Salt Lake County Health Department's Response to a Hep A Outbreak

State: UT Type: Model Practice Year: 2019

Salt Lake County Health Department (SLCoHD) serves roughly 1.2 million residents within incorporated and unincorporated Salt Lake County, Utah. Salt Lake County (SLCo) is located in north-central Utah and is part of the metropolitan region along the Wasatch Mountains. SLCo is Utah's most populous county comprising 40% of the state's population. The demographics of the population served within SLCo range from very wealthy to extreme poverty, with approximately 9% of the population living in poverty. California and Michigan reported outbreaks of hepatitis A (HAV) among persons experiencing homelessness and persons using illicit drugs in early 2017. SLCo saw its first case of HAV in a person experiencing homelessness in May of 2017. Within the next couple of months, it became clear SLCo was also experiencing an outbreak. Genetic sequencing done on case samples showed SLCo had more than two cases with the same genetic strain. Genetic sequencing also determined Utah's outbreak was the same strain as the outbreak occurring in California. The purpose of the public health Model Practice was to respond to and mitigate the HAV outbreak. The populations most at-risk for HAV in the outbreak include: Persons experiencing homelessness Persons using illicit drugs (injection and non-injection) Persons institutionalized (e.g., in jail or prison) Currently, numerous states are reporting outbreaks of HAV among persons experiencing homelessness and illicit drug users. West Virginia and Kentucky are reporting 50-100 new cases of HAV per week. There have been over 7,000 cases of HAV reported so far in 2018. The goal of the Practice is to return SLCo HAV transmission levels to baseline. The outbreak will be declared over when 100 days (two incubation periods) pass without an outbreak-related HAV case. Objectives of the program include: Coordinate response efforts in SLCo and stand up incident command system (ICS) and response procedures Conduct ongoing surveillance of HAV by epidemiological investigations of cases, as they are reported and/or identified, and contact tracing Conduct response to each case or trends utilizing three strategic approaches to vaccinate, sanitize, and educate Conduct proactive prevention and outreach to organizations serving at-risk populations, key stakeholders, and the general public Leverage and/or identify community, city, or county resources to reach at-risk populations Coordinate strategies for efficient external and internal communication to educate the public and share information with healthcare professionals regarding the HAV outbreak on who should be vaccinated. The Practice was implemented using a three-pronged approach to the outbreak which included vaccination, sanitation and education. The outbreak response includes a change in policy because the SLCoHD food code was changed to require food handlers exposed to HAV be vaccinated within 14 days of exposure or be excluded from the food facility for 28 days. Outbreak response vaccination efforts began in August 2017. A push to vaccinate all persons incarcerated in the SLCo Jail occurred in October 2017. October 2017 was also the month efforts began with syringe service programs (needle exchange). Culinary workers in the jail were targeted for vaccination and SLCo Jail agreed to not allow culinary workers in the kitchen unless they had been vaccinated. During the outbreak response all the objectives were met, the number of new cases continues to trend down, and hopefully the outbreak will end soon and the goal will be met. Vaccine efforts targeted high-risk populations and collaboration with community partners led to the success of the Practice. The public health impact of the Practice was to slow and hopefully stop the outbreak which may have led to fewer illnesses and deaths due to HAV. The website for SLCoHD is and the website for the HAV outbreak response for Utah is
HAV is an acute illness that causes nausea, vomiting, diarrhea, abdominal pain, dark urine and jaundice. Illness will lead to lifetime immunity. The recent outbreaks of HAV have had higher than normal hospitalization rates and fatality rates as high at 3%. The rise in persons experiencing homelessness and lack of affordable housing are precursors to the current HAV outbreaks. Persons experiencing homelessness are at higher risk for infectious diseases, exposure to elements and exposure to unsanitary living conditions. Contributing to the HAV outbreaks is the current opioid crisis. On average SLCo sees three to four cases of HAV per year. In May of 2017, SLCo saw its forth HAV case of the year and its first case in a person experiencing homelessness. In 2017, four states were reporting outbreaks of HAV; in 2018, 12 states are reporting HAV outbreaks. As of December 2018, SLCo has seen 194 outbreak related cases and three HAV related outbreak deaths since May of 2017. The innovative activities in this Practice may help other states in their outbreak responses. Determining the size of the at-risk populations has been difficult during the outbreak response. Each year a point in time count is made to determine the size of Utah's population of persons experiencing homelessness. This count includes people housed in shelters and those living on the streets. The point in time count done on 1/24/2018 found 1,427 persons experiencing homelessness in SLCo. Many in the community do not feel the point in time count is an accurate depiction of the size of the population of persons experiencing homelessness. Data from the Homeless Management Information System used by the State of Utah found between October 2016 and September 2017 10,133 persons experienced homelessness for the first time which was a decrease of 732 from the previous year. An individual was counted in this group if they entered an emergency shelter or other assistive programs in the state and had not been enrolled in the Homeless Management Information System previously. The point in time count and the count of persons experiencing homelessness for the first time still does not give an accurate estimate of the total size of the population of persons experiencing homelessness. The National Survey of Drug Use and Health for 2015-2016 reported the annual average percentage of past month illicit drug use other than marijuana at 3.3% for Utah. That would be approximately 40,000 SLCo residents. The SLCo Jail can house 2,200 inmates. The SLCo Jail averages 33,000-35,000 bookings each year. Many people are booked and released on the same day. Many of the at-risk individuals fall into more than one risk category making estimating the target population even more difficult. Historically, HAV outbreaks have been associated with food borne outbreaks, but a study conducted in the 1990s, to figure out why Utah had a high incidence of disease identified person to person spread of HAV was more common due to asymptomatic children spreading HAV to close contacts. To reduce spread, HAV vaccine has been required for Utah school entry since 2002. Outbreaks of HAV in recent years have been associated with contaminated food items, but starting in March of 2017, states began reporting outbreaks of HAV among persons experiencing homelessness and illicit drug users. While HAV vaccination is part of routine childhood vaccines, HAV vaccines for adults are only recommended for certain groups which until October 2018 did not include persons experiencing homelessness and does not include incarcerated individuals. This Practice was implemented using a three-pronged approach to the outbreak response which included vaccination, sanitation and education. This Practice is an innovative application of evidence-based practices from the Advisory Committee on Immunization Practices Immunization Recommendations and the Centers for Disease Control and Prevention. The vaccination efforts in this Practice had to be innovative to vaccinate the high-risk groups who often have a distrust of the government. Vaccine efforts targeted at persons experiencing homelessness required employees to go on foot to locations where persons experiencing homelessness congregate. While still maintaining safety, these vaccination efforts were done without a police presence because of the distrust of persons experiencing homelessness towards police. Collaboration with other community groups helped to target the illicit drug using population. SLCoHD collaborated with the SLCo Jail to vaccinate incarcerated individuals as well as individuals being booked and released” at the jail. It is estimated 60%-80% of incarcerated individuals have current or past illicit drug use. SLCoHD also collaborated with One Voice Recovery (OVR) which is a local syringe service program, to provide HAV vaccines for their clients. Health department employees went with OVR while they were doing their syringe services and provide HAV vaccine. The collaboration with OVR helped SLCoHD vaccinate high-risk hard to reach populations because OVR already had a trust relationship with the population. As of December 2018, over 12,500 vaccines have been provided by SLCoHD to at-risk groups. Surveys were given to clients receiving the vaccines between August 2017 and July 2018. Survey respondents' self-reported high-risk activities. See summary of the survey results in the evaluation section.
The objectives and goal of the Practice is to return the SLCo HAV transmission level to baseline. The Practice was implemented using a three-pronged approach to the outbreak response which included vaccination, sanitation and education. Vaccination SLCoHD began vaccination efforts in response to the outbreak in August 2017. The vaccine efforts were targeted at high-risk groups and any known contacts of cases. The first vaccine clinics were held at a local park, the downtown library and criminal justice services. SLCoHD found these traditional vaccine clinic models previously used for vaccine preventable infectious diseases (e.g., influenza, food borne HAV) did not work well with the high-risk groups. The high-risk groups are not inclined/don't have the resources to visit SLCoHD clinics to receive vaccine. SLCoHD found employees needed to go to persons experiencing homelessness and illicit drug users to vaccinated them. In September 2017, SLCoHD began doing foot clinics” with supplies in backpacks and nurses and screening employees on foot in the areas where the target population congregated. The first foot clinics focused on the area near by the downtown shelter and along the Jordan River where those experiencing homelessness are known to have encampments. In the middle of October 2017 foot clinics included the motels along North Temple and State Street in motels with known illicit drug users and persons experiencing homelessness. SLCoHD found employees had to be very outgoing and in the midst of people in order to get them to stop and consider the vaccine. Safety was a concern during foot clinic vaccine efforts, but employees found having police around was a deterrent for the target population, who would scatter when they saw police. There was a lot of mistrust of the health department prior to the outbreak response efforts. Persons experiencing homelessness primary interactions with health department employees was during the cleaning up of encampments which in the summer include the moving of individuals and trashing of anything left behind. SLCoHD addressed this issue by partnering with groups who are trusted by the target population such as the syringe service program OVR an Volunteers of America (VOA). OVR was instrumental in helping SLCoHD build a trust relationship with the target population. One thing complicating the outbreak response efforts was Operation Rio Grande which began in August 2017. Operation Rio Grande is an effort to address the homelessness and illicit drug use issues in the Salt Lake City downtown area. As a consequence of Operation Rio Grande many persons experiencing homelessness and illicit drug users spread from the downtown area to other areas of SLCo and Utah. Operation Rio Grande cracked down on criminal activity and as a result many of the high-risk groups were arrested and incarcerated. While the scattering of the target population hindered SLCoHD response, the incarcerations as a result of Operation Rio Grande may have helped vaccinate the target population while they were in jail. SLCoHD worked with The Road Home (shelter), VOA, Catholic Community Services and other groups who provide services to persons experiencing homelessness to promote vaccines for their clients. SLCoHD also worked with drug treatment facilities to vaccinate at-risk drug using clients. Vaccine clinics were done at senior centers to vaccinate seniors experiencing homelessness. In October 2017, Salt Lake City held its first annual Project Homeless Connect which connects persons experiencing homelessness with services in the community. SLCoHD participated in Project Homeless Connect in 2017 and 2018 and provided HAV vaccines, influenza vaccines, wound care kits, and education about the services offered by the health department. During the outbreak response SLCoHD used their Medical Reserve Corp (MRC) for the first time. The MRC helped with vaccine clinics in the evening at the downtown shelter. The population of persons experiencing homelessness at the shelter in the evenings is different than the population during the day due to persons experiencing homelessness who have day jobs. In September 2017, SLCoHD partnered with the SLCo Jail to vaccinate high-risk individuals in the booking area of the jail. In September and October 2017, SLCoHD began seeing multiple cases of HAV in the jail, so in the beginning of October 2017 SLCoHD made a major push at the jail and vaccinated over 1,100 inmates. SLCoHD employees did the majority of vaccinations at the SLCo Jail, rather than the jail's medical employees. The jail's medical services were under-staffed and unable to take on the responsibility of vaccinations. SLCoHD felt the vaccination efforts at the jail would be integral to the outbreak response, so SLCoHD is responsible for vaccine efforts done at the jail. During most of the outbreak SLCoHD employees were vaccinating in the booking area of the jail three times a week. At the end of October SLCoHD began working with syringe service programs including OVR to help target high-risk difficult to reach illicit drug users. Sanitation As part of Operation Rio Grande, the environmental health division of SLCoHD was asked to do daily clean ups of the downtown area. In addition, throughout the outbreak, cleanups were done downtown, along the Jordan River and throughout the Salt Lake Valley to clean up encampments. These cleanups included the removal of solid waste and the disposal of sharps. Sanitation efforts included educating shelters, libraries, restaurants, parks, porta-potty companies and others about proper cleaning and products needed to effectively disinfect areas potentially contaminated with HAV. In addition to vaccine, proper hand hygiene is a great way to reduce the spread of illness. SLCoHD investigated the possibility of putting hand washing stations in the downtown area. Due to winter approaching, safety concerns, and lack of an agency willing to take ownership of the project, including finance and the maintenance of the stations, these efforts were unsuccessful. SLCoHD also investigated adding a hand washing sink to the local soup kitchen. The soup kitchen serves over 600 meals in a 30-minute time period. This and the small size of the soup kitchen made it impossible to add hand washing area, so hand wipes are used instead. The soup kitchen and the health department came up with the idea to use hand wipes as the meal ticket. Meal tickets used to be laminated paper tickets that were reused. Now the used wrapper of the hand wipe is the meal ticket. Education Education about the HAV outbreak began with information provided to local healthcare about the outbreak and asking them to immediately report suspect cases of HAV. Information about the outbreak, proper cleaning and restriction of ill workers was provided to downtown restaurants first, and then all SLCo restaurants. Media releases were done to educate the general public. Education was also done for homeless service providers, police and fire, libraries, drug treatment facilities, senior centers and recreation centers. Flyers were created and posted at the shelter, day center, soup kitchen and other areas were persons experiencing homelessness congregate to educate the population. To inform LHDs and share best practices, Utah Department of Health (UDOH) began HAV coordination calls with the 13 LHDs in Utah. These calls were held weekly, biweekly or monthly depending on need throughout the outbreak. In addition to UDOH and the LHDs, the call included representatives from the SLCo Jail and the Utah State Prison. Representatives from CDC would also join the calls to give updates about the national perspective and what was happening in other states. These calls allowed the LHDs the opportunity to discuss the epidemiology and response efforts taking place. Since SLCo has the largest population and the majority of cases in the state, SLCoHD outbreak response efforts served as best practice examples for other LHDs. Sometimes other states would join the call to listen to the activities being done in response to the Utah outbreak. The highest months of case counts were in December 2017 and January 2018 with 25 cases each. The monthly case counts began trending downward in February 2018. Candy bars were used as an incentive for persons experiencing homelessness to be vaccinated. In April 2018 SLCoHD began using gift cards as an incentive to receive the first vaccine and for persons experiencing homelessness to bring at-risk friends to be vaccinated. Funds ran out for the incentives and SLCoHD began using candy bars again. One struggle with this outbreak was the isolation of infectious individuals. Normally SLCoHD isolates infectious individuals in their home, but that was not possible with persons experiencing homelessness, and the concern was they were returning to the shelters and camps and potentially infecting others. In April 2018, SLCoHD was able to get all the contracts in place to house infectious cases in hotels. It was difficult to find a hotel willing to allow SLCoHD to house infectious individuals. The hotels willing to allow SLCoHD to house infectious individuals were in areas where illicit drug use and prostitution were occurring and some of the cases did not want to stay there. SLCoHD was able to contract with OVR to house individuals in a room available for OVR's clients. This is another example of the great partnership SLCoHD created with OVR. In February 2018 SLCoHD made a temporary amendment to the food code requiring all employees who are contacts to HAV be vaccinated within 14 days or the employee will be excluded from work for 28 days. This amendment became a permanent part of the food code in May 2018. This outbreak response required multiple divisions and programs of the health department work together to achieve the goal and objectives. This outbreak response required the different divisions to break down silos and work together. Representatives from Administration, Medical Office (infectious disease, epidemiology and emergency management), Community Health, Environmental Health (food protection and sanitation and safety), and Family Services (immunizations) participated in the outbreak response. These groups worked together to achieve the objectives by interviewing cases, vaccinating contacts and high-risk individuals, educating about the outbreak, and analyzing trends. Communication between these groups included weekly and now monthly SLCoHD internal response calls. Budget for HAV response between August 2017 and August 2018: Expenses Personnel: $597,708 Operating: $170,457 Admin/Facilities: $83,121 Total: $851,285 Revenue Federal: $217,667 Local: $50,120 Total: 267,828 Expenses – revenue or the cost paid from the health department fund = $583,458
The outbreak response achieved the objectives and is close to being able to achieve the Practice goal. Only one case was reported in October 2018 and two cases in November 2018. Objectives of the program included: Coordinate response efforts in SLCo and stand up ICS and response procedures Conduct ongoing surveillance of HAV by epidemiological investigations of cases, as they are reported and/or identified, and contact tracing Conduct response to each case or trends utilizing three strategic approaches to vaccinate, sanitize, and educate Conduct proactive prevention and outreach to organizations serving at-risk populations, key stakeholders, and the general public Leverage and/or identify community, city, or county resources to reach at-risk populations Coordinate strategies for efficient external and internal communication to educate the public and share information with healthcare professionals regarding the HAV outbreak on who should be vaccinated. Primary sources of data included surveys of clients vaccinated collected at the time of vaccination by health department employees. These surveys included information on the location of the vaccination effort, having experienced homelessness since May of 2017, recreational drug use since May of 2017, and incarceration since May of 2017. Surveys were used to determine if vaccine efforts were targeting the high-risk populations. Survey results showed efforts at homeless service providers and foot clinics were effective at targeting persons experiencing homelessness. Vaccine efforts at the jail and drug treatment facilities were effective at targeting illicit drug users. Survey results: Average of all respondents 45% reported drug use 75% reported experiencing homelessness 35% reported incarceration 91% reported at least one high-risk activity Average of individuals vaccinated at the jail 61% reported drug use 43% reported experiencing homelessness 42% reported incarceration 93% reported at least one high-risk activity Average of individuals vaccinated at foot clinics 53% reported drug use 86% reported experiencing homelessness 32% reported incarceration 95% reported at least one high-risk activity Average of individuals vaccinated at homeless service providers 39% reported drug use 81% reported experiencing homelessness 27% reported incarceration 95% reported at least one high-risk activity Average of individuals vaccinated at drug treatment facilities 65% reported drug use 52% reported experiencing homelessness 41% reported incarceration 94% reported at least one high-risk activity Another primary source of data was the analysis of risk factors of the cases including high-risk activities and locations were HAV cases spent their time. This surveillance helped to determine which vaccine locations were prioritized. For example, in September and October 2017, 10 cases of HAV were associated with the jail. Vaccine efforts in the jail began in September 2017 and in the beginning of October 2017 a major vaccine clinic took place in the jail to vaccinate all inmates. There was a peak number of cases associated with the jail in October 2017, and by November cases had decreased by 50%. Since December 2017, the jail has seen between zero and two cases per month. A huge success of this Practice was the vaccine efforts in September and October 2017 helped to reduce the number of HAV cases associated with the jail. Being responsive to the changing epidemiology of the outbreak has been part of SLCoHD public health 3.0. In April 2018, with fewer cases reporting experiencing homelessness and more cases reporting illicit drug use, efforts became more targeted at illicit drug users including working with OVR and vaccinating at low-income housing where illicit drug use is known to be occurring. In August 2018, a higher proportion of cases were again reporting experiencing homelessness and resources were again targeted at locations where persons experiencing homelessness congregate. Spatial analysis of cases' addresses was done, which led to targeted education efforts on cleaning and HAV information at affordable restaurants and inexpensive hotels in geographic areas of concern. The heat map showed evidence the outbreak epidemiological centers were the downtown shelter and the SLCo Jail. SLCoHD initially encountered some resistance to vaccination efforts at the jail but findings showing the SLCo Jail at higher risk helped to convince SLCo Jail of the importance of vaccinating inmates.
SLCoHD learned vaccine efforts in response to outbreaks among persons experiencing homelessness and illicit drug users cannot be large vaccine clinics such as has been done in the past. The vaccine efforts must be specifically targeted at the high-risk groups. Communication and collaboration between SLCoHD community partners were instrumental in achieving the objectives especially when involving stakeholders who already have relationships with those groups. It is important these relationships be maintained because the high-risk populations will continue to need health department services given their higher risk for chronic and infectious diseases. SLCoHD plans on having memorandums of understanding (MOUs) with homeless service providers and syringe service programs to continue the relationships built during the HAV outbreak response. A SLCoHD employee will be responsible for ensuring MOUs are created and maintained with the community groups. SLCoHD is committed to continue to be involved in the Project Homeless Connect in future years. SLCoHD facilitates a meeting called SLCo Illegal Encampments, which consists of police, syringe service programs, aging services, social workers, municipal partners, local shelters, VOA and employees from various programs within SLCoHD. The goal of the group is to work together to address encampments and other concerns for persons experiencing homelessness. SLCoHD did not declare a public health emergency as part of the outbreak response but did set up ICS. Having the ICS structure helped to define clear leads of each section and branch and helped to streamline communications between the sections. The ICS structure and the regular meetings resulted in increased accountability from all the health department programs responding to the outbreak. SLCoHD communicated early in the outbreak with local hospitals to notify them and request they notify the health department of cases as soon as HAV was suspected in order to interview cases who may be difficult to reach after their release. SLCoHD learned throughout the outbreak that many emergency room providers were unaware an outbreak was occurring. SLCoHD was rarely notified of suspect cases of HAV, with most of the notifications coming through the labs rather than the provider. SLCoHD also worked with hospitals to have them vaccinate high-risk individuals seen in their emergency departments. Even though local hospitals emergency room populations are approximately 30% illicit drug users or persons experiencing homelessness, only a small number of vaccines have been provided to at-risk populations in the emergency department. SLCoHD learned through this Practice that communication about infectious disease outbreaks and ways the hospitals can help public health need to be improved. SLCoHD notified the media about the outbreak early in the response. Notifications also occurred when restaurant food handlers possibly exposed patrons. The media response was more prominent with the food handler exposures leading the general public to be more aware of the small number of restaurant-related exposures, rather than awareness of the outbreak's most at-risk populations of illicit drug users and persons experiencing homelessness. Another consideration moving forward is the difficulty in isolating persons experiencing homelessness. The motels SLCoHD worked with to isolate persons experiencing homelessness did not always work well because of their proximity to high-risk activities. Having MOUs in place with partners like OVR will help to address isolation needs in the future. Given the number of outbreaks still happening around the United States SLCoHD plans to continue vaccination efforts to the high-risk populations on a reduced scale. Vaccinations at the jail and shelters will be done by SLCoHD employees on a scheduled basis. Continuing to have a physical presence at these locations will help to sustain the relationships built with community partners. In addition to the vaccines done at the jail by SLCoHD, the Utah State Prison is responsible for giving the combination HAV and hepatitis B vaccine to all inmates. In addition to giving HAV vaccines, SLCoHD immunization nurses have been bringing other adult vaccines to clinics held at homeless service provider locations. Because of the Medicaid expansion a percentage of the target population now has insurance and vaccine coverage. This has been an innovative way to provide adult vaccines to a population at-risk for vaccine preventable diseases. San Diego County reported their cost to respond to their HAV outbreak was approximately $12.5 million as of the end of April 2018. San Diego County is more populous than SLCo with over three million residents. As of August 2018, the cost of SLCo response has been $851,285. SLCoHD response has been targeted at the high-risk groups and this specifically targeted approach has allowed SLCoHD to reach the objectives, and soon the goal, in a cost-effective manner. UDOH did a cost comparison of hospitalization stays verses the cost of vaccination. UDOH found the average cost of hospitalization for one case is $15,644. The cost of vaccine is $25.73 per dose. With the high hospitalization rate within the outbreak and approximately 63% of hospitalized cases who had no insurance, UDOH was able to justify the need for support in paying for vaccines to a local healthcare association.
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