manner.

JCDH created a website so that public safety personnel could download, complete, and submit an Informed Consent and Testing Authorization Form.  We worked with the lab to gain direct access to their laboratory information system (LIS) and established a Call Center staffed by administrative staff to field calls from the public safety personnel, verify consents, input their demographic information and symptom screening, and create lab requisitions.

After specimens are obtained and dropped off at the lab, the results were sent directly to the individual that was tested via secure SMS text messaging and an e-mail with results was securely sent to the Health Officer’s designee.  All individuals with a positive result are called to ensure that he/she did indeed receive their test result.  Quarantine guidance for the individual and all household contacts are reviewed.  Individuals testing positive are asked about how they currently feel, onset of any symptoms, the reason for testing (e.g. occupational exposure), whether their employer has been notified, etc.  This information is documented in a spreadsheet and then sent to contact tracing team for further investigation.

Eventually we expanded access to expedited testing to all municipal employees in the county.  During the calendar year 1,636 public safety, municipal and government employees have been tested through the expedited testing program.

In accordance with Public Health Law of Alabama, the Jefferson County Department of Health is governed by a local County Board of Health, which is under the general supervision of the State Board of Health.  The Jefferson County Board of Health is a six-member board made up of five members from the Jefferson County Medical Society and the current president of the Jefferson County Commission.  The Jefferson County Health Officer is employed by the Board of Health, serves as the chief executive of the health department, and is responsible for investigation of cases or outbreaks of notifiable diseases.

In Jefferson County, Alabama, there are 35 municipalities within its boundaries that inherently and historically limit regional cooperation.  Per a 2017 report[1], “The region has a long tradition of fragmentation. It has a history of division along racial and economic lines. Recent problems with corruption, political disputes, and intergovernmental competition make it more difficult to forge cooperative arrangements.”  Additionally, there are six major hospital systems and four Federally Qualified Health Centers in the county.

Years ago the Jefferson County Healthcare Coalition (HCC) was established to assist healthcare facilities in the event of a major incident or disaster affecting healthcare organizations occurs in Jefferson County.  It is comprised of local healthcare and response organizations.  The HCC works together to maximize surge capacity and capability before, during and after the pandemic. The members include representatives from the general public, volunteer organizations, first responders, local governments, education, public works, utilities and healthcare providers including hospitals, long-term care facilities and emergency medical services.  A JCUC branch was also created for the HCC which primary coordinated efforts between the hospitals and nursing homes. 

In compliance with the Federal Emergency Management Agency (FEMA) directive, Unified Command was established on March 28th with JCDH Health Officer and the Jefferson County Emergency Management Agency (EMA) Director as Unified Incident Commanders, respectively.   Partner agencies include the Jefferson County Commission, JCDH, Jefferson County EMA, the University of Alabama at Birmingham (UAB), City of Birmingham, City of Hoover, Birmingham Airport, Birmingham Housing Authority, and others.  Despite previous emergency response efforts, this has been the first time in the county’s history that this many agencies coordinated their efforts.

Under JCUC’s Operations Section, a Public Safety Branch was created and charged with coordinating countywide public safety response efforts.  Also under JCUC’s Operations Section, a Public Health Branch (led by JCDH’s Deputy Health Officer) was created and charged with the goal of coordinating community testing efforts.  Initially a Community Testing Group, led by an administrator at UAB as appointed by the Public Health Branch Director, was activated under the JCUC Public Health Branch with the followings objectives:

·       Disseminate a unified testing strategy;

·       Promote CDC’s Self-Checker;

·       Standardize testing criteria based on symptoms;

·       Identify and facilitate targeted county-wide specimen collection sites based on population density, access, etc.;

·       Inform community stakeholders of testing resources and sites.

Later, the Public Health Branch formulated a countywide Collaborative comprised of three separate groups of the following persons to help inform the testing strategy and ensure equity.  Infectious disease, epidemiology and public health experts came from academic medical centers, higher education institutions, and health department administrators.  Various providers of community COVID-19 testing included an academic medical center, urgent care centers, and Federally Qualified Health Centers.  Representatives of the communities and political entities each of the five County Commission districts included a city manager, church event coordinator, urgent care clinic manager, home builders association executive, mayor, church administrator, and a physician.

The community testing strategy was created under the following guiding principles:

·       Testing should be widely available, affordable, convenient to access, and equitably distributed throughout Jefferson County;

·       Lessen healthcare disparities throughout the entirety of Jefferson County;

·       With increasing testing capacity, a lower threshold for testing should be considered for those who are symptomatic given an expanding list of symptoms as reported by the CDC.  Furthermore, there should be a greater focus on asymptomatic testing for those in high-risk professions or those who come into contact with large numbers of people on a frequent basis.

Once the community testing strategy was finalized, it was disseminated to the community via a weekly Unified Command Update that is published on the JCUC COVID-19 website and managed by the JCUC Joint Information Center.  Simultaneously, we met with elected officials to ensure buy-in and solicit support for this effort.  The presumption was that mayors had the authority to direct personnel assets from fire, EMS, and law enforcement.  We posit that the community testing strategy was well received since we had, in part, sought feedback from community members that had been appointed by elected officials.

The JCUC Public Health and Public Safety Branches, respectively, then coordinated the first-ever countywide testing effort between different governmental public safety agencies.  Now that the Public Health Branch had developed the plan, the JCUC Public Safety Branch was charged with communicating the relevant portion of the strategy with each public safety agency throughout the county.  Quarantine and occupational exposure guidance was also disseminated to each agency after review and approval by JCDH’s Medical Director of Disease Control who was JCUC’s Subject Matter Expert.

[1] Together We Can - Charting a Course to Cooperation for Greater Birmingham. Public Affairs Research Council of Alabama; 2017

Using the tenets of the Plan-Do-Study-Act (PDSA) Cycle, several lessons were learned leading to refinements to the program.  As this program is still operational, there are ongoing adjustments that are in the process of development.  Do to the success of the program, we have received requests outside of the county to expand our footprint.

The appointed paramedic was trained to pickup the specimen kits from the lab, observe nasal self-collection at the workplace, and then drop of the specimens to the lab for processing.  We hypothesized that one concern that would be alleviated by this process would be prevention of lost job productivity by not having public safety personnel individually drive to the lab to obtain specimen kits.  Soon after the program was implemented, we received word that some personnel decided to go directly to the lab, pickup a specimen kit, self-swab in the lab parking lot, and then return to kit to the lab.  The property owner that leased office space to the lab expressed concern about this practice and demanded that it cease.  The lab contacted the health department who in turn immediately contacted the JCUC Public Safety Branch to send out communication to stop self-swabbing in the parking lot, and thus refining the process.

The modified nasal self-collection technique has proved high fidelity as only 14 out of 3,316 specimens (0.4%) resulted as "Indeterminate" meaning 99.6% of the specimens were able to be processed.  The indeterminate results likely reflect lack of detection of  human RNaseP meaning the specimen quality was poor.  Nevertheless, all personnel with this result successfully re-swabbed themselves.  For comparison, an at-home self-collected nasal swabs kit that received FDA EUA, detected RNaseP in 28 out of 29 (96.7%) specimens.  Thus, it appears the modified technique may be superior than others that have been utilized.

Another process improvement that is currently in development entails modification of the lab ordering process.  As more public safety and municipal employees use this process, there has been increasing demands on our Call Center.  Also, if testing is needed in the evening or on weekends, personnel requested testing will need to wait until the office is open during normal business hours in order to have the lab order created.  After consultation with the lab vendor, a software solution was created to bypass the need for personnel to call.  A QR Code was developed that can be scanned with a mobile device and will send personnel to a website portal.  The QR Code will be disseminated by the JCUC Public Safety Branch and posted in applicable workplaces.  Once the user registers on the site, they will e-sign a consent form, input their symptom screening, and then a lab requisition will automatically be generated.  The personnel will then self-swab at their workplace and then the assigned paramedic will drop of the specimens to the lab.  Thus, public safety and municipal employees will be able to get tested in evenings and on weekends without having to wait until the health department is open.

Alabama’s recent White House Coronavirus Task Force report recommends “Proactive weekly testing of groups representative of the community (teachers, community college students, county workers, staff in crowded or congregate settings, hospital personnel, large private sector employers) will help identify the depth and breadth of community infection.”  JCDH is currently developing a process for paramedics to perform rapid antigen testing serially for surveillance of public safety personnel.  This will require compliance with the Clinical Laboratory Improvement Amendment (CLIA) Certificate of Waiver.  We will leverage the process that has already be successful.  Public safety and municipal employees will continue to perform COVID-19 PCR tests if they are symptomatic or a close contact to a positive case but will also use rapid antigen tests for surveillance.

We have demonstrated that this model is scalable given the expansion to all county municipal employees without delay in receiving results.  Furthermore across the country, the traditional public health workforce (i.e. nurses, disease intervention specialists) has been strained given competing pandemic response duties and budgetary cuts[1]^,[2].  The use of nontraditional workers (e.g. paramedics) to aid in public health pandemic responses provides more flexibility and efficient use of limited resources.  In Jefferson County, the paramedics did not receive any additional financial compensation for their work as the aforementioned duties are considered a part of their typical job and are provided in-kind.  Because of the unique skillset of paramedics, we recommend their consideration in any future public health epidemic responses.  Incorporating the use of personnel in non-traditional ways will create a more robust to respond during crises.

This pandemic has shown the importance of strong partnerships and ongoing training and coordination to response to any public health threat.  Unified Command’s Public Safety, HCC, and Public Heath Branches have demonstrated that regional cooperation is possible and can work.  

[1] Meit M, et al. An Examination of Public Health Financing in the United States. (Prepared by NORC at the University of Chicago.) Washington, DC: The Office of the Assistant Secretary for Planning and Evaluation. March 2013.

[2] Lang A, et. Al. A funding crisis for public health and safety: state-by-state public health funding and key health facts : 2018.  Washington, DC: Trust for America’s Health. March 2018.