Responding to the COVID-19 pandemic in the past year has dazed and fatigued the entire world. The morbidity and mortality due to COVID-19 has varied from country to country. Although, pandemic preparedness is a familiar subject for public health preparedness officials, the response to the pandemic got a slow start.  The key public health actions of testing, contact tracing, isolation and quarantine are known to be the most effective strategies in controlling the pandemic. Limited availability of viral PCR testing in the initial months of the pandemic exacerbated community spread. The HHD took the lead in designing the response to the pandemic for the fourth largest city in the country. Houston has an estimated population of 2.3 million individuals and is a minority-majority city, with people of color making up 68% of the population. 

The HHD response consisted of testing, contact tracing, advising and arranging isolation and quarantine for those infected, mass door to door health education and health literacy efforts, intense public communication through traditional and non-traditional media and serving as subject matter experts in public health response. Testing was the first step to control the pandemic. The HHD recognized that no single testing strategy was likely to achieve success in helping control COVID-19. In response, multiple testing options were made available to meet the needs of the City’s diverse population.  

Entrusted with leading the COH in providing guidance and a strategic plan for testing, the HHD devised an innovative plan using the constructs of “Access and Equity” as the foundation for the plan, very early on in the pandemic. The Phase 1 strategy had two primary goals: 1) establish a minimum baseline testing rate of 5 per 1000 population for all zip codes within the COH; and 2) make testing available to vulnerable populations.  The Phase 2 strategy’s primary goal was to increase widespread access to testing based on weekly positivity rates.  The initial baseline level of testing for all zip codes had a goal of 0.5%. 

Eleven (11) Priority One Zip Codes for testing were established in Phase 1. By the end of July 2020, baseline level of testing (5 per 1000 population) was achieved in each of the COH zip codes. To date, almost 1 million tests have been completed in Houston and the HHD and its affiliates have provided 2/3rd of the cumulative testing completed. This application describes the way the HHD led the COH in a data driven response to the pandemic community spread, using more than 40 data products and maps and leveraging existing and new partnerships with providers.

This is a continuing demonstration of real-life Public Health 3.0, in a large local health department. 

The COH is minority-majority city, with people of color making up 68% of the population. As with most other large jurisdictions, COVID-19 has disproportionally affected people of color. Where race/ethnicity is known, 31.2% of cases are Hispanic/Latino and 24.5% are Black/African American; 52.7% of deaths are Hispanic/Latino, and 21.4% are Black/African American. The COH was committed to providing access to a minimum baseline level of COVID-19 testing for all zip codes within the City (5 per 1000 population). Additionally, the COH is invested in supporting vulnerable populations. The HHD has historically focused on underserved populations, those that are vulnerable at multiple levels including health inequities. The aspects of the environment in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness are closely related to the health outcomes they experience. The HHD recognized that no single testing strategy was likely to achieve success in helping control COVID-19. In response, multiple testing options were made available to meet the needs of the City’s diverse population.  

The initial Phase 1 COVID-19 testing strategy for the COH were supported by two key concepts – access and equity. “Access zip codes” and “equity zip codes” were established to help create the final priority zip codes.  

Three steps were used to first establish the “access zip codes”. 

1. Two surveillance data sets –a syndromic surveillance dataset that area laboratories submitted to the Centers for Disease Control and Prevention (CDC) that included positive COVID tests in the Houston area daily and the Houston Electronic Disease Surveillance System (HEDSS) – were examined and mapped at the zip code level. 

2. 80 zip codes common in both datasets were identified as having low testing penetration. This list was further filtered to include only zip codes with at least 30% of the population residing in the COH, resulting in 35 zip codes.  

3. These 35 zip codes were prioritized into three tiers – Tier 1, 2, and 3 based low testing levels – and were coded as red, yellow, and green. Only red and yellow tiered zip codes were included in the final “access zip codes” group due to being far less than the baseline minimum of 5 tests for 1000 population.  

Next, “equity zip codes” were established in two steps. 

1. Existing data identifying neighborhoods with the risk of poor outcomes from a COVID infection was reviewed. A report developed by Dr. Stephen Linder from the UT School of Public Health was used to identify 31 zip codes that have 30% or more of its population in the COH and whose residents have vulnerabilities (60+ years of age, cardiovascular disease and/or respiratory illnesses, etc.) and would be more likely to experience poor outcomes in terms of disease severity and the likelihood of cases requiring critical care.  

2. The poverty level of these 31 zips were examined. Poverty was used as a proxy for social, economic, and environmental disadvantage. Zip codes where 20% or more of the population live below the Federal Poverty Level were selected, and 20 zip codes were identified as “equity zip codes.” 

Finally, to locate the priority zip codes for testing, zip codes that met the criteria for both access and equity were reviewed. This yielded 11 zips codes that were included in the final “Priority One Zip Codes” list. These 11 zip codes were mapped and overlaid with the COH Council Districts.  

Phase 2 testing included A) fixed community-based testing sites, B) mobile testing teams that move among high positivity zip codes, C) special population strike teams for vulnerable groups (long-term care facilities, homeless shelters, etc.), D) at-home testing for other vulnerable populations (elderly, disabled, etc.), and also support of testing by healthcare partners at FQHCS, hospitals, and commercial sites. 

A) Fixed testing sites that were free and easily accessible were established. Some sites were run solely by the HHD and others were managed by other partner organizations. These fixed site were strategically placed throughout the city to ensure that all COH residents had access to a testing site within 5 miles of their residence.  

B) Mobile and Strike testing unit teams were established to meet testing needs. Mobile Teams offered testing based on location and geography and the need for disease containment using a data driven approach. Strike Teams offered testing in special populations or specific facilities.  

C) The Strike Team was informed by data from HEDSS  as well as data from the wastewater testing project. Routine testing of wastewater from high density geographic areas that have long-term care facilities, homeless shelters, and transitional care centers have informed the HHD of increasing or decreasing trend of infection in wastewater.  

D) At-Home testing was made available for homebound and disabled populations, including seniors, elderly, disabled, veterans, and recently incarcerated individuals.  

Eleven (11) Priority One Zip Codes for testing were established in Phase 1. By the end of July 2020, baseline level of testing (5 per 1000 population) was achieved in each of the COH zip codes. The Centers for Disease Control (CDC) recommended that jurisdictions reach a minimum testing level of 2% of their population per month. As testing continued, the level of testing was reached more than 2% of the population in each zip code. During Phase 1, the total number of tests done in Houston (based on HEDSS data) was 282,661, with HHD completing 184,842 of these tests – almost 65% of all tests done in Houston. As of December 21, 2020, a cumulative total of 892,231 tests have been completed in Houston, with HHD completing 602,210 of these tests – almost 67% of all tests done in Houston.  

This data driven, strategic approach used to establish a city-wide testing plan ensured that COH residents had a baseline level of access to testing and that testing was equitable based on vulnerability. 

 In response to the  COVID-19 pandemic, multiple testing options were made available to meet the needs of the City’s diverse population.  

The initial Phase 1 COVID-19 testing strategy for the COH were supported by two key concepts – access and equity. “Access zip codes” and “equity zip codes” were established to help create the final priority zip codes.  

The Phase 1 strategy had two primary goals: 1) establish a minimum baseline testing rate of 5 per 1000 population for all zip codes within the COH; and 2) make testing available to vulnerable populations. The initial baseline level of testing for all zip codes had a goal of 0.5%. 

The Phase 2 strategy’s primary goal was to increase widespread access to testing based on weekly positivity rates. 

Phase 1 required the identification of “Access Zip Codes” (areas with lowest testing penetration) and “Equity Zip Codes” (areas with vulnerable populations at greater risk for poorer health outcomes in terms of disease severity and likelihood of cases requiring critical care). The cross-section of these two groups were used to establish “Priority One Zip Codes”. The HHD, with testing partners, focused on setting up testing sites in these Priority One Zip Code areas during Phase 1. Once the Phase 1 level testing rate was achieved, the HHD moved to widespread access to testing based on weekly positivity rates. Phase 2 testing included fixed community-based testing sites, mobile testing that moves to high positivity zip codes, special population strike teams for vulnerable groups (long-term care facilities, homeless shelters, etc.), at-home testing for other vulnerable populations (elderly, disabled, etc.), and also support of testing by healthcare partners at FQHCS, hospitals, and commercial clinics. 

Three steps were used to first establish the “access zip codes”. 

Two surveillance data sets –a syndromic surveillance dataset that area laboratories submitted to the Centers for Disease Control and Prevention (CDC) that included positive COVID tests in the Houston area daily and the Houston Electronic Disease Surveillance System (HEDSS) – were examined and mapped at the zip code level. 

80 zip codes common in both datasets were identified as having low testing penetration. This list was further filtered to include only zip codes with at least 30% of the population residing in the COH, resulting in 35 zip codes.  

These 35 zip codes were prioritized into three tiers – Tier 1, 2, and 3 based low testing levels – and were coded as red, yellow, and green. Only red and yellow tiered zip codes were included in the final “access zip codes” group due to being far less than the baseline minimum of 5 tests for 1000 population.  

Next, “equity zip codes” were established in two steps. 

Existing data identifying neighborhoods with the risk of poor outcomes from a COVID infection was reviewed. A report developed by Dr. Stephen Linder from the UT School of Public Health was used to identify 31 zip codes that have 30% or more of its population in the COH and whose residents have vulnerabilities (60+ years of age, cardiovascular disease and/or respiratory illnesses, etc.) and would be more likely to experience poor outcomes in terms of disease severity and the likelihood of cases requiring critical care.  

The poverty level of these 31 zips were examined. Poverty was used as a proxy for social, economic, and environmental disadvantage. Zip codes where 20% or more of the population live below the Federal Poverty Level were selected, and 20 zip codes were identified as “equity zip codes.” 

Finally, to locate the priority zip codes for testing, zip codes that met the criteria for both access and equity were reviewed. This yielded 11 zips codes that were included in the final “Priority One Zip Codes” list. These 11 zip codes were mapped and overlaid with the COH Council Districts.  

Phase 2 testing included fixed community-based testing sites, mobile testing that moves to high positivity zip codes, special population strike teams for vulnerable groups (long-term care facilities, homeless shelters, etc.), at-home testing for other vulnerable populations (elderly, disabled, etc.), and also support of testing by healthcare partners at FQHCS, hospitals, and commercial 

Fixed testing sites that were free and easily accessible were established. Some sites were run solely by the HHD and others were managed by other partner organizations. These fixed site were strategically placed throughout the city to ensure that all COH residents had access to a testing site within 5 miles of their residence.  

Mobile and Strike testing unit teams were established to testing needs. Mobile Teams offered testing based on location and geography and the need for disease containment using a data driven approach. Strike Teams offered testing in special populations or specific facilities. The Strike Team was informed by data from HEDSS as well as data from the wastewater testing treatment plant project. Routine weekly testing of wastewater by HHD, in collaboration with academic partners, from geographic areas that have congregate settings such as long-term care facilities, homeless shelters, and transitional care centers have informed the HHD of increasing or decreasing trend of infection from wastewater testing.  

At-Home testing was made available for homebound and disabled populations, including seniors, elderly, disabled, veterans, and recently incarcerated individuals.  

This data drive, strategic approach used to establish a city-wide testing plan ensured that COH residents had a baseline level of access to testing and that testing was equitable based on vulnerability. 

Availability of syndromic surveillance data and collaborative reports developed by others in public health was essential in using this tiered approach to developing a priority testing plan. Flexible and cooperative partnerships with other testing organizations has also helped insured an equitable access to testing locations for the COH residents. 

The initial Phase 1 COVID-19 testing strategy for the COH were supported by two key concepts – access and equity. The approach to reflect an intersection of access and equity used a data driven strategy using zip code level information about testing site locations and positivity rates, as well as economic disadvantage and poor health outcomes. The Phase 2 testing strategy implemented looked at widespread access to testing as determined by positivity rates. 

Analysts/epidemiologists throughout the department have been re-assigned to support COVID-19 response as their primary duty, and additional analytic support were hired using CARES funding. An internal dashboard was developed to help monitor key indicators that would help to inform department operations. The HHD receives daily lab results via HEDSS.  Positivity rates are mapped by GIS analysts on a weekly and 5-week cumulative basis and waste-water testing analysis are completed on a weekly  basis. City-wide COVID-19 viral testing is monitored at a daily, weekly, and 5-week summative level, and adjustments to testing sites are made using these data points.   

The HHD adopted the CQI methodology. Feedback was sought from various stakeholders (community, leadership, council members, collaborative partners etc.) on how access to testing could be enhanced throughout the course of the pandemic. A Data to Action committee was formed internally to review the stakeholder feedback and made concrete recommendations on improvements. 

The HHD led the city in a data driven response to the pandemic community spread, using more than 40 data products and maps and leveraging existing and new partnerships with providers. Availability of syndromic surveillance data and collaborative reports developed by the HHD Team was essential in using this tiered approach to developing a priority testing plan. Flexible and cooperative partnerships with other testing organizations has also helped in identifying testing site locations to provide an equitable access to testing for the COH residents.  This is a continuing demonstration of real-life Public Health 3.0, in a large local health department.