Editor's Note: CIDRAP's Promising Practices: Pandemic Influenza Preparedness Tools online database showcases peer-reviewed practices, including useful tools to help others with their planning. This article is one of a biweekly series exploring the development of these practices. We hope that describing the process and context of these practices enhances pandemic planning.
Dec 4, 2007 (CIDRAP News) – Homeless people could face significant disadvantages during public health crises, which is why Public Health –Seattle & King County has developed a plan to help the county's homeless service agencies prepare for an influenza pandemic.
The plan provides information on what to expect during a pandemic and how to prepare for and respond to issues of special concern to the homeless. Research by the University of Minnesota's Center for Infectious Disease Research and Policy (CIDRAP) has found it to be one of the most comprehensive pandemic plans for the homeless in the United States.
After a glut of media coverage on pandemic flu and social distancing, homeless shelters began calling Public Health–Seattle & King County with concerns about how to cope with a pandemic, said Janna Wilson, head of the department's Health Care for the Homeless Network.
"They had a pretty complicated set of questions and were asking for guidance that was more tailored to them and their clients," Wilson said. Apart from social distancing and caring for sick clients, key concerns included:
- How homeless people would receive vaccines and antiviral drugs
- How to manage such a crisis with limited resources
- How to keep operating despite staff shortages
Early collaborative efforts
In response, the public health department created an ad hoc pandemic flu work group, which began meeting in September 2006 to develop the guide. The guide was created through a collaborative process with input from public health specialists, local clinics, homeless service and mental health agencies, among others, Wilson said.
But the group had a framework around which to build its guide. "Luckily we were able to base it loosely on a guide the Toronto health department had published," Wilson noted.
Working with the homeless services agencies proved to be a valuable learning process and led to more thoughtful overall community planning, she added. "The questions they posed were very instructive and made our health department think more in depth about emergency preparation for vulnerable populations," said Wilson.
King County is home to more than 1.8 million people. A severe pandemic would affect as many as 540,000 people and cause more than 11,000 deaths, according to county planners' estimates. There are at least 8,000 people without permanent housing, according to county estimates. The Seattle/King County Coalition for the Homeless conducts a "One Night Count" each year—of the 7,839 people counted on Jan 26, 2,368 were staying in emergency shelters and 3,312 lived in transitional housing.
"Our focus is definitely on the shelters, because they are the facilities where social distancing has been more challenging," Wilson said. In a flu outbreak, disease control would be particularly daunting for large, congregate shelters where the homeless are in close quarters, compared with apartment-style shelters, she added.
In general, the homeless are more susceptible to disease because of their living conditions, chronic and acute medical problems, addiction and mental illness, and a lack of access to regular healthcare, according to the county's Health Care for the Homeless Network. These factors may also increase their risk of contracting influenza.
The county's shelters are already familiar with the difficulties of infectious disease outbreaks. Recently, there was a norovirus outbreak in a men's shelter that spread very quickly, and several shelters dealt with a tuberculosis outbreak a few years ago, Wilson said. While facilities are already aware of the need for safe daily practices, Wilson said the threat of a pandemic evoked additional concerns.
One clinic's steps
At Community Psychiatric Clinic (CPC), a community-based mental health agency whose clientele includes the homeless, portions of the guide were used in revising the organization's entire business continuity plan, said Stacey Glyde, administrative service manager. Glyde was part of the committee that helped create the pandemic guide.
The plan provided an impetus for CPC to start thinking about its own efforts, Glyde said.
CPC applied for county grants made available for preparedness to initiate specific activities around pandemic planning, such as training presentations for staff and installation of hand hygiene stations with hand sanitizers, tissue, and trash cans at the agency's different locations.
"It seems to be very effective," Glyde said of the steps aimed at getting people to think about consistent hand hygiene. Hand cleaning is one of the tips the guide recommends for routine infection control.
For some facilities where every day is an emergency, however, long-term contingency and continuity planning may be difficult.
"For one thing, it's challenging to make time to plan," Wilson said. "[Also,] space is at a premium. They may simply not feel they have the space to store food and water."
Bob Goetchius manages the St. Martin de Porres Shelter in Seattle, for men older than 50. Capacity remains the biggest challenge when thinking about a pandemic, said Goetchius, whose facility houses at least 212 clients each night.
"We're not going to have the capacity to deal with [a flu pandemic]," he said.
Goetchius also served on the ad hoc committee that developed the guide. "Are we prepared? No. Would we like to be prepared? Yes."
Many people are turned away from shelters nightly and forced to sleep on the street, he said, adding that he wonders how already-strained facilities would manage the people who are likely to seek help during a pandemic.
"Without capacity you couldn't do anything," he said. "None of our shelters have excess room."
Financial constraints present additional challenges. Goetchius said that as a nonprofit agency, St. Martin de Porres already runs on a "shoestring budget."
"To fund for emergencies is beyond our abilities," he said. The county is already working to address such problems.
New resources, adaptable guidance
Since the guide was released, new resources to help homeless shelters implement pandemic planning have been developed, including small grants and training programs. The county has already been providing ongoing technical assistance, best practice guidelines, and training sessions with public health nurses on different health issues, Wilson said.
Wilson added that the county and its partners in homeless services are also working to bolster resources that would be useful during a pandemic, such as creating a flu recovery center for homeless people. In addition, the county is developing a communication listserv with homeless service agencies.
The guide states that it can be adapted to suit different facilities' operating needs and is useful for agencies that provide the homeless with a place to stay as well as other services, such as meal programs, employment agencies, mental health agencies, and drop-in centers. It includes prepandemic, pandemic, and postpandemic guidelines, including how to establish an incident command system, care for the sick (what the guide calls a "tea and toast" level of care, which would be the same as what one receives at home), reduce client mobility to prevent disease, and deal with deaths on site.
The plan has been distributed widely, Wilson said, and at least five other communities have asked if they can tailor it to their own needs. She added that it is difficult to gauge how much agencies are changing their approach, although changes have occurred.
"We get more value if other communities use it," she said.
View tools and reviewers' comments for the "Pandemic Planning Guide for Homeless Shelters" practice