Since commercial testing first became available, AHD has focused resources on recruiting and supporting all interested Alexandria medical practices, urgent care centers, Inova Alexandria Hospital, and Neighborhood Health to expand COVID-19 testing. AHD has used multiple outreach methods (email, conference calls, blast-faxes, site visits) and has provided information (e.g. about federal reimbursement for testing patients without insurance), technical specimen-collection guidance, laboratory contacts, and training (including fit-testing for proper seals of respirators). Many healthcare providers stated that their inability to obtain personal protective equipment (PPE) had been a barrier to testing, as CDC recommendations and best practices require the proper use of PPE in order to prevent the transmission of the coronavirus from patients to healthcare providers.
In response to this stated barrier, AHD acquired PPE through multiple sources: Virginia Department of Health, Virginia Department of Emergency, Strategic National Stockpile, H1N1 Cache, and private donations. AHD distributed, through May 2020, the following quantities of PPE to Alexandria healthcare providers willing to conduct COVID-19 testing and to be publicly listed as doing so:

As of May 28, there are 11 testing sites within the City limits of Alexandria willing to be listed in a public format, available in four languages and updated every two weeks. (Note: there are additional practices that provide testing for their current patients; they have requested not to be listed publicly, as they do not have capacity to accept and test new patients). Among the publicly listed sites, more than half provide free testing for eligible patients. Additionally, there are two practices “just over the City border” at which Alexandrians obtain services and both of those practices provide free testing for those who are eligible.

Alexandria Health Department, working with the City’s Joint Information System, has developed numerous materials in different languages and formats highlighting where people can access testing on an ongoing basis. These materials have been distributed to other City agencies, Alexandria City Public Schools, faith-based organizations, and community partners. AHD and the JIS have also placed these materials across the City through signage, delivered information to every household through the mail, and distributed content directly to the most vulnerable residents through meal bags for low-income families. Community partners and residents have been encouraged to call the COVID-19 Hotline (703.746.4988) for assistance in locating a testing facility.

AHD has coordinated and facilitated testing in both targeted facility and neighborhood settings.

The facility settings—long-term care facilities (LTCFs), including both skilled nursing facilities and assisted living facilities, and group homes—are home to many of Alexandria’s most-at-risk for severe disease from COVID-19. These populations are most likely to need hospitalization, most likely to need an intensive care bed with a ventilator, and most likely to die due to their advanced age and/or underlying medical conditions. AHD has coordinated, facilitated and followed through with technical assistance a point prevalence survey (PPS) at all eight Alexandria LTCFs interested (one facility has declined). AHD has also conducted and facilitated testing at multiple. AHD’s focus on those most-at-risk for severe disease is congruent with a public health justice perspective.

To reach specific neighborhood settings, AHD and the City of Alexandria signed a Memorandum of Understanding with Neighborhood Health, a federally qualified health center and primary care home, to provide testing events across the City. This initiative is meant to reach people based on 1. Those who have underlying medical conditions, 2. Those experiencing social conditions that makes exposure more likely such as crowded housing or a job without sick leave, and 3. Epidemiological trends such as ZIP code positivity rates. As of September 2, there have been 7 events across Alexandria, serving around 100 people per event. Many of the participants have been uninsured residents who may not otherwise have been able to access free testing. AHD works with community partners to select and coordinate the testing site where Neighborhood Health and Medical Reserve Corps volunteers implement the tests.

Alexandria has a high rate of testing per 1,000 population (both before and after the 5/25 community testing events). The table below presents the testing per capita rate in the Northern Virginia jurisdictions. Alexandria has consistently had the second highest testing rate per capita in the region.

* Per 1,000 population (Sources: vdh.virginia.gov/coronavirus and census.gov/quickfacts)

Thus, Alexandrians are being tested at a comparable, or higher, rate than residents in other Northern Virginia jurisdictions through its existing medical infrastructure (medical practices, hospital and community health center).

On May 15, AHD was informed of a “turn-key” community testing opportunity through a Virginia Department of Emergency Management (VDEM) contract with MAKO laboratories. This VDEM-MAKO contract was available throughout the State, and other Northern Virginia health districts were offered the same opportunity during the first week of the contract implementation. AHD opted to conduct both of its community testing events on the same day in order to serve two different targeted communities simultaneously.

The purpose of the Alexandria Memorial Day testing events was to provide testing—and information for ongoing testing sources and community resources—to Alexandrians who might not have been able to access such services. Other Northern Virginia jurisdictions with open, community-wide testing from 10:00 am to 6:00 pm, experienced full capacity sometime 1:00-4:00 pm. This did not happen in either of Alexandria’s two events (neither at Landmark nor at Cora Kelly).

The below table summarizes the 5/25 Memorial Day testing events results

 * The contractor MAKO reported on May 25 that they had collected 2,980 tests but later corrected that to 2,953.

** ZIP Codes 22311 and 22312 are shared with Fairfax County. There were 296 attendees from these ZIP Codes at Landmark and 19 at Cora Kelly; based on AHD’s experience of approximately 50% of these ZIP Codes’ reportable diseases being Alexandrians, 148 of the Landmark attendees from 22311 and 22312 were assigned as Alexandrians and 10 of the Cora Kelly attendees from 22311 and 22312 were assigned as Alexandrians.

Of the 2,953 attendees at both events, less than two-thirds were Alexandrians; there was a higher percentage of attendees who were Alexandrians at the walk-in only event at Cora Kelly (67%) compared to the drive-in/walk-in event at Landmark (57%). Of the 236 who tested positive at both events, only 29% were Alexandrians; 43% of those who tested positive at the Cora Kelly event were Alexandrians while only 24% of the positives from the Landmark event were Alexandrians.

While the purpose of the Memorial Day testing events was to serve Alexandrians, more than one-third of participants were non-Alexandrians. This indicates a wide appeal by non-Alexandrians to attend Alexandria events. The low percentage of Alexandrians testing positive indicates that Alexandrians who have symptoms and desire testing are obtaining it through the Alexandria’s medical practices, urgent care centers, Inova Alexandria Hospital and Neighborhood Health.

Despite AHD’s repeated requests for demographic data collection and the inclusion of race, ethnicity, and symptom questions on the registration form, MAKO has not provided this information to AHD for analysis.

People receive test results for this specific point in time. However, they may be infected in between testing and receiving results, creating a false sense of security. Additionally, those without a doctor or medical home do not have the benefit of finding a regular source of care, which is essential for testing, and health conditions beyond COVID-19 issues.

Care should be available when a person is ready, not when it is convenient for local government staff.

Opportunities to be tested without symptoms can attract people who otherwise do have health insurance and medical home but “just want to know” if they have COVID-19. This may be a disservice to populations experiencing high positivity rates, specifically those living in crowded housing conditions or working in jobs without sick leave benefits.

During the 9 days from awareness to testing, AHD spent more than 400 hours in planning and preparation. This involved mostly 12 persons and the majority of the work fell on 5, who logged more than 50 hours each during the 9 days solely on this initiative (50-60-60-80-90 hours among the 5). The 12 carrying the greatest burden are in leadership roles in AHD’s ICS structure, as this work planning and preparation work for large events cannot be accomplished by others. During the community testing event preparation, AHD diverted resources from other community imperatives, and AHD did NOT conduct essential other functions, including recruitment, training and PPE deliver to physician practices, critical for Alexandria to maintain and enhance testing capacity; education, training and PPE delivery to LTCFs, where more than 50% of Alexandria’s COVID-19 related fatalities are occurring. Furthermore, following up on nearly 3,000 tests—most of which belong to other jurisdictions—is incredibly time consuming.

Additionally, the Alexandria Memorial Day testing events were incredibly time-consuming for the City of Alexandria’s Command Staff and Joint Information System teams, detracting from other COVID-19 response and recovery activities. 

Although there were up to 300 tests available for community members at the May 16 event, only 236 people were tested. This may be due to the extremely brief window that community partners (Tenants and Workers United, Casa Chirilagua, and Community Lodgings) had to recruit people for the appointment slots. However, there were also a number of no-shows for appointment slots, suggesting that demand is lower than previously expected.

While Neighborhood Health did not track how many attendees were Alexandria residents, their leadership estimate that “at least 80%” of attendees walked up to the event, indicating that they were Alexandria residents living in the neighborhood. Attendees who did not have an existing source of medical care had the option of immediately enrolling as Neighborhood Health patients on that day. Neighborhood Health followed up with all persons with positive test results to further ensure that everyone with COVID-19 would receive appropriate medical care. Alexandria Health Department followed up with persons with positive test results as well, as this is a reportable condition; AHD also followed up with persons with negative test results to explain the implications of the results.

There were several clear advantages of this targeted neighborhood strategy:

• Reaches a target community of those:
  • In ZIP Codes with a high testing positivity rate
  • In areas with low-income, low-wealth, over-crowded housing
  • Who have higher risk of severe COVID-19 disease due to underlying medical conditions
• Enables attendees who do not have an existing source of care to immediately enroll in a medical home
• Allows for more focused outreach, attracting Alexandria residents versus larger scale communications that can bring in people from other jurisdictions