Upon request from tribal nations, and as part of the Centers for Disease Control and Prevention's (CDC's) emergency response, CDC staff provided both remote and on-site assistance to tribes to plan, prepare, and respond to the COVID-19 pandemic. From April 2, 2020, through June 11, 2021, CDC deployed a total of 275 staff to assist 29 tribal nations. CDC staff typically collaborated in multiple work areas including epidemiology and surveillance (86%), contact tracing (76%), infection prevention control (72%), community mitigation (72%), health communication (66%), incident command structure (55%), emergency preparedness (38%), and worker safety (31%). We describe the activities of CDC staff in collaboration with 4 tribal nations, Northern Cheyenne, Hoopa Valley, Shoshone-Bannock, and Oglala Sioux Tribe, to combat COVID-19 and lessons learned from the engagement.

The Hopi Tribe is a sovereign nation home to ~7500 Hopi persons living primarily in 12 remote villages. The Hopi Tribe, like many other American Indian nations, has been disproportionately affected by COVID-19. On 18 May 2020, a team from the US Centers for Disease Control and Prevention (CDC) was deployed on the request of the tribe in response to increases in COVID-19 cases. Collaborating with Hopi Health Care Center (the reservation's federally run Indian Health Service health facility) and CDC, the Hopi strengthened public health systems and response capacity from May to August including: (1) implementing routine COVID-19 surveillance reporting; (2) establishing the Hopi Incident Management Authority for rapid coordination and implementation of response activities across partners; (3) implementing a community surveillance programme to facilitate early case detection and educate communities on COVID-19 prevention; and (4) applying innovative communication strategies to encourage mask wearing, hand hygiene and physical distancing. These efforts, as well as community adherence to mitigation measures, helped to drive down cases in August. As cases increased in September-November, the improved capacity gained during the first wave of the pandemic enabled the Hopi leadership to have real-time awareness of the changing epidemiological landscape. This prompted rapid response coordination, swift scale up of health communications and redeployment of the community surveillance programme. The Hopi experience in strengthening their public health systems to better confront COVID-19 may be informative to other indigenous peoples as they also respond to COVID-19 within the context of disproportionate burden.

The Hopi Tribe, a sovereign nation in northeastern Arizona, includes approximately 7,500 persons within 12 rural villages (1). During April 11–June 15, 2020, the Hopi Health Care Center (HHCC, an Indian Health Services facility) reported 136 cases of coronavirus disease 2019 (COVID-19) among Hopi residents; 27 (20%) patients required hospitalization (J Hirschman, MD, CDC, personal communication, June 2020). Contact tracing of Hopi COVID-19 cases identified delayed seeking of care and testing by persons experiencing COVID-19–compatible signs and symptoms*; inconsistent adherence to recommended mitigation measures,† such as mask-wearing and social distancing; and limited knowledge of the roles of testing, isolation, and quarantine procedures§ (2). Based on these findings, the Hopi Tribe Department of Health and Human Services (DHHS) collaborated with HHCC to develop a community-focused program to enhance COVID-19 surveillance and deliver systematic health communications to the communities. This report describes the surveillance program and findings from two field tests.¶

On June 3, 2020, a woman aged 73 years (patient A) with symptoms consistent with coronavirus disease 2019 (COVID-19) (1) was evaluated at the emergency department of the Hopi Health Care Center (HHCC, an Indian Health Services facility) and received a positive test result for SARS-CoV-2, the virus that causes COVID-19. The patient's symptoms commenced on May 27, and a sibling (patient B) of the patient experienced symptom onset the following day. On May 23, both patients had driven together and spent time in a retail store in Flagstaff, Arizona. Because of their similar exposures, symptom onset dates, and overlapping close contacts, these patients are referred to as co-index patients. The co-index patients had a total of 58 primary (i.e., direct) and secondary contacts (i.e., contacts of a primary contact); among these, 27 (47%) received positive SARS-CoV-2 test results. Four (15%) of the 27 contacts who became ill were household members of co-index patient B, 14 (52%) had attended family gatherings, one was a child who might have transmitted SARS-CoV-2 to six contacts, and eight (30%) were community members. Findings from the outbreak investigation prompted the HHCC and Hopi Tribe leadership to strengthen community education through community health representatives, public health nurses, and radio campaigns. In communities with similar extended family interaction, emphasizing safe ways to stay in touch, along with wearing a mask, frequent hand washing, and physical distancing might help limit the spread of disease.

Genome-wide association studies (GWAS) have mapped risk alleles for at least ten distinct cancers to a small region of 63,000 bp on chromosome 5p15.33. This region harbors the TERT and CLPTM1L genes; the former encodes the catalytic subunit of telomerase reverse transcriptase and the latter may play a role in apoptosis. To investigate further the genetic architecture of common susceptibility alleles in this region, we conducted an agnostic subset-based meta-analysis (ASSET) across six distinct cancers in 34,248 cases and 45,036 controls. Based on sequential conditional analysis, we identified as many as six independent risk loci marked by common single nucleotide polymorphisms (SNPs): five in the TERT gene (region 1: rs7726159, P=2.10x10-39; region 3: rs2853677, P=3.30x10-36 and PConditional=2.36x10-8; region 4: rs2736098, P=3.87x10-12 and PConditional=5.19x10-6, region 5: rs13172201, P=0.041 and PConditional=2.04x10-6; and region 6: rs10069690, P=7.49x10-15 and PConditional=5.35x10-7) and one in the neighboring CLPTM1L gene (region 2: rs451360; P=1.90x10-18 and PConditional=7.06x10-16). Between three and five cancers mapped to each independent locus with both risk-enhancing and protective effects. Allele specific effects on DNA methylation were seen for a subset of risk loci indicating that methylation and subsequent effects on gene expression may contribute to the biology of risk variants on 5p15.33. Our results provide strong support for extensive pleiotropy across this region of 5p15.33, to an extent not previously observed in other cancer susceptibility loci.

PROBLEM: Substantial racial/ethnic health disparities exist in the United States. Although the populations of racial and ethnic minorities are growing at a rapid pace, large-scale community-based surveys and surveillance systems designed to monitor the health status of minority populations are limited. CDC conducts the Racial and Ethnic Approaches to Community Health across the U.S. (REACH U.S.) Risk Factor Survey annually in minority communities. The survey focuses on black, Hispanic, Asian (including Native Hawaiian and Other Pacific Islander), and American Indian (AI) populations. REPORTING PERIOD COVERED: 2009. DESCRIPTION OF SYSTEM: An address-based sampling design was used in the survey in 28 communities located in 17 states (Arizona, California, Georgia, Hawaii, Illinois, Massachusetts, Michigan, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Virginia, West Virginia, and Washington). Self-reported data were collected through telephone, questionnaire mailing, and in-person interviews from an average of 900 residents aged ≥ 18 years in each community. Data from the community were compared with data derived from the Behavioral Risk Factor Surveillance System (BRFSS) for the metropolitan and micropolitan statistical area (MMSA), county, or state in which the community was located and also compared with national estimates. RESULTS: Reported education level and household income were markedly lower in black, Hispanic, and AI communities than that among the general population living in the comparison MMSA, county, or state. More residents in these minority populations did not have health-care coverage and did not see a doctor because of the cost. Substantial variations were identified in self-perceived health status and prevalence of selected chronic conditions among minority populations and among communities within the same racial/ethnic population. In 2009, the median percentage of men who reported fair or poor health was 15.8% (range: 8.3%-29.3%) among A/PI communities and 26.3% (range: 22.3%-30.8%) among AI communities. The median percentage of women who reported fair or poor health was 20.1% (range: 13.3%-37.2%) among A/PI communities, whereas it was 31.3% (range: 19.4%-44.2%) among Hispanic communities. AI and black communities had a high prevalence of self-reported hypertension, cardiovascular disease, and diabetes. For most communities, prevalence was much higher than that in the corresponding MMSA, county, or state in which the community was located. The median percentages of persons who knew the signs and symptoms of a heart attack and stroke were consistently lower in all four minority communities than the national median. Variations were identified among racial/ethnic populations in the use of preventive services. Hispanics had the lowest percentages of persons who had their cholesterol checked, of those with high blood pressure who were taking antihypertensive medication, and of those with diabetes who had a glycosylated hemoglobin (HbA1C) test in the past year. AIs had the lowest mammography screening rate within 2 years among women aged ≥40 years (median: 72.7%; range: 69.4%-76.2%). A/PIs had the lowest Pap smear screening rate within 3 years (median: 74.4%; range: 60.3%-80.8%). The median influenza vaccination rates in adults aged ≥65 years were much lower among black (57.3%) and Hispanic communities (63.3%) than the national median (70.1%) among the 50 states and DC. Pneumococcal vaccination rates also were lower in black (60.5%), Hispanic (58.5%), and A/PI (59.7%) communities than the national median (68.5%). INTERPRETATIONS: Data from the REACH U.S. Risk Factor Survey demonstrate that residents in most of the minority communities continue to have lower socioeconomic status, greater barriers to health-care access, and greater risks for and burden of disease compared with the general populations living in the same MMSA, county, or state. Substantial variations in prevalence of risk factors, chronic conditions, and use of preventive services among different minority populations and different communities within the same racial/ethnic population provide opportunities for public health intervention. These variations also indicate that different priorities are needed to eliminate health disparities for different communities. PUBLIC HEALTH ACTION: These community-level survey data are being used by CDC and community coalitions to implement, monitor, and evaluate intervention programs in each community. Continuous surveillance of health status in minority communities is necessary so that community-specific, culturally sensitive strategies that include system, environmental, and individual-level changes can be tailored to these communities.