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The Hopi Tribe, comprising 12 rural villages in the mesas of northeastern Arizona, designed a public health protocol that successfully curbed COVID-19 on the reservation.

From April to June, the Hopi were hit hard, with 10-15 new cases per day at one point, in a population of just 7,500. Overall, 136 tribe members developed COVID-19 with 27 hospitalized through June 15, reported Rachel M. Burke, PhD, of the CDC COVID-19 Response Team, and colleagues.

At least in part, the outbreak was complicated by delays in seeking care and testing; mask-wearing and social distancing was low; and education regarding when to quarantine and isolate was lacking, Burke and colleagues determined.

In response, the Hopi Tribe Department of Health and Human Services (DHHS) partnered with the Hopi Health Care Center and the CDC to deploy a team of community health workers to every household in two villages with high case counts, Oraibi and Bacabi. Community health representatives went door to door, tested exposed individuals, and provided educational materials to families -- all within 5 hours, the researchers wrote in the agency's .

In the initial canvassing, five two-person teams visited 101 households and interviewed 259 people across the two villages. Just 5% declined screening, and 54% of individuals were screened for COVID-19, of which 4 were referred for testing. The process was repeated across all villages such that each was canvassed at least once between July and October.

Community health representatives also recorded interviews with Hopi residents who contracted COVID-19 and included their testimonies in flyers dispersed in the community, as well as radio segments that aired on local stations, said co-author Duane Humeyestewa, MBA, executive advisor to the Hopi Tribe's office of the chairman.

"What it really came down to was engaging the community so they could follow all the measures put in place," Humeyestewa told 名媛直播. "Everyone needed to respect everyone else in the community by masking, following the guidelines, and showcasing they acknowledged this thing was impacting the community."

Team members and tribal representatives felt the program was successful enough to be developed further, according to their MMWR report. "[R]esources will be sought to expand the program to canvas villages on a more frequent basis," Burke and colleagues wrote. "Additional potential modifications to the program include streamlining the household interview and distributing masks," as well as an evaluation to determine how much impact it has had.

American Indian and Alaska Natives (AI/AN) are disproportionately burdened by COVID-19, with an than white people. Higher rates of heart disease, obesity, and diabetes among AI/AN populations contribute to this disproportionate disease burden, but much of it is due to longstanding health inequities that have isolated many tribes from the resources they need to prevent the virus from spreading.

Many tribal members living on reservations lack access to running water, electricity, or internet. On the Hopi reservation, it's common for up to six people from multiple generations to be living together in small dwellings, said co-author Royce Jenkins, DHHS director.

"We have limited resources and because we live out in the middle of nowhere, broadband and internet and communication are very limited," Jenkins told 名媛直播. "We can't have people work from home because they don't have the necessary resources."

The Hopi reservation is surrounded by the Navajo Nation, which dominated headlines in May for having the highest per capita rate of positive COVID-19 cases in the country. After the state of Arizona initiated a phased reopening in the summer, cases started to rise in surrounding areas, inevitably affecting the Hopi, Humeyestewa said.

"It's really challenging because community members have to drive through the Navajo Nation to get to essential services and grocery stores," Humeyestewa said. "Those hotspots are brewing around Hopi again."

Cases and hospitalizations among the Hopi have indeed spiked again in the past month. Since the pandemic began, there have been 429 cumulative cases. Following the initial outbreak in April to June, there was another peak in July and August and then a period of no new cases. But in the past 14 days, 29 active COVID-19 cases were diagnosed, Jenkins said.

Although the staff canvassing across the villages travel with personal protective equipment (PPE), there have also been cases among canvassing community health workers, Jenkins said.

As the winter approaches, the Hopi tribe faces cold temperatures that will force them to stay inside more, potentially contributing to the spread. Co-occurring influenza is also a concern.

The mental health burden of losing tribal members to COVID-19 and being isolated from the rest of the community is also exacerbated in the winter months, Humeyestewa said. From week to week, the Hopi tribe hosts ceremonies based on the lunar cycles, where families share food and personal items. With social distancing measures in place, these ceremonies become impossible.

"People are feeling a certain kind of loss," Humeyestewa said. "They are spiritually connected to those cycles. People sustain their lives on that."

This year's harvest, typically reaping squash, beans, and corn grown in the mesas, was not as plentiful as years prior due to droughts. In a subsistence farming community, not being able to share the harvest with an already limited supply of food is a real issue, Humeyestewa said.

"It means people have to go out into the community grocery store and bring back food, versus what they have always done in the past, which is living on the harvests from the fall," Humeyestewa said.

The reservation's COVID-19 response emphasized sharing community stories to keep the tribe connected spiritually and emotionally while still promoting physical distancing.

The Hopi tribe was the first to coordinate with the CDC to build a surveillance program like this on reservation, but their best practices have since been shared with other tribes across the country, Humeyestewa said.

The DHHS was also able to hire an epidemiologist in September for work they usually had to contract out to other agencies or handle on their own, Jenkins said.

"If the program is expanded, it will be evaluated after 1 year of implementation according to predefined indicators for impact on COVID-19 case detection and community knowledge and practices," according to the agency.

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