Q&A: How Navajo Nation Dealt With COVID-19

The Navajo Nation occupies territory of more than 17 million acres in Arizona, Utah, and New Mexico. Its population is a mixture of urban dwellers and rural residents living far and wide, and often without running water, cell phones, or even electricity. The underlying health conditions of Native Americans have been well-documented and include diabetes, heart disease and alcoholism. So, when COVID-19 struck, Jonathan Iralu, MD, and his staff had to act fast in innovatively. Iralu is the Indian Health Service (IHS) Chief Clinical Consultant for Infectious Diseases at Gallup Indian Medical Center. The innovations included being one of the first healthcare facilities in the country to establish outdoor testing and screening, and even a tent for intubation. Iralu also had to convert 20 rooms at the medical center into negative pressure rooms in a hurry. “It’s extremely complicated…. I’m not an engineer, but I learned a little bit about engineering last few months.”

Infection Control Today®: Tell us a little more about the challenges you face and what you did about them?

Jonathan Iralu, MD: We live in a very rural part of the United States, but this facility itself is in what’s called a border town to the Navajo Nation. We serve both an urban population and we also serve a very rural population with folks who live far from the city and many of them do not have amenities like running water, cell phone access, in some cases, even electricity. So that’s the general situation here. We had no experience with COVID-19. Like almost everybody in the world, until around until March of 2020 when the infection exploded in this area, and we had to start from scratch and create a COVID care treatment program here in Gallup.

ICT®: Native American reservations along with long-term care facility seem to be the nexus of COVID-19 out. Why is that? I mean speaking here about Native American reservations.

Iralu: That’s a very, very good dish question. One, we know that the virus arrived in this general region through folks traveling from urban areas back to rural areas. And it appears that it initially affected a group of people attending a church conference. And we know that anywhere in the world when there are people coming together in congregate settings, whether they be schools, churches, indoor sporting events, or eating places, those are high-risk situations. We think that a lot of the spread initially started in those kind of events. Later on, we saw spread through family units. If a family lives even in a remote place, if they have multiple people living in the same home, it’s very easy for everybody in that family to be affected with the virus.

ICT®: Can you tell us a little bit about the challenges that you faced?

Iralu: Number one, just the facility issues. This is an older building. Roughly 60 years old, and it was necessary early on to make it a safe place to handle COVID to keep staff safe, keep the patients safe. We initially, very early on, started to do outdoor testing under the portico so that people could drive up to a covered area to be protected from rain and to get swabbed right in their car. We were one of the first to do that in our state. In addition, we created an outdoor triage area. Folks who are coming in with possible or probable COVID could get screened outdoors in tents and could be managed safely in a respiratory care unit where they could get immediate care by expert emergency room physicians. And we even set up a tent where you could do an outdoor code or intubation. This allowed us to take care of people outside of the building and for everything from just somebody coming in with the sniffles to someone who has respiratory failure and needs to go on a ventilator. That was an innovation we had to make really fast at the very beginning. We also made some upgrades to the hospital facility itself, turning certain rooms into negative airflow rooms to make them safer. We turned some old office space into hospital beds. This facility required a lot of upgrading.

ICT®: How to you go about turning 20 rooms in the negative pressure rooms?

Iralu: It’s extremely complicated. You have to seal up some of the ductwork on the sides of the rooms because in the old days, you’d have pipes going through the walls or through the ceiling that are not sealed. See each room is contiguous in airflow with all the rooms and an entire word so you have to seal up those holes. And the engineers also have to do things like punch holes in the windows, connect a HEPA air filter fan to blow air out at a rate faster than the air is being pumped into the room by the air conditioner. I’m not an engineer, but I learned a little bit about engineering last few months.

ICT®: Some sections of the healthcare system have been accused—perhaps unjustly—of acting too slow when COVID-19 arrived. It seems as if you didn’t miss a beat.

Iralu: We read the reports coming out of Wuhan, China. And we were very concerned. We thought that we were in a rural place. And we were worried that the referral hospitals in the big city might possibly become filled. And we would not be able to transfer sick patients to places like Albuquerque or Flagstaff. We wanted to be prepared so that we could handle patients here in Gallup and on Navajo. We’re trying to be prepared so that we could handle patients with COVID here.

ICT®: How do you measure success?

Iralu: You measure success when you start to see a decline in the incidence of COVID. First we talked about the building obviously to take care of the acutely ill people you need. You need that. But you also need to do contact investigation and case management. On Navajo, there’s a group led by Doctor Sonya Shin and Doctor Jill Moses who are doing contact tracing and then case management. They look after folks after they’re discharged home from the hospital or from the emergency department. And a lot these involve people like public health nurses, tribal community health workers, etc. Working in collaborations. You have the Navajo Nation working with Indian Health Services, some of the non-federal sites to deliver care at remote places.

ICT®: There’s been some talk about the infection preventionist or infection prevention expertise migrating out of the hospital setting and into the community because the community needs help in trying to battle this. Do you think that that’s going to happen on a large scale throughout the country? Should it?

Iralu: I think it must. The inpatient COVID-19 population is simply the tip of the iceberg. For every case in the hospital, there are lots of cases out in the community and to actually stop a COVID-19 outbreak, you need to get rapid diagnosis. So that’s why you need to have lots and lots of rapid testing. We use an in-house PCR-based essay that allows us to have an answer within a couple of hours. And then when that result comes back positive, you have public health nurses jumping all over that making telephone calls. I need to mention another important component of local response to COVID-19. I mentioned that we are both a rural and an urban health care center. And in the urban setting, there are many people who are experiencing homelessness and we were very concerned early on that there could be spread in places like homeless shelters and also in places where persons who are experiencing homelessness may congregate in a really tight place like a motel or something like that. We early on a team of doctors, public health nurses, and many, many volunteers got together to create with the State of New Mexico, a set of four motels in the Gallup area where people could spend their time in isolation after they were diagnosed with COVID-19. They wouldn’t have to take COVID-19 back to one of the homeless shelters. And I think this was a really, really helpful way to stop the spread in that community. Because if you don’t stop spreading in that community, when those persons who are experiencing homelessness return back to a real site, they could bring the virus with them. The other thing we use the motels for were isolate; to provide quarantine for persons who were exposed, so that if they were to develop COVID-19, they wouldn’t bring it home to their family far away. The motels were a local innovation that worked really well for this particular population.

ICT®: Did being on the Navajo Nation reservation give you a certain amount of freedom to act and react that possibly isn’t found in other places in the country?

Iralu: We are the Indian Health Service. We’re part of the US public health service. We have a mandate to take care of individual patients. We also have a huge mandate to take care of the entire population. We work as both primary care providers, and as public health workers. We have to stop outbreaks and we have to do it ourselves. We also have a very long tradition of collaboration with the tribe and with the state health department. We already have these automatic meetings now, For instance, for the disease tuberculosis, this past week I had teleconferences to work with two states and with the Navajo Nation Department of Health to address tuberculosis infection here. We’ve been working together as a team really tightly for decades. This is nothing new for us. It was simple to create collaborations when you’ve already been working together for a while. We’ve dealt with small outbreaks, not a pandemic, but we were, in a sense, prepped to deal with the pandemic because we have had experience working with outbreaks. Things like tuberculosis. There’s an endemic condition that’s present in rural places called hantavirus pulmonary syndrome. We were used to collaborating with the state and the tribe on these other conditions. For COVID-19, we didn’t have to reinvent the wheel when this new virus came.

ICT®: Do you think the worst is over?

Iralu: That’s the that's the million-dollar question, isn’t it? We know from other parts of the world that you can get really great control and then you can see secondary waves in the future. We are preparing for the worst. We are concerned about the influenza season that will come up later this year. It will be very challenging. Right up front, let’s say the drive-up test site or in the emergency department triage line to tell immediately who has influenza who has COVID-19. We anticipate that that will be a problem. We’d like to diminish the amount of influenza by vaccinating the whole population. But if your primary care clinics are shut down because of COVID-19, it’s hard to get the flu vaccine out so we’re trying to come up with novel ways to get the vaccine out to people. Influenza is an issue. School openings are an issue. And those are the two things that are in my mind right now. That we have to look out for.

ICT®: Are you for or against the opening of the schools?

Iralu: I see plus and minuses on both sides and I don’t have a strong opinion. I am interested to see what happens over the next week or two in some places. In a sense, we’re learning this on the fly. We’re learning about the epidemiology of COVID and how to prevent it as we go along.

ICT®: My audience comprises infection preventionist, among other healthcare professionals. Any final words of advice in terms of what you’ve experienced and what they can learn from what you experienced?

Iralu: I think making sure that your infrastructure for your facility is in good shape with the opportunity to have plenty of airborne isolation rooms is a good idea, especially if they're aerosol generating procedures that are going to go on. Make sure that you have excellent PPE. That’s the way to keep staff safe. And follow the CDC guidelines on quarantining if staff are exposed. Those are really important things to do. Be very well attuned to what’s going on in the community and to connect with public health officials from the city, county or state; wherever your jurisdiction is. Just hospital facilities ought to be working really closely with the local public health experts.

This interview has been edited for clarity and length.