Health Crisis Amongst the Homeless
Homeless is a massive problem in the United States and around the world. There are 62,000 individuals in homeless shelters, each night, in New York City alone. The homeless population is also at high-risk of developing illnesses, due to a number of factors such as malnutrition and unsanitary living conditions. A lack of access to or use of vaccinations further increases the likelihood of an outbreak within the homeless population. A study of three homeless shelters in New York illustrated a 75% non-coverage rate for influenza immunizations. Homelessness and mobility can also make it difficult for the homeless population to complete vaccination schedules.
The recent hepatitis A outbreaks in several counties in California, Kentucky, and Utah are just the most recent in a history of outbreaks among the homeless population. There have been past outbreaks of meningococcal disease, measles, and tuberculosis. But the scale of the most recent Hepatitis A outbreaks has manifested into significant press coverage. With 21 deaths in California alone, this story raises the question: what can be done?
There are several different methods of outreach that attempt to increase immunization rates in the homeless population. Several counties in California have offered free Hepatitis A vaccines in response to the outbreak, but there also exist a multitude of possible methods to prevent outbreaks from happening in the first place. Studies of different intervention approaches reveal that education, along with access to vaccines, is potentially the most effective way to increase immunization in the homeless community. Offering vaccinations seems to not be enough; one review of homeless medical records revealed that only 25% of those who had visited a medical clinic received a vaccine for influenza. Within the literature there appears to be a consensus that education must be paired with an accessible and simple vaccine schedule.
Yet the question still remains: what is being done? Several counties in states like California, where the Hepatitis A breakout occurred, began offering free vaccinations, but only after the outbreak had happened.
A tuberculosis outbreak in 2013, among the homeless population, prompted the CDC to work with public health groups in order to “improve screening, diagnosis, and treatment for people experiencing homelessness” along with improving control activities for TB. Homeless children, who are either uninsured, underinsured, Medicaid eligible, or American Indian or Alaska Native, can receive free vaccinations through the Vaccines for Children Program. This program, as the name suggests, does not cover adults. Additionally, homeless children in certain states, such as Minnesota, are not required to have immunizations to attend school, overriding the immunization laws in effect.
In states where breakouts have not recently occurred, most of the efforts to vaccinate the homeless population seem to take place at the county level. The Health Care for the Homeless Program gives grants to “community-based organizations” in order to help them provide health services and housing to homeless individuals in all fifty states, the District of Columbia, and Puerto Rico. The scale of these programs and their coverage rates are not readily available. The Heath Care for the Homeless Program reports 840,130 individuals served by the grantees in 2015, but this number does not address repeat participants or how many of these received immunizations versus other medical services.
These efforts seem valiant, but simply do not do enough. There have been cases of several different, vaccine-preventable diseases within the homeless population in the United States, in the past ten years. As long as homelessness remains, homeless individuals are more at risk for developing infectious diseases. Once these outbreaks occur, they can move beyond the homeless population and affect individuals of all walks of life. There is a wealth of scientific literature examining what methods seem most effective at raising immunization rates within the homeless population, but these methods must be put into place in order to address the greatest problems facing providers currently: communication, infection control, isolation, quarantine, and resource allocation. Improving these factors as soon as possible can help prevent another outbreak within the homeless population and the deaths that inevitably follow.