hen the COVID-19 pandemic first began, cities and states across the nation were scrambling for everything from information and general guidance to personal protective equipment and testing kits. As it continues to spread, more and more importance has been placed on testing as a way to both identify those with COVID-19 and to begin the contact tracing process.

Despite its size and the fact that many cities and villages are in remote locations, Alaska has excelled at implementing a testing protocol and making it accessible to the public. There are 175 testing offices throughout the state—from single sites in villages such as Ninilchik, Elim, and Unalakleet to roughly two dozen sites within the city of Anchorage. Working together, everyone from the Department of Health & Social Services (DHSS) to municipalities, tribal health services, hospitals, and drug stores have stepped in to make sure that testing is easy and available to those who need it.

“I am very proud of the work we have done together, from our healthcare partners to DHSS and others,” says Audrey Gray, lead public information officer of the Anchorage Emergency Operations Center. “We are a well-tested community, which is assisting us in identifying cases early to prevent further spread of COVID-19 in our community.”

The state has been so effective, in fact, that it was featured in a September 2020 Wall Street Journal article touting it as one of the most comprehensive COVID-19 testing operations in the nation.

While no one could have predicted how fast the virus would spread across the world and particularly across the nation, DHSS and its community partners geared up early to get testing sites operational.

“In the very beginning, the state was the only entity that had tests; they received the tests from the CDC, and they did all of the specimen testing at their Fairbanks and Anchorage labs,” says Michael Bernstein, chief medical officer of Providence Health & Services Alaska. “Not long after, a number of commercial labs in the US developed their own tests, and we were able to get some of those at hospitals that had testing equipment.

“Initially, the only way to get access to a test was to go to our emergency room, but we realized very quickly as we began seeing more people who needed tests that it was a very poor use of our ER,” he continues. “We were getting overwhelmed.”

Providence, which is the largest healthcare provider in the state, was contacted by Dr. Anne Zink, DHSS’ chief medical officer, who asked about the feasibility of setting up a drive-through testing center on hospital-owned property that was not currently in use.

“We quickly did some remodeling and established a drive-through, and for a period of time, we were the only drive-through center,” says Bernstein, adding that the state then encouraged other areas to establish similar sites. “As far as organizing and funding, at first we did it ourselves. We had partnerships with Alaska Regional Hospital and Alaska Native Medical Center because they didn’t have testing sites yet, so they put a couple of their people permanently at our site to enter patient information into their own medical records.”

Once the site became even busier, the municipality stepped in to help out. “After seeing the large public response to the testing site, the Municipality of Anchorage [MOA] put out an Invitation to Bid for more testing sites, which was awarded to Visit Healthcare,” says Gray, adding that MOA then began to focus on areas of town that were medically underserved.

Anchorage is home to seven municipally funded COVID-19 testing sites and a DHSS site at the airport, as well as several privately owned testing sites within healthcare facilities. To create a testing site, Visit Healthcare uses a portable system, including a durable, all-weather tent, that can be set up and taken down each day and sanitized every night at the warehouse. With cold weather coming, testing staff will be housed in small, enclosed mobile buildings as well.

“Visit Healthcare has a team of employees for each site, and they also maintain a mobile team that goes to shelters and assisted living homes,” says Gray. “The warehouse has a logistics manager, office staff, and there is a main lead for the Anchorage operations.”

It takes a village to establish and run a test site—according to Gray, in Anchorage this includes the MOA for contracting, oversight, and some public information; the Alaska Public Health Laboratory and a laboratory in the Lower 48 for running tests; the Alaska State Epidemiology Office for reporting testing outcomes; MOA Traffic and Engineering for traffic patterns at the sites; and contractors who are doing the work.

According to the CDC, there are two types of tests available for COVID-19: viral tests, which tell individuals if they have a current infection, and antibody tests that tell them if they had a past infection. People who should get tested are those with symptoms of COVID-19; those who have had close contact (within 6 feet of an infected person for as little as 15 minutes in a 24-hour period) with someone confirmed to have COVID-19; and people who have been asked to or referred to get tested by healthcare providers or another health facility.

According to Gray, anyone can be tested at MOA sites, a policy that has changed significantly since the beginning of the COVID-19 response. “Initially it was only symptomatic people, then it expanded to high-risk contacts of positive cases, and then to everyone who desired a test,” she says, adding that testing is not recommended after being ill with COVID-19 because the dead virus can continue to shed from the body for many months after recovery.

To get tested, individuals need to pre-register and to check each site’s requirements. That information can be found on the DHSS COVID-19 website. It’s important to note that each site has different rules; some healthcare facilities only take their own patients; other sites may or may not require a medical referral; and some will not accept medical vouchers.

The actual testing process is simple; at the Lake Otis site on Providence’s property, once a person’s registration is verified, they receive instructions from a team member, who verifies their identity and then performs the test.

“Our sites are using the SARS COV-2 assay with both oral and nasal swabs, though if there are small children, they may do a nasal swab instead of an oral one if needed,” says Gray.

“The team members are personable and have even been known to sing Baby Shark to toddlers to make the swabbing process more comfortable,” she adds. “They also help alleviate fears of the children about the process.”

Once testing is complete, patients receive instructions about when they should expect their results and a follow-up email with instructions. If the test comes back positive, they will also receive a call from a nurse, as well as a follow-up call from public health.

“While it can take up to seven days to get results, people frequently get them in two to four days,” says Caleb Terpstra, manager of Providence Rehabilitation Services and Outpatient Pediatric Therapies, who serves as supervisor of the Lake Otis site.

He adds that those coming for drive-through testing can rest assured that it is a safe and efficient process.

“We are hyper-careful of the process and protecting the workers, and with more than 32,000 tests [performed] at the Lake Otis location, not one caregiver has been found to have gotten COVID-19 from this station,” says Terpstra, adding that patients remain in their cars and testers are fully outfitted in personal protective equipment.

“I’ve been really encouraged by the level of support that we’ve gotten from the state—even when we had supply chain shortages at the beginning, the municipality and the state really stepped up with help providing testing kits and supplies and answering questions,” he adds. “They are taking testing very seriously, and it gives me quite a bit of confidence that we’re doing it right in Alaska.”

As with any such endeavor, there was a learning curve at the beginning, and, as more is learned about COVID-19, testing sites are adapting to meet changes in CDC recommendations, as well as to make the process more comfortable for patients and testing staff.

“While having enough supplies was a real issue at the beginning, we’re not as worried about that now, though it is still a limited resource, so we need to be careful,” says Terpstra. “We have also expanded the scope of who we test; we’ve transitioned from only testing patients with symptoms to those who are asymptomatic but may need clearance for travel or work.”

He adds that recently the municipality has asked for testing to include more of the general population, most specifically those people in known high-risk categories.

While Providence staff originally worked at the Lake Otis site, it became necessary to find a replacement workforce so employees could go back to work inside the hospital. Providence has since contracted with Fairweather to provide staffing and has also switched from using its own EPIC electronic medical record system to register patients to a web application, called covidsecureapp.com, created by Capstone Clinic, which allows for advanced patient testing, notification, and observation tracking.

“Since the introduction of the app, which was developed in record time, we’re seeing wait times significantly reduced,” says Terpstra. The app also provides ways for patients to monitor symptoms, find testing sites, and keep track of their test results.

Having people in the field has allowed the state and health professionals to learn more about the needs of testing staff and Alaska residents.

“While running the drive-through clinic, we learned a lot more about how to keep the staff warm and what needed to be done to keep them protected from symptomatic people; we needed to put in more safety precautions to keep the staff safe,” explains Ashley Johnson, who manages the Lake Otis site and is a continuous improvement specialist for Providence Alaska Medical Center.

“There is also a lot of back-end processing that has to occur; a lot of work needs to be done ahead of time, and there’s a lot of work that happens after the patient leaves to make sure that everything is properly processed and prepared to be sent to the state for processing,” she adds.

People coming through the site also brought increased knowledge as it became apparent that there were gaps in the information they needed. “People had a lot of questions when they came to the site; for example, we realized that a lot of people didn’t know that they needed to quarantine afterwards,” says Johnson. “We learned as we went along the types of things that we needed to provide, like informational fliers, that went beyond testing.”

“Every day we made continuous improvements; every day brought something a little different, so we spent a lot of time observing and monitoring and constantly readjusting,” says Terpstra.

The one thing that they were not expecting, and were very relieved to see, was just how much support they received from the community.

“People had signs in their windows thanking us as heroes, and people dropped off food three or four times a day,” laughs Terpstra. “Our staff was worried about gaining weight! The community support was overwhelming—but in a good way.”

Unfortunately, as COVID-19 numbers have started to rise again in Alaska, this type of support is going to be required for the long-term.

“In the first 100 days, we did just under 10,000 tests, and since June 23, we’ve done an additional 23,000 tests, just at the Lake Otis site,” says Terpstra. “But in the past couple of weeks, we’ve been seeing daily averages going up, and now we’re averaging 300 to 350 tests per day.”

As of mid-October, the state had performed more than 634,000 tests with an average turnaround time of 2.6 days. Some people were being tested for the first time, while others required repeat testing.

“I think from a patient experience, things are going really, really well, and the fact that we’ve done this many tests without any of our staff getting sick tells me that we’re doing a quality job,” says Terpstra.

As things continue to change during the pandemic, Bernstein predicts that someday soon, there may be tests that people can take at home instead of having to visit testing sites.

“Looking toward the future—it’s hard to know the timing because these tests would need FDA approval—but someday soon COVID tests could be like the home pregnancy tests you buy in the drug store, and for $5 you’ll be able to test yourself at home to see if you have COVID,” he says, adding that there are already dozens of these types of tests in development.

In the meantime, Alaska’s testing sites will continue to provide safe, accessible testing to the people of the 49th State.