Abstract
Rural communities are often underserved by public health testing initiatives in Alabama. As part of the National Institutes of Health’s Rapid Acceleration of Diagnostics‒Underserved Populations initiative, the University of Alabama at Birmingham, along with community partners, sought to address this inequity in COVID-19 testing. We describe the participatory assessment, selection, and implementation phases of this project, which administered more than 23 000 COVID-19 tests throughout the state, including nearly 4000 tests among incarcerated populations. (Am J Public Health. 2022;112(10):1399–1403. https://doi.org/10.2105/AJPH.2022.306985)
Funded as part of the National Institutes of Health’s Rapid Acceleration of Diagnostics‒Underserved Populations initiative (RADx-UP),1 COVID Community-Engaged Testing in Alabama (COVID COMET AL) is a partnership between the University of Alabama at Birmingham (UAB) Center for AIDS Research and community partners, including ConnectionHealth, a community health worker (CHW) organization; Acclinate, an organization that promotes diversity within health care and clinical trials; and five Area Health Education Centers (AHEC) that are geographically distributed to serve rural communities in Alabama’s 67 counties.
Grounded in the Adopting and Demonstrating the Adaptation of Prevention Techniques (ADAPT) framework2 and informed by a precision public health approach,3 descriptive epidemiology was used to identify the rural counties most impacted by COVID-19 for prioritization of a testing intervention delivered locally by community partners. In addition to providing test kits and access to a centralized laboratory, the COVID COMET AL intervention included peer health advocates,4 CHWs,5 and venue-based testing6,7 deployed in local rural counties by AHEC and ConnectionHealth, with Acclinate providing communications and marketing support.
We planned to deploy the COVID COMET AL combination intervention program in six highly impacted rural Alabama counties in two successive waves of three counties each. As a community-engaged testing program, we adjusted this strategy in response to feedback from community partners, the Human Subjects Unit, and the Community and Scientific Advisory Board. In reviewing epidemiological data, these groups felt that the widespread impact of COVID-19 on all rural communities statewide was so substantial that the testing program should not be limited to only six of Alabama’s 67 counties.
Accordingly, the investigative team and community partners opted to leverage local resources and relationships to deploy the testing initiative across the entire state, while prioritizing rural counties most severely impacted by COVID-19 as determined by epidemiology. CHWs from the partner organizations, as well as nurses and other personnel in venues such as jails and schools that were working with AHEC, provided testing services. These testing services included Aptima polymerase chain reaction (PCR) testing8 with 48-hour return of results and Visby point-of-care PCR testing9 with on-site results in 30 minutes.
The overarching vision for the RADx-UP program is “one consortium of interlinked community-engaged research projects across the United States [working] to understand COVID-19 health disparities and to deploy implementation strategies to improve the reach, acceptance, uptake, and sustainability of COVID-19 testing.”10 As part of this consortium, the purpose of COVID COMET AL was to empower community partners to deploy testing and mitigation services in rural communities across Alabama that are disproportionately impacted by COVID-19 to attenuate intersectional health inequities.
From October 2020 through February 2022, testing was conducted in myriad rural community settings spearheaded by regional AHEC offices (Figure 1), with high uptake in rural jails, particularly with the point-of-care Visby PCR test (Figure 2). A total of 23 394 tests were conducted via COVID COMET AL, including 18 503 Aptima PCR tests and 4891 Visby point-of-care PCR tests. Using the definition from the Alabama Rural Health Association, we conducted 14 667 tests (62%) in rural counties.11 Tests were conducted in 55 of Alabama’s 67 counties, and they were sent to a central laboratory at the UAB Heersink School of Medicine for analysis. As part of standard COVID-19 testing protocol, CHWs would collect participant demographic data via a standardized form to submit with each test.
FIGURE 1— COVID COMET AL Testing Density in Alabama: October 2020‒February 2022
FIGURE 2— COVID COMET AL Testing Numbers and Percent Positivity in Alabama: October 2020‒February 2022
Note. COVID COMET AL = COVID Community-Engaged Testing in Alabama.
Of the total, 12% (n = 2708) returned positive results, while 88% (n = 20 632) were negative. We were unable to analyze less than 1% (n = 54) of tests. Of those individuals tested, 54% (n = 12 701) were Black, 35% (n = 8104) were White, 5% (n = 1283) were Hispanic, 2% (n = 578) were Asian, and less than 1% (n = 12) were American Indian or Alaskan Native or Native Hawaiian or other Pacific Islander. Less than 1% (n = 195) identified as “some other race,” and we did not capture racial data for 2% (n = 521) of tests. As a note, following reporting guidance from the US Centers for Disease Control and Prevention, “Hispanic” was captured as a racial, instead of an ethnic, category.
Fifty-three percent (n = 12 505) of those tested identified as female, and 45% (n = 10 492) identified as male. Less than 1% (n = 10) identified as another gender, and we were unable to capture gender data for 2% (n = 387) of those tested. Nearly 13% (n = 2992) of those tested were minors (aged < 18 years), 36% (n = 8331) were aged between 18 and 40 years, 39% (n = 9031) were aged between 41 and 65 years, 12% (n = 2841) were aged between 66 and 85 years, and nearly 1% (n = 198) were aged older than 85 years. We were unable to capture the age of one participant.
Leveraging local partnerships within each AHEC service area, the COVID COMET AL team was consistently able to provide testing services within jails and other congregate living facilities throughout the state. The team conducted 3852 tests in jails, 11% (n = 382) of which were positive. The majority of these tests were the Visby point-of-care PCR test (n = 3168), which allowed jails to test new inmates for COVID-19 and receive results in 30 minutes, obviating the need for mandatory isolation in the case of a negative result and informing quarantine measures in a timely manner when indicated.
Notably, testing procedures established with AHEC community partners and their existing relationships with local entities in their catchment areas proved valuable in scaling up testing services to meet local demand in the face of the Delta and Omicron surges (Figure 2). Between July 25 and September 25, 2021, 669 people were tested weekly, on average, with a 13.9% average weekly positivity rate marking a significant increase in both testing volume and positivity rate (P < .01; 8.8% higher positivity rate; 95% confidence interval [CI] = 7.7%, 9.8%) during the Delta wave when compared with a weekly average of 137 tests and total positivity rate of 5.1% between October 2, 2020, and July 24, 2021. These numbers increased further during the Omicron wave, between December 25, 2021, and February 11, 2022, with a weekly average of 842 tests and a 25.8% positivity rate, reflecting a significant change from the baseline 5.1% positivity rate (P < .01; 20.7% higher positivity rate; 95% CI = 19.4%, 21.9%).
Although RADx-UP funding for direct testing services ended February 28, 2022, the COVID COMET AL infrastructure at UAB continues to support community partners providing community-based testing. Alabama AHEC provides ongoing COVID-19 testing in rural counties statewide via a multicomponent intervention strategy including peer health advocates, CHWs, and venue-based testing, largely funded by the Alabama Department of Public Health. The centralized UAB laboratory and the data management cores continue to provide services, including data reporting and visualization, for ongoing COVID-19 testing initiatives led by community partners. They plan to continue these roles indefinitely because AHEC continues to request them and because they bring value to other community partners.
We report on an academic‒community partnership funded via a federal initiative and adapted to meet local needs by providing 23 394 COVID-19 tests to Alabamians statewide. Notably, testing services reached several underserved populations, including individuals experiencing incarceration and people living in rural counties, who have not historically been reached by screening and testing initiatives for both communicable and noncommunicable diseases. Building upon these relationships and testing successes, the UAB Center for AIDS Research is pursuing opportunities to provide testing services for sexually transmitted infections, including HIV, and vaccine-preventable diseases, like influenza, to rural Alabamians facing intersectional inequities. The inroads made with local rural jails hold the potential to broaden public health screening and prevention programs for a largely underreached population, a promising legacy of the COVID COMET AL project.
ACKNOWLEDGMENTS
COVID Community-Engaged Testing in Alabama (COVID COMET AL) is part of Rapid Acceleration of Diagnostics–Underserved Populations, a National Institutes of Health‒funded initiative to increase access to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing among vulnerable populations. COVID COMET AL’s National Institutes of Health award is a supplement to the University of Alabama at Birmingham Center for AIDS Research, 3P30AI027767-33S1.
The COVID COMET AL team would like to acknowledge its community partners on this project—specifically, the Alabama Area Health Education Centers, the Alabama Quality Management Group, ConnectionHealth, and Acclinate. In addition, the team would like to thank its Human Subject Unit and its Community and Scientific Advisory Board for providing guidance to ensure this project was ethical, culturally competent, and scientifically robust.
CONFLICTS OF INTEREST
All authors report no conflicts of interest.
HUMAN PARTICIPANT PROTECTION
This project received expedited approval from the institutional review board at the University of Alabama at Birmingham, protocol number IRB-300006055, on September 16, 2020.
