Jessie M. Gaeta

Tobacco-, Alcohol-, and Drug-Attributable Deaths and Their Contribution to Mortality Disparities in a Cohort of Homeless Adults in Boston

OBJECTIVES We quantified tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities among homeless adults. METHODS We ascertained causes of death among 28 033 adults seen at the Boston Health Care for the Homeless Program in 2003 to 2008. We calculated population-attributable fractions to estimate the proportion of deaths attributable to tobacco, alcohol, or drug use. We compared attributable mortality rates with those for Massachusetts adults using rate ratios and differences. RESULTS Of 1302 deaths, 236 were tobacco-attributable, 215 were alcohol-attributable, and 286 were drug-attributable. Fifty-two percent of deaths were attributable to any of these substances. In comparison with Massachusetts adults, tobacco-attributable mortality rates were 3 to 5 times higher, alcohol-attributable mortality rates were 6 to 10 times higher, and drug-attributable mortality rates were 8 to 17 times higher. Disparities in substance-attributable deaths accounted for 57% of the all-cause mortality gap between the homeless cohort and Massachusetts adults. CONCLUSIONS In this clinic-based cohort of homeless adults, over half of all deaths were substance-attributable, but this did not fully explain the mortality disparity with the general population. Interventions should address both addiction and non-addiction sources of excess mortality.

Zoonotic and Vector-Borne Infections Among Urban Homeless and Marginalized People in the United States and Europe, 1990–2014

INTRODUCTION In high-income countries, homeless individuals in urban areas often live in crowded conditions with limited sanitation and personal hygiene. The environment of homelessness in high-income countries may result in intensified exposure to ectoparasites and urban wildlife, which can transmit infections. To date, there have been no systematic evaluations of the published literature to assess vector-borne and zoonotic disease risk to these populations. OBJECTIVES The primary objectives of this study were to identify diversity, prevalence, and risk factors for vector-borne and zoonotic infections among people experiencing homelessness and extreme poverty in urban areas of high-income countries. METHODS We conducted a systematic review and narrative synthesis of published epidemiologic studies of zoonotic and vector-borne infections among urban homeless and very poor people in the United States and Europe from 1990 to 2014. RESULTS Thirty-one observational studies and 14 case studies were identified (n = 45). Seroprevalence to the human louse-borne pathogen Bartonella quintana (seroprevalence range: 0-37.5%) was identified most frequently, with clinical disease specifically observed among HIV-positive individuals. Seropositivity to Bartonella henselae (range: 0-10.3%) and Rickettsia akari (range: 0-16.2%) was noted in multiple studies. Serological evidence of exposure to Rickettsia typhi, Rickettsia prowazekii, Bartonella elizabethae, West Nile virus, Borellia recurrentis, lymphocytic choriomeningitis virus, Wohlfartiimonas chitiniclastica, Seoul hantavirus (SEOV), and Leptospira species was also identified in published studies, with SEOV associated with chronic renal disease later in life. HIV infection, injection drug use, and heavy drinking were noted across multiple studies as risk factors for infection with vector-borne and zoonotic pathogens. CONCLUSIONS B. quintana was the most frequently reported vector-borne infection identified in our article. Delousing efforts and active surveillance among HIV-positive individuals, who are at elevated risk of complication from B. quintana infection, are advised to reduce morbidity. Given documented exposure to rodent-borne zoonoses among urban homeless and marginalized people, reducing human contact with rodents remains an important public health priority.

Predictors of Frequent Emergency Room Visits among a Homeless Population

Background Homelessness, HIV, and substance use are interwoven problems. Furthermore, homeless individuals are frequent users of emergency services. The main purpose of this study was to identify risk factors for frequent emergency room (ER) visits and to examine the effects of housing status and HIV serostatus on ER utilization. The second purpose was to identify risk factors for frequent ER visits in patients with a history of illicit drug use. Methods A retrospective analysis was performed on 412 patients enrolled in a Boston-based health care for the homeless program (HCH). This study population was selected as a 2:1 HIV seronegative versus HIV seropositive match based on age, sex, and housing status. A subgroup analysis was performed on 287 patients with history of illicit drug use. Chart data were analyzed to compare demographics, health characteristics, and health service utilization. Results were stratified by housing status. Logistic models using generalized estimating equations were used to predict frequent ER visits. Results In homeless patients, hepatitis C was the only predictor of frequent ER visits (OR 4.49, p<0.01). HIV seropositivity was not predictive of frequent ER visits. In patients with history of illicit drug use, mental health (OR 2.53, 95% CI 1.07–5.95) and hepatitis C (OR 2.85, 95% CI 1.37–5.93) were predictors of frequent ER use. HIV seropositivity did not predict ER use (OR 0.45, 95% CI 0.21 – 0.97). Conclusions In a HCH population, hepatitis C predicted frequent ER visits in homeless patients. HIV seropositivity did not predict frequent ER visits, likely because HIV seropositive HCH patients are engaged in care. In patients with history of illicit drug use, hepatitis C and mental health disorders predicted frequent ER visits. Supportive housing for patients with mental health disorders and hepatitis C may help prevent unnecessary ER visits in this population.

Homelessness, HIV, and Incomplete Viral Suppression

Background. The importance of HIV viral suppression is widely known, however few studies have examined the effects of homelessness on HIV viral suppression. Methods. The study included HIV-seropositive patients in a health care for the homeless program (HCH). Electronic medical record data for 138 patients were analyzed to compare demographic characteristics, health characteristics, and utilization by housing status. For the 95 individuals with available HIV viral loads, multivariable logistic analysis was performed to examine factors associated with incomplete viral suppression. Results. The adjusted odds ratio of incomplete HIV viral load suppression was 3.84 times higher in homeless compared with housed (95% CI 1.36–10.36) individuals. Illicit drug use and combined antiretrovirals (cART) were associated with HIV viral suppression. Conclusions. Homelessness predicted incomplete HIV viral suppression. Stable housing may improve viral suppression and access to cART. Drug use was associated with viral suppression, likely because of patient engagement with on-site addiction services.

The willingness of people who inject drugs in Boston to use a supervised injection facility

BACKGROUND In Massachusetts, the number of opioid-related deaths has increased 350% since 2000. In the setting of increasing overdose deaths, one potential intervention is supervised injection facilities (SIFs). This study explores willingness of people who inject drugs in Boston to use a SIF and examines factors associated with willingness. METHODS A cross-sectional survey of a convenience sample of 237 people who inject drugs and utilize Bostons needle exchange program (NEP). The drop-in NEP provides myriad harm reduction services and referrals to addiction treatment. The survey was mostly self-administered (92%). RESULTS Results showed positive willingness to use a SIF was independently associated with use of heroin as main substance (odds ratio [OR]: 5.47; 95% confidence interval [CI]: 1.9-15.4; P = .0004), public injection (OR: 5.09; 95% CI: 1.8-14.3; P = .002), history of seeking substance use disorder (SUD) treatment (OR: 4.99; 95% CI: 1.2-21.1; P = .05), having heard of SIF (OR: 4.80; 95% CI: 1.6-14.8; P = .004), Hispanic ethnicity (OR: 4.22; 95% CI: 0.9-18.8; P = .04), frequent NEP use (OR: 4.18; 95% CI: 1.2-14.7; P = .02), current desire for SUD treatment (OR: 4.15; 95% CI: 1.2-14.7; P = .03), hepatitis C diagnosis (OR: 3.68; 95% CI: 1.2-10.1; P = .02), posttraumatic stress disorder (PTSD) diagnosis (OR: 3.27; 95% CI: 1.3-8.4; P = .01), report of at least 1 chronic medical diagnosis (hepatitis C, human immunodeficiency virus [HIV], hypertension, or diabetes) (OR: 3.27; 95% CI: 1.2-8.9; P = .02), and comorbid medical and mental health diagnoses (OR: 2.93; 95% CI: 1.2-7.4; P = .02). CONCLUSIONS Most respondents (91.4%) reported willingness to use a SIF. Respondents with substance use behavior reflecting high risk for overdose were significantly more likely to be willing to use a SIF. Respondents with behaviors that contribute to public health burden of injection drug use were also significantly more likely to be willing to use a SIF. Results indicate that this intervention would be well utilized by individuals who could most benefit from the model. As part of a broader public health approach, SIFs should be considered to reduce opioid overdose mortality, decrease public health burden of the opioid crisis, and promote access to addiction treatment and medical care.

Experience and Outcomes of Hepatitis C Treatment in a Cohort of Homeless and Marginally Housed Adults

Joshua A. Barocas, MD, Marguerite Beiser, NP, Casey León, MPH, Jessie M. Gaeta, MD, James J. O’Connell, MD, and Benjamin P. Linas, MD, MPH Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts (Barocas); Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts (Barocas); Boston Health Care for the Homeless Program, Boston, Massachusetts (Beiser, León, Gaeta, O’Connell); Division of Infectious Diseases, Boston Medical Center, Boston, Massachusetts (Linas); Boston University School of Medicine, Boston, Massachusetts (Linas)

Self-reported Animal and Ectoparasite Exposure among Urban Homeless People

Abstract:Homeless people in the United States may experience poor hygiene and spend extended periods of time outdoors, which increases exposure to animal and insect vectors of disease. Despite these risks, efforts to understand frequency and risk factors for zoonotic and vector-borne infections among homeless people have been limited. We queried homeless people in Boston, Massachusetts (n=194) to evaluate exposure to urban wildlife and ectoparasites associated with infection. Thirty percent of participants reported seeing rodents daily, and 25% reported daily sightings of cats. Body lice and fleas were reported by 4% and 11% of participants, respectively. Sleeping outdoors and heavy drinking were positively associated with rodent and ectoparasite exposure. Frequent sightings of rodents and rodent feces among homeless people in particular areas may indicate human exposure risk to urban rodent-borne pathogens, including Leptospira spp, Seoul hantavirus, and Rickettsia akari. Epidemiologic studies of zoonotic and vector-borne infections in this population are warranted.

Prevalence of Housing Problems Among Community Health Center Patients

Prevalence of Housing Problems Among Community Health Center Patients In 2016, the Health Resources and Services Administration (HRSA) Health Center Program provided primary care to more than 25 million medically underserved patients through a nationwide network of community health center (CHC), health care for the homeless, migrant health center, and public housing primary care clinics.1 Although the latter 3 clinic types serve individuals with housing problems by definition, little is known about the scope of housing problems among CHC patients, who constitute 91% of Health Center Program patients nationally.1 We used data from a national survey to assess the prevalence and health-related correlates of housing problems among CHC patients.

Changes in public order after the opening of an overdose monitoring facility for people who inject drugs

BACKGROUND In the face of an increasingly fatal opioid crisis, Boston Health Care for the Homeless Program (BHCHP) opened the Supportive Place for Observation and Treatment (SPOT), a unique low-threshold harm reduction program for monitoring people who have injected drugs and are at imminent risk of overdose. This study examines the impact of the opening of the SPOT program on measures of injection drug-related public order in the neighborhood surrounding the facility. METHODS Data was collected at 10 weeks prior and 12 weeks post SPOT implementation on: number of over-sedated individuals in public, publicly discarded syringes, publicly discarded injection-related litter, and instances of active injection drug use or exchange of drugs. Changes were evaluated using Poisson log-linear regression models. Potential confounders such as weather and police presence were measured and controlled for. RESULTS The average number of over-sedated individuals observed in public significantly decreased by 28% (4.3 [95% Confidence Interval (CI) 2.7-6.9] v 3.1 [CI 1.4-6.8]) after SPOT opened. The opening of SPOT did not have a significant effect on the other measures of public order. The daily average number of publicly discarded syringes (28.5 [CI 24.5-33.1] v 28.4 [CI 22.0-36.5]), pieces of publicly discarded injection-related litter (376.3 [CI 358.6-394.8] v 375.0 [CI 345.8-406.6]), and observed instances of active use or exchange of drugs (0.2 [CI 0.1-0.9] v 0.1 [CI 0.0-0.1]) were not statistically significantly different after the opening of SPOT. CONCLUSIONS The opening of SPOT was associated with a significant decrease in observed over-sedated individuals. Other measures of injection-drug related public order did not improve or worsen with the opening of SPOT, however, they have been shown to improve with the implementation of a supervised injection facility.

Prevalence and risk factors for MRSA nasal colonization among persons experiencing homelessness in Boston, MA

Homeless individuals face an elevated risk of methicillin-resistant Staphylococcus aureus (MRSA) infection. Identifying the prevalence and risk factors for MRSA nasal colonization may reduce infection risk. A cross-sectional study was conducted at a health clinic for homeless persons in Boston, MA, USA (n=194). In-person interviews and nasal swab specimens were collected. MRSA isolates were genotyped using pulse-field gel electrophoresis (PFGE) and assessed for antibiotic susceptibility. The prevalence of MRSA nasal colonization was 8.3 %. Seventy-five percent of isolates reflected clonal similarity to USA300. USA100 (18.8 %) and USA500 (6.3 %) were also recovered. Resistance to erythromycin (81.3 %), levofloxacin (31.3 %) and clindamycin (23.1 %) was identified. Recent inpatient status, endocarditis, haemodialysis, heavy drinking, not showering daily and transience were positively associated with MRSA nasal colonization. Carriage of community-acquired MRSA strains predominated in this population, although nosocomial strains co-circulate. Attention to behavioural and hygiene-related risk factors, not typically included in MRSA prevention efforts, may reduce risk.