Since 2016, 18 states have reported outbreaks of hepatitis A among people who use drugs and/or experience homelessness. Before these outbreaks began, the United States experienced an estimated 4000 cases of hepatitis A annually. These outbreaks have resulted in more than 15,000 cases and 8500 hospitalizations in just those 18 states. For various reasons associated with the characteristics of the at-risk populations, widespread transmission occurs soon after the first cases are reported.
In May 2017, an individual presented at a hospital in Salt Lake County, Utah, for routine follow-up. Staff caring for the patient noted the individual was jaundiced and decided to test the patient’s liver function for hepatitis. The patient was found to be suffering the effects of hepatitis A. Over the next 20 months, the Salt Lake County Health Department (SLCoHD) and other local health departments in Utah worked to address a hepatitis A (HAV) outbreak that ended up being the largest HAV outbreak in the state’s history, resulting in 281 confirmed cases and 2 deaths. Of those cases, 196 were in Salt Lake County. Prior to the outbreak, Salt Lake County averaged 3 cases of HAV each year.
An early case in Salt Lake County occurred in an individual who reported recent relocation from San Diego, California, which at the time was experiencing a known HAV outbreak. SLCoHD disease investigators contacted San Diego to learn more about their outbreak.
The factors associated with this outbreak were different than the usual HAV cases, and those differences made this outbreak more challenging to address. These differences included the identified at-risk groups (homeless and/or illicit drug users) and the mode of transmission (direct person-to-person rather than contaminated food products, though food contamination was still always a possibility).
The main challenge associated with this outbreak was that the at-risk populations were unlikely to seek help until they were very ill, and by that time many more individuals would be exposed. The at-risk populations were also distrustful of government, including public health, and communication with this population was challenging, as many of public health’s usual methods (mass media, worksites, social media, etc.) did not reach this group. Many affected individuals also had no address or phone number, or if they did, their contact with others in the population was casual so specifics were unknown.
To reach this population, SLCoHD sought to vaccinate individuals in jail, substance abuse treatment facilities, and homeless shelters, and to hold mass vaccination efforts (with incentives) at common gathering points for people experiencing homelessness. The health department soon realized many at-risk individuals were still not taking advantage of these opportunities to protect themselves.
The department began conducting “foot clinics,” where SLCoHD staff would visit areas of the community known to have homeless encampments and offer vaccines on-the-spot. Although this was effective, the effectiveness was not maximized until the department established a partnership with a local syringe exchange program that was well-known to the population. This partnership also assisted with the drug-using population that was not homeless, which helped the department gain access, trust, and contact information.
Another effort by SLCoHD targeted hygiene and fomite transmission. The department contacted nonprofits and churches offering meals to people experiencing homelessness and emphasized the importance of handwashing. Although the meal providers were sympathetic to the need, they had their own goal of quickly moving large numbers of individuals through meal lines, making mandatory handwashing a difficult option.
However, by working together, the department and providers adopted an alternative: To receive a meal, each individual had to present a meal ticket, which had previously been a laminated paper ticket reused repeatedly by multiple people. Under the alternative, the health department provided individually wrapped sanitizing hand wipes effective against HAV, and the empty hand-wipe packet became the individual’s meal ticket.
Another challenge associated with homelessness became apparent: After receiving treatment and meeting the standard for release, hospitals were releasing individuals even though they were still infectious. Whether they had housing arrangements or not, this was a problem as the risk of disease spread remained. The health department recognized that isolation was important until the infectious period passed but did not know how to accomplish that for people experiencing homelessness. With appropriate approvals and agreements, the department determined that infectious individuals would be housed in contracted motels after hospital release. The individuals were given incentives and meals with the understanding they were to remain isolated with no visitors. Although this strategy was not successful in every situation, it did prove to be a valuable strategy.
SLCoHD learned many lessons from this experience; most importantly, that our usual response strategies that have been employed successfully at other times may not work in every situation. Public health needs to continually evaluate situations to assure we are reaching the desired outcome and, if not, must be nimble to allow for creative and nontraditional approaches. We can help facilitate nimbleness by proactively developing trusted partnerships (often nontraditional partnerships) before these events occur.
Gary L. Edwards is executive director of the Salt Lake County Health Department. Mr. Edwards has worked in public health for over 35 years.
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