Vaccinating the Vulnerable

From the Winter 2019 edition of Vanderbilt Medicine Magazine

On Halloween morning, a patient nervously listened to Greg Fricker, fourth-year medical student from Vanderbilt University School of Medicine, as he explained the importance of receiving an influenza vaccine.

Fricker told the patient that roughly 80,000 people died last year due to complications from the flu and confidently reassured him that getting the vaccine could in no way make him sick.

After the patient agreed to the vaccination, Fricker and Samuel Trump, a third-year medical student at Vanderbilt, took his temperature and asked him about his medical history before administering the vaccine.

The patient wasn’t taken into an exam room, and Fricker and Trump weren’t dressed in white coats. The pair stood on a Nashville greenway alongside the Cumberland River in T-shirts and jeans and administered the vaccine to a man who called that location “home.”

Beginning in July 2018, Fricker, director of Vanderbilt’s Shade Tree Clinic, began accompanying Vanderbilt’s Street Psychiatry team, founded and directed by Sheryl Fleisch, MD, assistant professor of Psychiatry and Behavioral Sciences, to provide vaccinations every Wednesday morning to some of the enterprise’s most vulnerable patients: Nashville’s homeless population.

The program’s distribution of vaccines — which includes both influenza and hepatitis A vaccines — began on the heels of an announcement from the Tennessee Department of Health that Davidson County was experiencing an outbreak of hepatitis A, a liver infection caused by the hepatitis A virus that is highly contagious and is primarily spread through the ingestion of food or drinks contaminated by an infected person. The virus can also be spread through sex.

Those most at risk for contracting the virus include substance users, men who have sexual contact with other men and those experiencing homelessness due to the increased likelihood of unsanitary living conditions and contact with contaminated food and water.

“Hepatitis A is one of those things where you could go anywhere from two weeks to six weeks after exposure before actually becoming sick, but you’re infectious that whole time, whether you’re symptomatic or not,” said Robert Miller, MD, Patricia and Rodes Hart Professor of Medicine. “You could be in one of the homeless camps for weeks infecting others and not even know that you’re sick, so it can be a difficult epidemic to manage.”

Since the outbreak was announced in December 2017, 491 cases of hepatitis A have been confirmed in Tennessee, with 152 of those cases being reported in Davidson County and another 211 confirmed in the surrounding Mid-Cumberland region. Of those confirmed statewide, 62 percent have resulted in hospitalizations, and one death has been reported. In comparison, Tennessee has seen an average of 13 cases per year for the last five years.

In response to the outbreak, Nashville’s Metro Public Health Department and Neighborhood Health, a Federally Qualified Health Center, quickly mobilized to set up clinics offering free hepatitis A vaccinations for Nashville’s low-resource communities. These events administered hundreds of vaccines to at-risk populations, but through Fleisch’s weekly outreach to patients in the city’s homeless camps, Vanderbilt was able to reach a population that was missing protection: patients who wouldn’t venture away from their camp to visit a clinic.

“I find you get a different population in these camps, because you see folks who never really interact with the health care system, who are the most vulnerable and who could potentially have the most harm done to them through getting a disease like hepatitis or any other disease that we can prevent with vaccines,” said Fricker. “But anytime you work with a group of folks who don’t usually interact with the health care system, there are misconceptions about vaccines.”

Through the Street Psychiatry Program’s model of outreach, Fleisch, psychiatry residents on yearlong rotations, medical students on daylong immersive experiences and a  homeless outreach coordinator from a local nonprofit organization visit encampments weekly to provide psychiatric and basic medical care to persons experiencing homelessness in Nashville. The first two hours of each morning involve “street rounds” to meet immediate needs, while the rest of the day is spent meeting patients for scheduled appointments at the location of their choosing.

The group first works to establish trust with patients inside the camps by offering needed supplies, such as bottled water, blankets, bug spray, clothing, personal hygiene products and lanterns. Taking the time to ask each patient how things have been going inside the camp gives the team insight into what that population may need most while allowing them to build lasting relationships. Through this established trust, patients become more open to discussing various types of medical care, including vaccinations.

“Just by us chatting with them, the majority of the people we meet who have not received the vaccine will end up getting it,” said Fricker, who said that roughly 84 percent of unvaccinated patients end up receiving the hepatitis A vaccine. “You get to know them beforehand, and then they’re so much more willing to discuss getting vaccinated with you. I think if you just went to these camps and you said, ‘Hey, you need to get this vaccine,’ you’re not leading with something that shows you care for them, and you don’t develop that trust.”

Because the group provides outreach to the same camps more than once, these relationships often build over time and can prove effective down the road. One patient’s relationship with Rachel Gibson, a homeless outreach coordinator, proved critical to his willingness to trust the Street Psychiatry team and ultimately receive the flu vaccine.

“I’m only doing this for you,” he said to Gibson as she held his hand through the vaccination process.

This patient had already received his hepatitis A vaccine through a separate program.

“As an outreach worker, establishing rapport is the foundation of my job. Building relationships with people experiencing homelessness allows me to better advocate for them and their wants and needs, and this has been especially apparent while accompanying the doctors giving vaccines,” said Gibson, who works for the nonprofit Park Center, which has partnered with Vanderbilt’s Street Psychiatry program for five years.

“I had been working with this particular person for months, and he trusts me. When initially asked to receive the vaccine, he refused, but after some reassurance and letting him squeeze my hand during, he got the vaccine. It was a simple interaction, but in that moment, it made the difference between accepting care and not.”

While the group strongly recommends both vaccines to the patients it encounters, Fleisch feels the high acceptance rate for hepatitis A immunizations and the lower acceptance rate of the influenza vaccine can help break down stereotypes regarding personal participation in one’s health care when it comes to those experiencing homelessness.

“People assume that someone who is experiencing homelessness doesn’t care about their health or doesn’t want preventive treatment, and I think the fact that we’re seeing people who, when given an explanation of two different vaccines, are able to discriminate between them and decide whether they want one or both, shows that person is thinking through it and is able to make that decision for themselves,” said Fleisch.

“There are a lot of individuals experiencing homelessness who have such a mistrust of the health care system that they’ve never had a chance to have their questions answered. So, by utilizing the skill set that we have through Psychiatry, we’re able to sit with them and answer the questions they have related to the vaccination to the point they feel comfortable making a decision. They feel like part of the process, and they are a part of the process.

“It’s so fascinating to see how somebody is willing to change when you explain to them what something like a vaccination can do for them and how it can potentially change the course of their life.”

Funding for the new vaccine program was made possible by the Simple Dreams Endowment in memory of Jack Kuhn, Jr., who died in 2012, but not before ensuring that his legacy continues by helping to enhance the lives and livelihood of those experiencing homelessness and mental illness. Impressed by the Vanderbilt Street Psychiatry team’s passion and commitment in serving people who can’t or won’t access more traditional health care services, Kuhn’s family couldn’t imagine a better fit for the gift dedicated in his name.

According to Carla Fink, a patient of Fleisch’s who received her hepatitis A vaccine through the outreach program, Vanderbilt’s model of bringing vaccines directly into encampments is the reason many of her friends and neighbors have received it.

“Nobody would’ve just gone to the doctor and made an appointment to get their vaccine. They wouldn’t ever consider getting a vaccine if that team wasn’t coming directly to us. Once [the team] explained the [hepatitis] outbreak and how sick people were getting, I said, ‘I absolutely want one,’” said Fink.

“I’ve had E. coli and salmonella so bad before that I’ve ended up in the hospital. I know what it’s like to feel that sick. I’d much rather be stuck with a needle than catch anything.”

Fink refused the influenza vaccine.

Vanderbilt’s Street Psychiatry team — in partnership with Fricker and Trump — maintains a thorough record of everyone who has received and declined each vaccine and, through Vanderbilt’s newly adopted electronic medical record system, eStar, that record is synced with the one kept by the Metro Public Health Department, ensuring that a single patient won’t receive any vaccination more than once.

“We want to make sure that we’re administering these vaccines in a safe way and in a way that uses resources appropriately,” said Fricker. “I keep records of all the consent forms we have and of the temperatures at which the vaccines were kept. All that work is a commitment to patient safety, which is especially important when working in low-resource settings. It would be really easy to let our standards slide, but that’s one thing that we’ve been very adamant about: making sure it’s done well, documented well, and that the information is easily accessible.”

According to Miller, Fricker, Trump and Fleisch, one of the other outcomes of this vaccine program is the ability to teach medical students how to safely administer vaccines and communicate with populations with which they may not be used to interacting.

“By working with medical students from the Shade Tree Clinic, we’re able to make an immediate preventive care impact for persons who would otherwise likely never seek this resource but are hugely susceptible to serious downstream medical problems by not having a simple vaccine,” said Fleisch. “Watching the senior medical students — Fricker and Trump — teach more junior medical students how to give a vaccine, keep it at the right temperature, and how to best address someone who has been living on the street has been really touching, and I think the individuals we work with on the street are very willing to allow that teaching to happen.”

“I think you learn so much from being out in the community,” said Miller. “Just the little things of seeing groups of people that are suspicious of you and don’t want to engage and other groups of people that embrace you — you just don’t understand all of that unless you get out in the street.”

The vaccination program also provides significant savings for the health care system, as each hepatitis A vaccine costs $55 compared to the average $37,000 it costs to hospitalize a patient with the hepatitis A virus for five days. While the vaccination is most effective when given in two doses, the first dose provides 94 percent protection against the virus for 10 years.

Fleisch looks forward to helping extend the vaccination program beyond the lifespan of Nashville’s hepatitis A outbreak to meet the immediate care needs of the population she serves.

“I think the provision of vaccines during our regular Wednesday morning street rounds is really a game-changer for individuals who live behind the walls of society,” said Fleisch. “It’s very important to me that we’re able to show the Vanderbilt community and the country that we are able to provide care on the street in the same way that we can provide care in a clinic setting.”

For Fricker, who also teaches a medical photography class on the side, the outreach extends beyond meeting a community need — it’s about finding work that excites him at the intersection of his passions.

“Many persons who experience homelessness haven’t seen or held a picture of themselves in years. Providing someone with a beautiful, dignified and meaningful image can help build and sustain trust along with serving as an important vessel for engagement,” said Fleisch. “Greg has discovered a truly creative way to further enhance our program, identifying that medicine can often come in many forms.”

“I get to combine everything that I’m passionate about: talking with folks in low-resource settings, providing vaccinations — which I think are amazing and life-saving and can really make a difference — and engaging with these individuals photographically and being able to share those images with my peers,” said Fricker. “I get to combine all of those interests together in one singular thing that I get to do on Wednesday mornings, and it’s really the highlight of my week.”