COVID-19 Collaboration

Rollins and the state form partnership
for pandemic response

Emory's Rollins School of Public Health | Rollins Magazine | Fall 2020

Over the course of a week in July, Dr. Allison Chamberlain discussed how best to boost the state’s testing capacity with Georgia Department of Public Health Commissioner Dr. Kathleen E. Toomey, brainstormed new COVID-19 collaborations with district health directors, and provided guidance to the Metro Atlanta Chamber of Commerce.

Chamberlain, assistant professor of epidemiology, is leading a partnership between Rollins and the Georgia Department of Public Health (GDPH). Called the Emory COVID-19 Response Collaborative (ECRC), the partnership was established in early June to assist the state in its response to the COVID-19 pandemic.

Through ECRC, Rollins faculty, staff, and students support the state’s efforts in key areas of its response, including: helping plan and implement response efforts; mounting rapid-response teams to deal with outbreak hotspots; bolstering surveillance and research to better understand the epidemic in the state; and training a cadre of early-career epidemiologists to join the fight. “We were extremely thoughtful in how we crafted the mission of ECRC to be maximally helpful to the state’s health department,” says Chamberlain. “The goal is to strengthen their ability to respond by putting our skills into their service.”

The partnership is welcomed by state officials. “As Georgia continues to reopen commerce, travel, and social engagement, ensuring that the citizens of Georgia are kept safe from disease and death is a public/private responsibility,” says Toomey. “To be successful, there must be ample and accessible COVID-19 testing, extraordinary community engagement, and an ability to trace contacts of new COVID-19 cases in order to forestall resurgent outbreaks. Expanding academic partnerships among Georgia’s public health system, Rollins, and other Georgia-based schools of public health will benefit us now and in the future.”

The ECRC is funded by a $7.8 million gift from the Robert W. Woodruff Foundation.

Allison Chamberlain (left) leads the Emory COVID-19 Response Collaborative, through which Rollins faculty, staff, and students aid the Georgia Department of Public Health’s pandemic response.

Allison Chamberlain posing in downtown Atlanta in front of an office building with her hands crossed at her body.

Deciphering the data

A red background image with a star burst in the center.

Sarita Shah and Neel Gandhi sitting with their laptops in the porch and smiling at the camera.

Sarita Shah and Neel Gandhi have been working with the Fulton County Board of Health since the pandemic began, and they are now lending their expertise to the state. (Editor's note: Shah and Gandhi are married, which is why they were able to be photographed next to each other without masks and other protective gear.)

Chamberlain is leading ECRC’s planning and implementation efforts, coordinating where key Rollins faculty can best assist GDPH with its COVID-19 response, including case investigations and data analyses. In Fulton County, Drs. Neel Gandhi and Sarita Shah have been leading a team to do just this. Associate professors of epidemiology and global health, Gandhi and Shah are building off work they’ve been doing for more than a decade on the diagnosis, treatment, and prevention of tuberculosis to help support the Fulton County Board of Health (FCBOH) since the beginning of the pandemic.

“We are able to help county epidemiologists take the data a step further,” says Shah. “Our expertise is in combining applied epidemiology with epidemiologic methods to better understand what is going on in order to inform strategic decisions.”

That means being able to drill down beyond who has the virus to discover how they might have contracted it, what course their disease took, and what modifying factors might have influenced the severity of their response. For example, disparities in COVID-19 case rates and disease severity have been widely reported, with black Americans more likely to be hospitalized and die from COVID-19. Shah and Gandhi are helping the Fulton County epidemiology team look deeper, teasing out the impact of older age and chronic medical conditions to show that these differences persist even after factoring in other risk factors.

Their work evolves with the pandemic. They help FCBOH staff revise the data that is presented in the thrice-weekly epidemiologic reports shared with leadership and the public. Many of the questions asked when investigating cases that were relevant in February—such as, travel outside the United States—are not meaningful today. Other areas can be expanded. As case counts among younger adults increased throughout June and July, the Rollins team was able to look into more specifics of who is getting tested by age, gender, race, and ethnicity, and give a more complete picture of how the epidemic is evolving.

“In the past, we worked closely with the Department of Health or national Ministry of Health overseas on a much longer timescale when it comes to tuberculosis,” says Gandhi. “But with this work, we are adapting week to week, and sometimes day to day. We’re brainstorming constantly with the health department to see where we might want to focus next to have the greatest impact. Our amazing team of students and staff have been quick to adapt and pivot to what’s next.”

Upon discovering staff were having trouble reaching people who had tested positive for COVID-19 to conduct case interviews and elicit contacts, Gandhi and Shah took a closer look. “We knew anecdotally that we weren’t reaching everyone, but we needed to understand why,” says Shah. “One of the Rollins MPH students developed a simple log that the entire team filled in when making calls. That very simple analysis showed us we were only reaching about half of the people who tested positive, and we were not identifying many contacts from those we did reach. We found the main problem was we just were not reaching people by phone, either because they weren’t home or they weren’t answering their phones.”

GDPH has since developed a mass media campaign, “Answer the Call,” to explain the fundamentals of contact tracing and encourage people to answer their phones.

“We were told the campaign was further supported by some of the data we were able to provide,” says Shah. “Because we had evidence, not just anecdotes, the health department could better understand the scope of the challenge we were having with reaching people. That really encapsulates what we are trying to do—bringing together public health work with a quantitative component so that we can help improve the processes.”

Responding to outbreaks

In mid-April, health care officials in Hall County contacted Rollins seeking assistance with a small, fledgling outbreak of COVID-19 among the area’s mostly Hispanic poultry plant workers. They feared, given the close working conditions of the plants, a spark could become a flame overnight.

Within days, Dr. Jodie Guest, vice chair of the Department of Epidemiology, had assembled a team of eight Rollins epidemiology students who trekked an hour north of Atlanta and set up testing sites in parking lots outside of poultry plants. Clad in gowns, masks, and gloves, plastic face shields, and hairnets, the team tested scores of workers and their families. These testing events confirmed the team’s concerns.

“We had not been working in Hall County long before they started reporting the highest rates of COVID-19 in the state,” says Guest. “The large outbreaks in Albany were making the national news, but the situation was rapidly accelerating in Hall County. We were finding that 20 percent and 30 percent of the Hispanic individuals coming in to be tested were positive, while the rates in the non-Hispanic population we tested were closer to 5 percent.”

Reaching this population—rural, low-income, and largely Hispanic—with public health messages and services is a challenge, but one Guest knows well. She currently leads the Emory Farmworker Project in which health sciences students and faculty travel to South Georgia for several weeks each summer to provide free exams and treatment to the area’s migrant farm workers. Not having worked in Hall County before, Guest made fast connections with the Chamber of Commerce, the health care system, school systems, and the Hispanic COVID-19 Task Force. Guest and her team received unprecedented access to the community they were there to serve when they were invited to ride along in school buses delivering meals to students. “The team rode in the buses for two months, passing out masks and information pamphlets,” says Guest. “It gave us an entrée into the local families that we don’t normally get.”

Jodie Guest oversees the testing site. (Editor's note: Guest wore full PPE for testing. She took off her mask and face shield for the photographer.)

That first week riding these buses gave Guest and her team critical information to help guide their response. The workers’ living conditions were just as crowded as their working conditions. “We were driving into neighborhoods of two- and three-bedroom homes and I was thinking, ‘These are big homes,’” says Guest. “But then we saw that 15 or more people were living in each house. Living rooms had hammocks hanging from the ceiling.”

It was apparent many didn’t have the luxury to social-distance at home or at work. These observations helped Guest become part of the conversation to find alternative housing solutions, like recovery units inside neighborhoods staffed by local volunteers trained to provide care.

Guest’s work in Hall County provided invaluable lessons on how her Rollins team can best support health districts. Thanks to the formation of the ECRC, Guest and her team are working closely with other district health officials and community leaders to stand up additional testing sites. In early August, her team worked with the Macon health district and the city of Milledgeville to host a one-day testing event. “The Milledgeville mayor came, the fire department came, and most importantly, the community members came,” says Guest. “We were able to test over 260 people and assist our health department partners in the process. We hope to continue to offer that type of collaborative assistance wherever it’s needed.”

Photos below | Jodie Guest and her team of Rollins epidemiology students test poultry plant workers for COVID-19 in Hall County.

Jodie Guest wearing PPE and posing at the Gainesville Covid-19 test site.

Jodie Guest oversees the testing site. (Editor's note: Guest wore full PPE for testing. She took off her mask and face shield for the photographer.)

A of Rollins epidemiology students setting up the COVID-19 testing site.

Two female Rollins students obtaining a salvia sample from a young female in order to conduct a covid-19 test.

A young female rollins student testing a person's saliva for the covid-19 virus.

A male rollins student in PPE setting up a table for covid-19 testing.

two rollins students packaging up saliva to send off for testing.

Jodie Guest and 2 students are working together to package up saliva samples for covid 19 testing.

Two rollins students being filmed by a local news station conducting a covid-19 testing.

Painting the big picture

Though the pandemic has raged on for more than six months, health experts still lack a firm grasp of its scope. That’s because scientists are relying largely on data from testing sites, which don’t often attract people who may be asymptomatic or are wary of coming to get tested at all. Rollins researchers are conducting a nationally representative household survey to get beyond these limitations.

Dr. Patrick Sullivan, Charles Howard Candler Professor of Epidemiology, and Dr. Aaron Siegler, associate professor of behavioral, social, and health education sciences, are leading the NIH-funded survey that will send at-home COVID-19 test kits to some 14,500 homes nationwide; the first kits were mailed in late June, and all kits were distributed by the end of August. They will send kits to the same households in December and early 2021.

“The first phase will allow us to get a snapshot of COVID-19 in the US during the third quarter of 2020,” says Sullivan. “Since our sample is representative, we can infer how many people across the country are infected during that period, how many are asymptomatic, and how many have antibodies to the virus.”

Sullivan and his team are publishing the results as they come in. Building off the experience they gained creating AIDSVu and HepVu, online tools showing state- and county-level prevalence of disease, they recently launched CovidVu.org to share their findings.

Following up in December and early 2021 will allow the team to track the progress of the virus. How many new cases cropped up during each period? Where are new cases concentrated? Are particular groups or areas acquiring enough antibodies to give them herd immunity?

In the national study, Sullivan and Siegler are oversampling communities with more racial and ethnic minority residents; this will allow them to get an accurate understanding of the impact of COVID among black and Hispanic people. In seven states, including Georgia, they are also sending kits to thousands of additional households in order to gain a more detailed picture of the virus in those states. The Georgia survey is being funded by the Robert W. Woodruff Foudation.

The team’s ability to create at-home testing kits for COVID-19 grew out of its work in other areas. “We have been exploring home testing for HIV and other infectious disease for almost a decade,” says Siegler. “We’ve been able to develop systems that allow people to efficiently collect specimens at home to send back for testing. We just had to adapt those.”

The standard-of-care test for the virus that causes COVID-19 involves inserting a six-inch swab far into the nasal cavity. The test much be performed by a clinician in personal protection equipment (PPE), which rules out self-testing at home. The research team tested an alternative method, something akin to “a sturdier, fancier Q-tip,” said Sullivan. Participants just swab the inside of each nostril for about 30 seconds. The results were comparable to the more invasive test.

The kits also include an antibody test. Participants prick their finger with a lancet similar to those used to check blood sugar and then place a drop of blood on a special sheet of paper. The kit is then mailed back to Sullivan’s lab for processing. The entire process should take the recipient of the test less than 10 minutes.

“This whole process has been a great example of how public health practice and public health research can play off each other to move the ball down the field,” says Sullivan.

Patrick Sullivan, left, is smiling and holding a laptop. Aaron Siegler, right, is holding a Covid test kit and smiling at the camera.

Patrick Sullivan, left, and Aaron Siegler are conducting a nationally representive survey, using home-testing kits, to get a clear picture of the pandemic in the US. They are also mounting a Georgia-specific survey in conjunction with the GDPH. (Editor's note: Sullivan and Siegler were photographed separately in an emply lobby.)

Bolstering the epi workforce

Another seminal feature of the collaboration is the establishment of the Rollins COVID-19 Epidemiology Fellows program, a two-year service and training fellowship that aims to bolster Georgia’s epidemiologic capacity. The program will recruit recent MPH graduates to be placed as entry-level epidemiologists within one of the state’s 18 health districts or at the GDPH. The fellows will be immersed in hands-on applied epidemiology to aid their district’s COVID-19 response, but they’ll also be given additional support and training through the program.

“The training is geared to foster their creativity, confidence, and effectiveness as epidemiologists,” says Chamberlain. “My hope is that the program comes to be seen as a prestigious career booster, like the CDC’s EIS [Epidemic Intelligence Service]. Fellows who join know they will gain invaluable experience at the most fundamental level of public health, and at the same time they are boosting the capacity of the state’s public health districts.”

Foundations throughout the state have expressed interest and support in the fellowship, led by the R. Howard Dobbs Jr. Foundation, which has committed additional funding for the Coastal Georgia District.

Story by Martha McKenzie | Designed by Linda Dobson

Visualizing COVID-19 disparities

Although COVID-19 has swept across the entire country, its burden has not been spread equally. Some communities—particularly those with a large minority population—suffer high infection rates, hospitalizations, and deaths. To shine a light on the virus’s differential impact, Rollins researchers have developed the COVID-19 Health Equity Dashboard.

“Our goal was to go beyond describing COVID-19 incidence in communities. We wanted to fill in the gaps about the interplay between the health outcomes and the underlying social determinants,” says Dr. Shivani A. Patel, Rollins Assistant Professor of Global Health, who leads the team that developed the dashboard.

On the homepage, users can see a snapshot of COVID-19 deaths across the country. Selecting a state brings up a map displaying COVID-19 mortality by county. Drilling down, users can select a county to see how it compares to the rest of the state and to the country in average daily cases and deaths, and in social characteristics, such as percentage of residents who are African American, percentage who live in poverty, or percentage who are obese.

The dashboard also allows users to compare counties within the same state. For each state, dashboard users can select a COVID-19 outcome measure—total, average, or per-100,000 COVID-19 cases or deaths—and a social determinants measure—household income, population density, percentage African American, among others. The result is side-by-side color-coded maps that allow users to visualize the relationship between the virus’s health impact and social determinants of health at a county level.

Going forward, Patel and her team plan to parse that data into a sub-county level to see how communities within the country are being impacted differentially.

“We see this as an evolving resource for a variety of audiences, including policymakers, public health practitioners, and even clinicians,” says Patel. “This dashboard could help officials assess whether local response to COVID-19 is equitable across communities. It will provide quick access to data to decide where it’s feasible to open business back up and where it’s not. Where should testing sites be located?

“There is no one-size-fits-all approach to combat this pandemic,” Patel continues. “To predict how it will unfold and to prepare for the future, it’s critical to understand the underlying risk factors that lead to higher incidence and mortality.”