Description of LHD Pinellas County, located on the west coast of Florida, has a population of approximately 975,280 residents.(1) According to the U.S. Census Bureau estimates, non-Hispanic, white persons comprised 74.7% of the Pinellas County population in 2017, followed by non-Hispanic Black persons at 10%. Nationally, 16% of the country is above the age of 65, whereas Pinellas County is at 24.8%. (2) Situated on 608 square miles, only 274 of which are land, Pinellas County is the most densely populated county in Florida, with a density of 3,292 people per square mile. The Florida Department of Health in Pinellas County (DOH-Pinellas) is one of 67 County Health Departments operating under the Florida Department of Health (DOH). DOH-Pinellas serves Pinellas County with more than 700 employees in five different health department locations throughout Pinellas.

Public Health Issue Hepatitis A is an acute viral disease of the liver that is spread person-to-person through the fecal-oral route. The infection typically causes self-limited symptoms; however, in persons with pre-existing liver diseases, hepatitis A may be fatal. (3) After the Advisory Committee on Immunization Practices recommended childhood vaccination in elevated communities in 1999 cases fell from 854 to 165 reported yearly by 2008 in Florida.(4) Florida rates of hepatitis A cases remained low and were commonly travel-associated until increases of locally-acquired cases were detected in early 2018. In Pinellas County, the increase was dramatic, from an average of three cases a year between 2013-2017 to 113 cases in 2018 and 262 by May of 2019. By that time, over 77% were hospitalized for the disease. DOH-Pinellas began response activities as a coordinated Incident Management Team (IMT) in October 2018. To further the response efforts, the Florida State Surgeon General declared a Public Health Emergency on August 1, 2019. Most Hepatitis A infections were found among white, non-Hispanic males and in the 30-49 age group. Common risk factors included homelessness, current or previous incarcerations and a history of illicit drug use. Investigations further revealed most cases did not spend time in shelters or rehab facilities, but reported couch-surfing, residing in motels or without a permanent address. In addition to increased community outreaches and public health advisories, an intervention was needed that would effectively identify sites frequented by high-risk persons to assist with the dissemination of education and hepatitis A vaccines.

Goals To properly respond to the hepatitis A outbreak, the DOH-Pinellas IMT established a goal to vaccinate highest risk individuals and provide education using the field approach of foot teams.

Objectives The objectives of the DOH-Pinellas Foot Teams were to 1) track disease spread and conduct timely investigations to identify areas at highest risk for hepatitis A transmission, 2) provide targeted vaccinations to individuals at highest risk, and 3) disseminate hepatitis A risk reduction information to the community.

Implementation A concept of operations was developed to enhance outreach to target those hard-to-reach populations. To identify areas where high-risk activity was occurring, arrest records for hepatitis A cases incarcerated within the last six months were retrieved from the Pinellas County Clerk of Court records. Of interest were arrests that involved drug use, drug paraphernalia, or possession of drugs. The record search provided the location, offense, and arrest date, and the data was categorically standardized before it was mapped in ArcGIS. Identified areas were prioritized based on cluster size and distribution within the county. Following the foot team model utilized by San Diego in their 2017 outbreak, teams comprised of nurses, disease investigators and trained support staff traveled location-to-location, person-to-person utilizing a wagon filled with supplies and incentives to provide no-cost vaccines and education to individuals in identified areas. The first foot team was deployed in May 2019.

Results/Outcomes The main objectives of this practice were met: Since implementation, at least two foot teams were mobilized each week providing 995 vaccines to high-risk individuals. Throughout the outbreak response period, DOH-Pinellas has administered over 23,870 hepatitis A vaccines in Pinellas County.

Public Health Impact Despite vaccinating a high number of individuals through traditional outreaches at drug treatment facilities, homeless shelters and the county jail, a significant portion of at-risk individuals were reached as a result of a more aggressive approach that included spatial data analysis and foot team operations. The spread of disease and identified hepatitis A cases has declined in Pinellas County from 52.9 per 100,000-person months in May 2019 to 2.5 per 100,000 in November 2019.

Website for LHD The official website is http://pinellas.floridahealth.gov/

References

1U.S. Census Bureau. Quick facts. Population (2019). https://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml?src=bkmk

2U.S. Census Bureau. Quick facts. Population (2019). https://www.census.gov/quickfacts/fact/table/US/AGE775218

3Centers for Disease control and Prevention. Hepatitis A overview (2019). https://www.cdc.gov/hepatitis/hav/havfaq.htm#general

4Prevention of Hepatitis A through Active or Passive Immunization – Recommendations of the Advisory committee on Immunization Practices (ACIP). MMWR. 2006. 55(RR07):1-23.

Hepatitis A Outbreak Response: Foot Team Deployment Using Geospatial High-Risk Activity Data

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