Outbreak & Response
When a viral outbreak occurs, an area’s homeless population is often considered a lesser priority in containment strategies and community responses, if considered at all. In 2017, San Diego had the largest outbreak of hepatitis A in modern history. Hepatitis A thrives in warmer temperatures and San Diego’s homeless population, an already at-risk population, was infected at a significantly higher rate than previously found in the US. The disease had already caused several mortalities, a rare occurrence as hepatitis A is largely self-limiting and does not typically result in chronic infection. This made the San Diego case exceptional. Over the course of the outbreak, 589 individuals had been infected, resulting in 20 deaths. In response to the initial state of emergency announcement, County health officials provided free vaccinations to the public and boosted prevention measures to contain the disease’s spread. The Cloudburst Group supported San Diego County to provide technical assistance for at-risk communities.
Cloudburst helped to identify the extent of the epidemic among the homeless population, then worked with the whole community—from county and city leaders to Continuum of Care leaders, providers, and businesses—to deploy a range of prevention strategies and contain the outbreak. The concentrated effort played a critical role in the epidemic ending sooner than expected, preventing further loss of life among the homeless population. This community-aligned strategy included: getting the unsheltered homeless into housing, providing access to sanitation stations, retooling the street cleaning solutions, and launching a vaccine campaign.
San Diego County health officials in coordination with technical assistance providers, including Cloudburst were able to collectively contain the outbreak, and in January 2018 the local health emergency notice was lifted. By the end of the outbreak, 203,000 hepatitis A vaccines were administered by the San Diego Health Department.
The hepatitis A outbreak in San Diego demonstrates the importance of following best practices for the prevention of viral diseases and how preventative measures can be targeted specifically to help homeless populations. The following are some of the key considerations when working with homeless populations during an outbreak of hepatitis A.
All persons in high risk groups should be vaccinated—including persons experiencing homelessness—and vaccines should be offered at all points of engagement. However, it is difficult to engage this population, especially outside of an emergency room setting where these individuals often receive healthcare. Targeted street-based outreach workers and mobile van units serving high-risk populations can help to reach homeless individuals and should be encouraged to provide hepatitis A and other vaccines to unsheltered individuals and persons living in encampments or otherwise not utilizing services within the shelters. Additionally, vaccinations should be offered to all staff at facilities serving these high-risk populations as they face potential danger of exposure. Anyone showing symptoms of hepatitis A should immediately be evaluated at the nearest healthcare facility; all cases should be reported to the public health department; and a community phone line should be set up.
Education and training focused on reaching homeless populations is critical. Hepatitis A outreach should provide information on enhanced hygiene practices, advise where to receive a vaccination, and how people showing signs of illness can receive treatment. These efforts should strive to educate shelter residents and staff about the risks associated with infection and its prevention. Additionally, a public advertising campaign and community talks can further amplify outreach efforts.
Enhanced hygiene and sanitation measures and distributing hygiene kits is essential for prevention. Waterless hand sanitizers are ineffective against this particular disease and hand-washing during a hepatitis A outbreak must be done with soap and water. Hot water and antimicrobial soap work best. The importance of water for sanitation means that places that lack running water or a sewage system, such as unsheltered homeless encampments, present a greater risk for infection. Portable hand hygiene stations utilizing hot water and placed at the entrances and exits of facilities serving homeless populations can encourage more frequent hand-washing. Cleaning highly-touched surfaces and bathrooms at least twice a day with a disinfectant labeled by EPA as active against norovirus or hepatitis A virus or using a diluted bleach solution (1:100) is also effective.
The cost of this outbreak was severe, but a quick, coordinated response from health officials and technical assistance providers incorporating the prevention best practices of vaccinate, report, educate, and engage was able to halt the epidemic and prevent further mortalities.
Written by Madeleine Nagy, Practice Area Manager in The Cloudburst Group’s Housing and Community Development practice area. Ms. Nagy helps communities develop systems of care for people in need of homelessness prevention or homeless assistance services, using data collection and analysis as the foundation for planning, maintaining, and improving these systems.