By Rob Lawrence
Law enforcement officers will inevitably interact with the homeless to deal with a range of issues from criminal activity such as theft or assault through to medical response due to drug overdose, exposure to the elements or trauma. Unfortunately, the nature of homelessness predisposes individuals to a range of communicable and infectious diseases.
The 2015 U.S. Department of Housing and Urban Development (HUD) report on homelessness estimated that about 564,000 homeless people in the United States live in shelters and on the streets. This figure, based on a point-in-time snapshot on a single January night, may well be a vast underestimation but gives a good indication of the scope of the problem.
Health risks to police officers when responding to the homeless are numerous, requiring both knowledge of infection control procedures, as well as the essential personal protective equipment (PPE) to take universal precautions.
COMMUNICABLE DISEASES AND INFECTIONS
The main communicable diseases and infections that often affect homeless populations more severely than other populations and represent a risk for attending officers are:
Influenza
Influenza is an infectious disease that is highly contagious with hundreds of strains that mutate frequently. Symptoms to look out for include coughs, runny or stuffy noses, sore throats and fever. In addition to precautions on scene, prior protection in the form of annual flu immunization is highly recommended for officers.
Hepatitis
Hepatitis B is a viral disease that attacks the liver, which can cause both acute and chronic diseases. One study found that 32.5% of individuals experiencing homelessness and using substances or facing mental health problems, tested positive for the hepatitis B virus (HBV). As the vaccination for the prevention of hepatitis B is administered in three doses, people experiencing homelessness often face barriers in completing their full dosage of treatment within the required six-month period. Hepatitis spreads when people encounter blood, open sores, or body fluids of someone who has the hepatitis B virus.
HIV and AIDS
HIV (human immunodeficiency virus) is a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases. It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex or through sharing injection drug equipment. If left untreated, HIV can lead to AIDS (Acquired Immunodeficiency Syndrome). No effective HIV cure exists.
HIV can be acquired by coming into direct contact with certain body fluids from a person with HIV who has a detectable viral load. These fluids are blood, semen and pre-seminal fluid, rectal fluids, vaginal fluids and breast milk. For transmission to occur, the HIV in these fluids must get into the bloodstream of an HIV-negative person through a mucous membrane (found in the rectum, vagina, mouth, or tip of the penis); open cuts or sores; or by direct injection.
Observation is key and, as with most scenes where drug paraphernalia is present, officers should be careful to avoid accidental needlestick injury. A minor risk also exists if an individual is bitten by a person with HIV. Each of the very small numbers of documented cases has involved severe trauma with extensive tissue damage and the presence of blood. There is no risk of transmission if the skin is not broken, and it should be noted that HIV is not spread through saliva.
Tuberculosis
Tuberculosis (TB) is a disease caused by bacteria that usually attack the lungs, but can also damage other parts of the body.
TB bacteria are spread through the air from one person to another. The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, speaks or sings. People nearby may breathe in these bacteria and become infected. You are more likely to get TB if you have a weak immune system. Symptoms of TB in the lungs may include a bad cough (with blood being coughed up) and fever. The affected person may complain of weakness or fatigue. TB is not spread by shaking someone’s hand or sharing food or drink.
PREVENTION AND PRECAUTIONS
Officers can take several steps to protect themselves:
Understanding vs. fear
Scene safety is of paramount importance. This does not simply include the criminal aspect of the scene but also the environment. In attending and dealing with the homeless, an understanding of their vulnerable situation and knowledge of the contagious nature of their potential healthcare conditions is essential.
Ensure you have the proper equipment on scene
When arriving on scene, creating a barrier between yourself and the people you encounter can be easily achieved with the use of medical-grade gloves that test to the American Society for Testing and Materials (ASTM) F1671 Viral Penetration standards. This offers a barrier to blood, body fluids and other potentially infectious materials. If necessary, wear a simple surgical mask or, once EMS arrives on scene, ask them to place a mask on the homeless individuals you are dealing with.
While wearing the appropriate PPE, avoid the urge to touch your nose, eyes or mouth as the content of the exterior surface of the barrier glove could then transfer to the body. Longer cuff gloves can prevent skin exposure to hazards when dealing with homeless individuals. In addition, because the homeless living environment may contain contaminated sharp objects, a thicker glove may provide an additional layer of protection from injuries.
Handwashing and sanitizing
A key universal precaution that should be practiced regularly (whether dealing with the homeless or not) is thorough handwashing. Do not rely on hand sanitizers alone. Even though they are easily carried, they do not kill all types of germs, such as a stomach bug called norovirus, some parasites and Clostridium difficile (C. diff), which causes severe diarrhea. Handwashing, however, reduces the amounts of all types of germs on hands. Such importance is placed on handwashing that the CDC has a web page devoted to it.
Get vaccinated
Despite recent and very public objections to immunization, vaccines do a great job of keeping people from contracting serious diseases. The obvious and annual vaccination to protect police officers is the annual flu shot. These are usually free of charge; many hospitals and health centers will conduct vaccination for public safety workers on request. Vaccines do exist for some of the other complications that officers may encounter such as hepatitis A and B and all are encouraged to consult their departmental policy for vaccination and immunization offerings. As the saying goes in the public health world, prevention is better than cure.
FURTHER ADVICE
Additional steps law enforcement agencies can take include:
Collaborate with public health
Many departments already have outreach programs and work within their localities to be part of a joint task force to support the plight of their homeless populations. For those that have not established such outreach, the first port of call should be to link up with the local public health district and its director of public health. In establishing such a partnership, an understanding of what the health community calls its “population at risk” will become clear in addition to access to any community health assessments that could provide additional intelligence particularly around the disease, infection and chronic conditions on the streets.
Implement mental health outreach programs
The majority of homeless people have chronic health conditions, and many have mental and behavioral health issues. In 2017, the National Institute of Mental Health identified that nearly one in five adults in the United States lives with a mental illness; in the homeless population, this accelerates to 25% of those on the street. People who have a severe mental illness are over-represented in the homeless population, as they are often released from hospitals and jails without proper community support. State and regional behavioral health departments can offer education and partnership in developing and delivering homeless care programs.
Invest to save
Agencies should ensure basic personal protective equipment is readily available to patrol officers. A plentiful supply of gloves and masks will encourage officers to carry and wear them. This in turn assists with the general health of the department as absence through illness reduces deployed effectiveness and overtime-related costs.
About the author
Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. Currently, he is the principal of Robert Lawrence Consulting. He previously served as the chief operating officer of Paramedics Plus in Alameda County, California. Before that, Rob was the COO of the Richmond Ambulance Authority, which won both state and national EMS Agency of the Year awards during his 10-year tenure.