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Health Advisory: Homeless Healthcare Reminder

Published: August 22, 2018

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Actions Requested

Consider screening for infectious diseases that are not uncommon in homeless communities such as TB, sexually transmitted infections (Syphilis, Chlamydia, and Gonorrhea), HIV, and Hepatitis A/B/C. Seize the opportunity of a healthcare visit and avoid delaying next steps.

  • TB:
    1. Evaluate symptomatic (prolonged cough, coughing up blood, fever, night sweats, weight loss, excessive fatigue) patients for active TB (see CDPH TB Ris kAssessments)
    2. Screen at risk patients for latent TB with an interferon-gamma release assay(IGRA) or tuberculin skin test (TST)
    3. Treat according to CDPH CA TB Controller's Joint Guidelines.
  • STIs, HIV, and Hepatitis C:
    1. Routinely (at least annually) screen for Syphilis, Chlamydia, Gonorrhea, HIV, andHepatitis C.
    2. Immediately treat suspected STIs following CA STD Treatment Guidelines.
    3. Call Disease Control at 707-565-4566 to initiate investigation of Syphilis or HI Vcases. This phone call is extremely valuable and ensures a timely response.
    4. Initiate screening and treatment of recent sexual partners for suspected STIs. Alternatively, you may refer partners to Sonoma County Disease Control.
  • Hepatitis A/B:
    1. Vaccinate individuals who are non-HAV/non-HBV immune and record in the California Immunization Registry (CAIR)
    2. Suspect acute hepatitis A in homeless patients presenting with symptoms(abdominal pain, nausea, vomiting, fever, jaundice and significant elevation in LFTs). Confirm by obtaining a complete viral hepatitis serology panel.
  • Collect as much contact information as possible, especially if an individual leaves a healthcare facility without diagnosis and/or treatment.
  • Report cases of Chlamydia, Gonorrhea, Hepatitis A/B/C, Syphilis, and TB to Sonoma County Disease Control within one working day of diagnosis. Include contact information for cases and contacts. Confidential Morbidity Reports (CMR) can be transmitted electronically through CalREDIE or faxed to Disease Control at (707) 565-4565.

Local Situation Update:

Homelessness is an ongoing issue in Sonoma County. Healthcare providers should be alert to this population’s heightened risk to certain infections, including TB, sexually transmitted infections (STIs), HIV, and Hepatitis A/B/C. Recently, there have been cases of TB and STIs among people experiencing homelessness in Sonoma County. There have been no local recent cases of acute Hepatitis A.

When homeless individuals are diagnosed, healthcare providers should consider the challenges involved with follow-up appointments. In recent syphilis cases, homeless patients have not been treated due to difficulties locating the patient. For suspected STIs, consider empirical treatment and screen/treat sexual contacts. In addition, collect complete contact information on the case and exposures – report this information to Disease Control.

Background

On July 10th, the County of Sonoma Board of Supervisors declared a Homeless State of Emergency. The most recent point-in time count found a 5.7% increase homelessness from 2017 to 2018. In addition, a larger proportion of homeless individuals reported recently becoming homeless (35% in 2018 compared to 24% in 2017). In response, Disease Control would like to remind healthcare providers to consider infectious diseases which are more likely to be circulating in this vulnerable population. A non-exhaustive list of infectious agents to consider includes TB, HIV, sexually transmitted infections (STIs), and Hepatitis A/B/C.

Resources

Sonoma County Community Development Commission Homeless Count:
Annual Homeless Census and Survey
CDC HAN Hepatitis A Homeless Outbreak:
https://emergency.cdc.gov/han/han00412.asp
CDC TB Guidelines:
https://www.cdc.gov/tb/publications/guidelines/treatment.htm
CDPH STD Screening Recommendations:
https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/CA_STD-Screening-Recs.pdf