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ID specialists search for ways to reach homeless
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People who are homeless are more vulnerable to many infectious diseases than the general population and harder to reach for treatment.
Diseases like tuberculosis, hepatitis, HIV/AIDS, STDs and others affect people who are homeless at higher rates than they do most others. The disparity in the burden of disease is due to a variety of factors, including a lack of health care access and coverage, substance abuse, a lack of shelter and sanitation, sex work, and crowding in shelters.
“Anything that you can catch by being in close proximity to other people tends to be more common in people who are homeless,” Kelly Doran, MD, an assistant professor of population health and emergency medicine at New York University School of Medicine and an ED physician at Bellevue Hospital in New York City, told Infectious Disease News. “People who are homeless also tend to have a variety of factors that may sometimes lead to them having weaker immune systems. They have higher rates of co-occurring substance use, mental health issues and other chronic medical conditions, all of which put them at risk for infectious diseases as well.”
A vulnerable population
Several studies have shown the extreme gap in infectious disease prevalence between homeless people and the general population. One, published in The Lancet in 2014, analyzed literature from high-income countries in North America, Europe and Oceania over a roughly 10-year period.
The researchers found that the prevalence of hepatitis C was as high as 36% among homeless people, compared with just 2% in the general population. Rates of infection with hepatitis B reached 30% among homeless people vs. less than 1% of the general population. Rates of TB (8% vs. 0.032%) HIV (21% vs. 0.6%) and scabies (56% vs. < 1%) were also significantly higher among people who are homeless.
In another study published in The Lancet in 2017, researchers similarly analyzed literature from high-income countries between 2005 and 2015. They found that, among men, homeless people had almost three times the infectious disease-associated mortality rate as the general population, and homeless women had more than a fivefold increase in mortality risk compared with women in the general population.
HCV is especially prevalent among homeless people in the United States, according to HHS, which estimates that 22% to 53% of the population is infected. Doran said most homeless people are not injection drug users — a significant driver of the HCV epidemic — but it is still a problem among that population.
“There is a minority, but still important, group of homeless people who do use injection drugs or other drugs, and alcohol,” Doran said. Injection drug use is definitely more prevalent among homeless people, but in general, the most common infections they face are more similar to what the rest of us face,” she explained, pointing out that they are more susceptible to diseases like pneumonia and influenza as well.
Jeffrey D. Klausner, MD, MPH, a professor of medicine and public health at the University of California, Los Angeles David Geffen School of Medicine and Fielding School of Public Health, said skin and soft issue infections also commonly affect homeless people.
Other threats include “infections related to poor hygiene like staphylococcal infections and those related to poor sanitation like water-borne diseases or hepatitis A,” Klausner said. “Traditionally, TB is a concern among the homeless due to crowded living conditions and comorbid conditions like diabetes, smoking and substance use. Rates of TB in homeless persons in Los Angeles, for example, are about 100 cases per 100,000 population, more than 30 times the national average.”
Matthew M. Zahn, MD, medical director of epidemiology at the Orange County, California, Health Care Agency and chair of the Infectious Diseases Society of America’s Public Health Committee, added shigellosis to the mix of diseases affecting the homeless population. An outbreak of the disease, caused by a Shigella bacterium that can be spread through poor hygiene, hit the homeless population in Orange County several years ago, Zahn said. He also listed norovirus and MRSA outbreaks as potential threats.
A months-long outbreak of HAV that began among homeless residents in San Diego illustrated the severity with which infectious diseases can strike the population and become widespread. The outbreak began in November 2016 and spread throughout California. A major driver of the outbreak was the disease’s spread among homeless people, although it affected nonhomeless people as well.
By the end of 2017, the California Department of Public Health counted 686 total cases of HAV, including 447 hospitalizations and 21 deaths, resulting from the outbreak. San Diego County saw the vast majority of cases — 577 — and 20 deaths.
Points of contact
During the California HAV outbreak, health care professionals had more contact with homeless people than normal. According to Zahn, homeless people are ordinarily more concerned with issues other than their health, making outreach difficult.
“For people who are homeless, even significant health issues like hepatitis A may be far down on their list of concerns,” he said. “Keeping themselves and their families fed, warm and safe is often priority one. That means that when you conduct health outreach, it is not a simple population to reach.”
To overcome that barrier, Zahn suggested visiting homeless shelters and speaking to people about their health conditions, risks for diseases and the steps they can take to protect themselves. Zahn said he has also visited homeless shelters in the past to educate staff in basic hygiene practices to help prevent the spread of disease. Correctional and mental health care facilities are other settings in which homeless people can be reached, Zahn said, because these are the settings in which they often encounter the health care system.
However, a place that is a frequent point of contact between health care providers and homeless people is the ER. Zahn said it is important for ID specialists to educate ER staff about emerging and ongoing disease threats among those without shelter. It is also important, he said, to thoroughly address those patients’ needs at that time.
“If homeless people are seen in the ER and their needs are met, then that’s a great outcome,” Zahn said. “But if their needs are not met and they leave the ER, conducting follow-up and care is extremely difficult.”
Doran said specialists play an important role for HIV-infected people who are homeless.
“Some people who are homeless strongly value the relationships they have with their HIV doctors,” Doran explained. “For more rare or complex conditions such as TB, there is certainly an important role for the expertise of infectious disease specialists.”
Doran stressed that ID specialists can increase health care access for homeless people by accepting Medicaid, which she said is their largest insurer. Allowing flexible schedules and walk-in hours and having case managers on site are other ways to improve health care for the homeless population.
She also said specialists can consult the National Health Care for the Homeless Council, a network of thousands of providers, patients and advocates working to improve access to comprehensive health care and secure housing for homeless people. Specialists can visit the organization’s website for resources to help homeless people and to find out if the group operates any clinics for homeless people in their communities, Doran said.
Klausner recommended a compassionate, nonjudgmental approach to the control of infectious diseases in the homeless population. To that end, clinicians should engage in mobile outreach and help ED staff in treating homeless people. He also recommended educating colleagues and civic leaders about the risk factors homeless people face.
Zahn said outreach efforts are crucial but require resources and funding.
“It’s really resource intensive,” he said. “For public health and for any group reaching out to the homeless, they’re doing very important work. But it has to be funded and supported adequately. If it’s not, you’re just not going to serve their needs.” – by Joe Green
- References:
- Aldridge RW, et al. Lancet. 2017;doi:10.1016/S0140-6736(17)31869-X.
- California Department of Public Health. Hepatitis A Outbreak in California. 2017. https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/Hepatitis-A-Outbreak.aspx. Accessed January 15, 2018.
- Fazel S, et al. Lancet. 2014;doi:10.1016/S0140-6736(14)61132-6.
- HHS. Viral Hepatitis in the News. 2017. https://www.hhs.gov/hepatitis/blog/2017/07/18/fighting-hepatitis-c-by-providing-treatment-at-homeless-shelters.html. Accessed January 15, 2018.
Disclosures: Doran, Klausner and Zahn report no relevant financial disclosures.