Case Study in Community Based Response – H1N1 Outbreak in Homeless in Salt Lake City

1. Case Study in Community Based Response – H1N1 Outbreak in Homeless in Salt Lake City Kevin McCulley Emergency Preparedness Coordinator Association for Utah Community Health, Utah’s Primary Care Association

2. Association Background • Represent Federally Qualified Health Centers and other accessible providers of care in Utah • The FQHC system in Utah provides a health care home to over 113,000 Utahns annually • 60% in poverty, 59% uninsured • Includes general population Community Health Centers, Migrant Health Care, and Homeless Health Care grantees • Provide ~60-70% of “Safety Net” visits in UT

3. Wasatch Homeless Health Care • Located in Downtown SLC • Know as the Fourth Street Clinic • Adjacent to other homeless services • In 2009 • 6,371 patients • 98.5% at 100% FPL or below • 80% uninsured • 56% living in shelters or on the street • 52% Caucasian, 10% Hispanic

4. 2009 H1N1 Outbreak • High rates of suspected H1N1 in homeless • High visitation rates impacted clinic’s regular primary care service delivery • Compounding the problem was the question of where to send suspect patients • Back to the shelter? Not good • 4th Street provided motel rooms and food delivery to suspected cases, which further impacted service delivery

5. Finding Solutions • Key assumptions • Critical to minimize spread of H1N1 among homeless, to both ensure safety of sheltered population and public • To minimize the spread, aggressive outreach, education, and vaccination was needed • To minimize spread, a system must be designed to segregate suspected/confirmed cases from general shelter populations

6. Minimizing the spread • High rates of chronic and untreated disease leave homeless population more vulnerable to poor outcomes • Homeless populations cannot be directed to “go home and stay in bed” • Homeless populations inhabit the same public spaces (library, stores, etc.) as general public • It is our responsibility to take care of those who need it the most

7. Outreach and Vaccination • ACIP recommendations did not include homeless populations in “priority target groups” for initial vaccination campaign • Worked with SL Health Department to allow all homeless to be a priority for vaccination, regardless of age or other ACIP standards • Massive vaccination campaign in soup kitchens, shelters, at clinic site, and housing units • Successfully vaccinated 4,000 homeless (~63%)

8. Outcomes • 4th Street was second only to Health Department for number of vaccines administered • High vaccination rate reduced suspected case presentation and minimized impact on normal clinic primary care operations • Procedures now in place for the next big thing

9. Alternate Care Site Planning • As the outbreak grew, and the impact on the clinic rose, the need for an ACS was clear • In the absence of vaccination, clinic could not in good faith send suspect cases back to shelters • Worked with SL Health Department and others to plan and design a respite facility for flu cases • Three components • Triage Center • Respite Care Facility Service • Infirmary at Road Home Shelter

10. Triage Center • At the point of entry into the clinic, patients with symptoms or suspected cases will be directed to a separate screening and assessment area • Serves to minimize disease transmission within the clinic and clinic waiting room • Initial estimates were for 50 patients each day during high outbreak period

11. Flu Infirmary at Shelter • Part of scaled response, use existing facility first by segregating a part of the shelter • Would still require staffing, medical supplies, and other services • Funding provided for planning activities and purchase of supplies through State Department of Health using ASPR funding

12. Respite Care Facility Services • Temporary housing for up to 80 infected patients • Combined effort of 4th Street, Road Home Shelter, and EMS and nursing student volunteers from University of Utah • Needed full coordination of medical care, food services, housekeeping, and other materials • Site identified on 4th Street campus • Estimated operational time of 4-5 months

13. Thank You! • Kevin McCulley • Emergency Preparedness Coordinator • Association for Utah Community Health • kevin@auch.org 801-716-4612