Hitting the Streets to Battle the Hepatitis A Outbreak

Mindy Coughlin, left, and Heidi Unruh, center, both San Diego County Health and Human Services Agency Public Health Nurses and an outreach worker from Friend to Friend talk to a homeless person about getting the hepatitis A vaccination in downtown San Diego earlier this year.

“We gonna do this right now? Let’s roll!”

With that, the 20-year-old homeless man who had approached on his skateboard was rolling up his sleeves, ready to receive his hepatitis A vaccination right there on the sidewalk in downtown San Diego.

As a new approach to combating an ongoing hepatitis A outbreak in San Diego County, the County’s Health and Human Services Agency has been sending out “Field Foot Teams” of Public Health Nurses to contact the hard to reach homeless population.

The outbreak, which has killed four people and hospitalized 142 out of the 196 cases, has disproportionally hit the homeless population and those who use illicit drugs. Approximately 60 percent of the cases are homeless and about 55 percent report illicit drug use. Some people who have contracted the disease have both risk factors.

The teams of two public health nurses are joined by homeless outreach workers from community groups or sometimes law enforcement officers. Together, they are taking their vaccination and education efforts directly to the homeless population.

“The teams go where they’re needed,” said Wilma Wooten, M.D., M.P.H., the County’s public health officer. “They go on the streets, to river beds or in canyons to reach the homeless population.

“These are people that aren’t going to come to a doctor’s office or community clinics. Because of that, we created the foot teams and are trying to reach people where they are.”

Wooten said the effort between public health, community partners and law enforcement has been a powerful team that plays to the strengths of all involved

“Everybody’s doing what they do best,” she said. “The outreach workers have relationships with these people and are trusted so they serve as an entry point for the nurses to reach out to them.”

It’s the same with law enforcement officers that work with the County’s Homeless Outreach Teams. They’ve earned the trust of many homeless people.

“It directly helps the nurses administer the vaccinations,” Wooten said.

A Morning on the Streets

On this particular morning, Public Health Nurses Heidi Unruh and Mindy Coughlin hit the streets downtown with two outreach workers from Episcopal Community Service’s Friend to Friend program.

A “go kit” with vaccinations, needles, gloves, alcohol wipes, band aids and other supplies is loaded into a cart that doubles as a seat and in effect becomes a mobile vaccination clinic on wheels.

The foursome head out and a few feet from their starting point have their first successful interaction of the day with a couple.

The pair were familiar with the outbreak, and while Unruh was explaining the vaccination to them, the woman wanted to know if they tested for hepatitis A and what the symptoms were.

Public Health Nurse Heidi Unruh, right, opens up a band aid while Mindy Coughlin finishes up a vaccination.
Public Health Nurse Heidi Unruh, right, opens up a band aid while Mindy Coughlin finishes up a vaccination.

After Unruh ran through the symptoms, the man had already rolled up his sleeve and stuck his arm out, ready for his vaccination.

While they were busy with the couple, one of the outreach workers was approached by another gentleman who had also heard about the outbreak and was ready to get his vaccination.

That type of success was repeated throughout the morning. Most of the people who said no told the nurses that they had already been vaccinated at one of the vaccination clinics the County had already held or by their own healthcare provider.

There were several Unruh recognized that she had vaccinated herself on one of her previous trips to the area.

“It can sometimes take up to three attempts before someone says yes,” she said. “But they talk amongst themselves and other people can sometimes convince them.”

In fact, that was happening quite often. On her last visit to the area, Unruh said one gentleman was walking back and forth to both sides of an overpass recruiting people to get their vaccinations.

“Individuals tell other individuals, and oftentimes they know someone who has been hospitalized,” she said. “Sometimes you just have to explain the outbreak to them.

“Most will at least listen to your pitch and if they decline we give them a fact sheet and ask them to consider getting the vaccination.”

As they hit mid-block, a man in his wheelchair was excited to see them and eager to get his vaccination. “Thank you guys for coming out,” he said.

The first day on the streets, Unruh walked six miles. Today, the group has to wrap up by mid-day. So after administering 12 doses of the vaccine in the first hour, they decided to set up inside the Neil Good Day Center courtyard to finish out their day.

They were greeted warmly by the homeless that were outside the building and the Center’s staff, who quickly got them a folding table and chairs so they could set up a spot to vaccinate people.

With the outreach workers explaining to people about the outbreak and that they could get a free vaccination, a steady flow came to the table to get their shots.

An older gentleman said he was reluctant at first, but “She (Unruh) convinced me.”

As he was rolling up his sleeve, he yelled over to his friend who was sitting nearby.

“Hey Steve, you’re next! Bring a friend.”

By the time they packed up the Foot Team had vaccinated 35 people during the two hours they were out. Dozens more had been given information about the outbreak.

More Foot Teams On the Way

There are other Foot Teams working in other areas of the county and more are on the way. Last week a team went out with three Chula Vista Police Department officers to four South County parks and into a river bed known as “The Jungle.” They vaccinated 34 homeless people.

“We have behavioral health workers, community organizations, the police and public health all working together for a common goal and making a collective impact,” said Wooten. “We are developing more teams out of public health and each region of the County is developing additional teams.”

“Anything our community partners can do to get the word out or help reach this population so we can immunize and educate them can be helpful.”

Tom Christensen is a communications specialist with the County of San Diego Communications Office. Contact