One Health Mobile Medical Unit

State: FL Type: Promising Practice Year: 2015

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The West Central Florida Medical Reserve Corps (WCFMRC) has a unique perspective on One Health and collaboration. Perhaps due to the large number of veterinarians in the unit, the WCFMRC is working to dramatically enhance zoonotic disease prevention in a truly vulnerable population in our community - the homeless. Innovative and novel events engage volunteers, integrate the WCFMRC with the regional veterinary medical association to better prepare for public health disaster response, and raise the visibility of veterinarians in public health while serving the human health needs of the homeless and the veterinary needs of their pets. Many homeless people in Pasco County have companion animals. Without routine appropriate preventive veterinary care, the animals could serve as a source of zoonotic disease to their owners and others. Additionally, conversations about pet care can frequently serve as "gateway" conversations to address personal care issues such as diabetes, hypertension and obesity. In 2012, the Sixth Circuit Public Defender’s office launched a Mobile Medical Unit (MMU) outreach program to provide routine and preventive medical care, as well as legal consulting services, to the homeless in Pasco County. On a regular schedule, the MMU travels to locations used by the homeless, such as ministries and shelters, to gain access to services. A medical care provider sees patients on a walk-up basis. The MMU continues to expand its reach to diverse populations through cultivation of community partnerships across the county. The Florida Department of Health in Pasco County (DOH-Pasco) provides medical oversight for the MMU. In June, October, and December 2013, and in June and August 2014, veterinarians, veterinary technicians and administrative support staff deployed by the WCFMRC joined the MMU to provide zoonotic disease prevention to animals owned by the homeless. Preventive procedures included a physical exam, rabies vaccination, flea prevention and gastrointestinal parasite control. Vaccination certificates were provided to the owners. Simultaneously, people were seen aboard the MMU by the human medical provider for routine care. An encouraging statistic from the initial event was that 9% of those utilizing services that day came for both animal and human medical services illustrating a true "One Health" approach to community health and disease prevention. With the lack of routine preventive medical care and low-level housing circumstances, sometimes only tents, the homeless are certainly more vulnerable than the average person to zoonotic disease. Couple these circumstances with a general lack of education and conditions for a public health disaster begins to emerge. These events provided a positive experience and introduced the idea of safe practices around animals to the homeless it served. Organized and active outreach to this vulnerable population to prevent transmissible and zoonotic diseases should be a priority for public health and community partners. Animal companions can help relieve the loneliness and negative health consequences that can accompany the newly homeless. Strategies for safely maintaining that beneficial human-animal bond should be promoted. Engaging local veterinary medical associations, local health departments, and service providers can work. After all, herd health is most effective when the entire herd is included.

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Pasco County Health Department
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One Health Mobile Medical Unit
Pasco County is a mixed urban, suburban, and rural county on the Gulf of Mexico and has one of the highest populations of homeless individuals in Florida. Of the ~475,000 residents of Pasco County, 3,305 were homeless on any given day in 2013 and ~3200 of those were “unsheltered” homeless. This unsheltered population lives and sleep in cars, abandoned buildings, or makeshift campgrounds. Approximately 25% of unsheltered homeless in Pasco are chronically homeless, meaning they have been homeless for >1 year or experienced >4 episodes of homelessness in the past three years. With such a high percentage of people living in undeveloped areas for extended periods of time, interactions with wild animals are inevitable. Such interactions could be harmful for the individual, especially for those who live in the woods and invade territories of wild animals. Since many homeless people do not have medical insurance or ready access to routine medical care, it is possible that many injuries may go unchecked and in time result in serious complications such as infection, sepsis, and even death. In addition, most homeless people lack access to routine preventive health care such as standard vaccinations. Moreover, their compromised living circumstances hinder routine hand washing, a simple, universal precaution that protects against zoonotic diseases, such as rabies or leptospirosis, that are prominent in Florida. Another factor influencing the homeless’ vulnerability to zoonotic diseases is the ownership of animals, typically dogs. The percent of animal caretakers among the homeless varies from group to group, but is estimated to be 10-24%. Access to routine preventive veterinary care is also very uncommon, increasing the vulnerability of the pet and the owner to zoonotic disease transmission.Since 2012, the Sixth Circuit Public Defender’s Office (PD) has operated a Mobile Medical Unit MMU) in Pasco County under medical oversight of DOH-Pasco that provides basic medical care and outreach services to homeless people. People come to the MMU to receive treatment for minor injuries and illnesses, vouchers for prescriptions/medication, physicals for work/school, and referrals for other services. In late 2012, the PD, DOH-Pasco and the Pasco Hernando Veterinary Medical Association (PHVMA) began collaborating to address this gap in infectious disease prevention. The One Health MMU’s goal was to increase access to veterinary care for animals owned by homeless persons and to provide an opportunity for gateway conversations with homeless persons regarding issues such as their own preventive medical care, diet, and mental health. Another goal was to decrease the population’s exposure to rabies and gastrointestinal parasites (i.e. hookworms) over time by decreasing the prevalence of such pathogens in this population. The One Health effort provides each animal a physical exam, administration of a gastrointestinal dewormer, ectoparasite control application, and a rabies vaccination. In June 2013, the first One Health MMU was held. The response was overwhelming – more than 40 people came seeking services for themselves and for 36 animals. One Health MMU events were held again in October and December 2013 and June and August 2014. In June 2014, the first annual “repeater” was seen! Spike, a Chihuahua owned by Beverly, returned to the MMU for his first-ever annual rabies booster. Spike was originally seen in June 2013 at the first event. Despite remaining unsheltered and homeless for the intervening year, Beverly was able to produce the original vaccine certificate from the previous visit! In September 2014, a bite report was filed on a dog owned by a homeless person. Current vaccine status was verified as the dog had been seen at a One Health MMU event and no post-exposure prophylaxis for rabies exposure was recommended for the bite victim resulting in a cost savings to the county of ~$7,000. At different One Health events significant mental health symptoms have been demonstrated by individuals unknown to the MMU who presented seeking care for their pets. The behavior was significant enough to merit intervention by the PD’s office and mental health professionals and those individuals were subsequently stabilized. Several people were distrustful of the medical profession in general, but sought care for their beloved pets. Through discussion with veterinarians, those individuals were convinced to seek care that day at the neighboring MMU event and several septic crises and resulting ER visits were avoided. The success of this practice is a result of significant efforts and relationships between the agencies involved: a Public Defender’s Office, DOH-Pasco, PHVMA, and WCFMRC. This effort has significantly raised the visibility of public health in our community and addressed a significant and ongoing need in one of the most vulnerable populations of people and animals. The DOH-Pasco website is: http://www.floridahealth.gov/chdpasco/default.html.
Pasco County, Florida, located in coastal west central Florida, has the second largest homeless population in the state, but only ranks 12th in overall population. The county still has many rural areas which can hinder public health outreach and communication with vulnerable populations such as the homeless. Adding to the vulnerability of Pasco County’s homeless is the fact that the majority of them are unsheltered and living outdoors full-time. The large number of homeless persons living unsheltered in rural areas is more likely to come into direct or indirect contact with wildlife or free-roaming domestic animals (strays). In fact, many of the homeless in Pasco County own animals themselves. The DOH-Pasco designed a program to reach this large vulnerable population (~3,305 people) to provide zoonotic disease prevention and open an avenue of communication to enhance their zoonotic disease risk perception. Assessment of existing efforts was quickly done. Since 2012 the DOH-Pasco collaborated with the Sixth Circuit Public Defender’s office to operate a mobile medical unit (MMU) that provides primary care to the uninsured and homeless on a routine basis. But, little had been done to directly address the issue of zoonotic diseases and animal care. An innovative program was instituted in 2013 to instigate conversations and raise awareness of zoonotic disease risk among the homeless and to provide zoonotic disease prevention to their animals. The DOH-Pasco has a significant contingent of veterinarians in their West Central Florida Medical Reserve Corps (WCFMRC) and a great working relationship with the local veterinary medical Association, the Pasco Hernando Veterinary Medical Association (PHVMA). Providing a One Health MMU is more complex than just having veterinarians report for work! The State of Florida regulates such activity through issuance of “Limited Service Permits” and costs are incurred for a biannual renewal of the permit and for the registration of each location. The WCFMRC purchases the biannual permit, with a WCFMRC member and the President of the PHVMA listed as the “Responsible veterinarian” on the permit and the PHVMA purchases each location registration. Several pharmaceutical companies were solicited by the PHVMA to provide vaccines for zoonotic diseases, gastrointestinal dewormers, ectoparasite prevention/treatments, and complete healthy diets to be distributed to each animal seen by the One Health MMU. The WCFMRC deploys member veterinarians to each One Health MMU event, occurring roughly 4-5 times annually, and provides equipment such as canopies, exam tables, chairs, and consumables. The veterinarians only deploy in conjunction with the primary care MMU and staff so that any human medical problems that might be discovered by the veterinarians can be addressed immediately by the medical provider on board the unit. For example, a man who was clearly in need of mental health stabilization and posed a danger to those around him presented with his four dogs. He had never been previously seen at the MMU although had been homeless for nearly a year. Once his behavior and symptoms were observed by medical staff on site, he was treated and stabilized that afternoon. Additionally his dogs had never been seen by a veterinarian. All the pets received preventive care and vaccine certificates that day. At another One Health MMU event, a man presented his St. Bernard mix dog for exam. The veterinarian noticed a wound on the man’s wrist and inquired. The dog had bitten the man two weeks before. He assured the veterinarian that he did not need care at the MMU as he did not trust doctors and, although the wound had festered for many days, it was now scabbed over and only swollen, but not draining. The veterinarian quickly developed a rapport with the dog and the man and then proceeded to walk the man 30 ft to the MMU and introduce him to the nurse practitioner so that he could be treated. The wound likely would have landed the man in the emergency room in a few more days as it was not healed nor improving. The dog bit someone else a few months later and that person avoided post-exposure prophylaxis for rabies because proof of current vaccine status was available from the One Health MMU event. This resulted in a cost savings of $7,000 for the county and spared the individual the pain, discomfort and inconvenience of treatment. As a result of initial pilot data collected via an exit survey at the initial One Health MMU event in 2013, DOH-Pasco is now launching an Institutional Review Board approved protocol for data collection in the area of zoonotic disease risk and risk perception among those seeking care at the MMU. This research is the first of its kind and a result of collaboration with DOH-Pasco, WCFMRC veterinarians and clinical psychologists at the nearby University of South Florida. Data collected from this investigation will be used by DOH-Pasco to better tailor zoonotic disease prevention/treatment among an incredibly vulnerable and difficult to reach population in Pasco County.
The Florida Department of Health in Pasco County (DOH-Pasco) is a mostly rural county north of Tampa and has one of the highest populations of homeless individuals in the state of Florida. Of the ~475,000 citizens of Pasco, 3,305 were homeless on any given day in 2013 and ~3200 of those were “unsheltered” homeless.  This unsheltered population are living and sleeping in a car, abandoned building, or makeshift campground. Approximately 25% of unsheltered homeless in Pasco are chronically homeless, meaning they have been homeless for >1 year or experienced >4 episodes of homelessness in the past three years. With such a high percentage of people living in undeveloped areas for extended periods of time, interactions with wild animals are inevitable. Such interactions could be harmful for the individual, especially for those who live in the woods and invade territories of wild animals. Since many homeless people do not have medical insurance or ready access to routine medical care, it is possible that many injuries may go unchecked and in time result in serious complications such as infection, sepsis, and even death. Additionally, most homeless people lack access to routine preventive health care such as standard vaccinations. Moreover, their compromised living circumstances hinder routine hand washing, a simple, universal precaution that protects against zoonotic diseases that are prominent in Florida, such as rabies, leptospirosis, and brucellosis. Another factor influencing the homeless’ vulnerability to zoonotic diseases is the ownership of animals, typically dogs. The percent of animal caretakers among the homeless varies from group to group, but is estimated to be 10-24%.  Access to routine preventive veterinary care is also very uncommon, increasing the vulnerability of the pet and the owner to zoonotic disease transmission. Since 2012, the Sixth Circuit Public Defender’s Office (PD) has operated a Mobile Medical Unit in Pasco County under Medical oversight of DOH-Pasco that provides basic medical care and outreach services to homeless people. People come to the Mobile Medical Unit to receive treatment for minor injuries/illnesses, vouchers for prescriptions/medication, physicals for work/school, and referrals for other services.  In late 2012, the PD, DOH-Pasco and the Pasco Hernando Veterinary Medical Association (PHVMA) began collaborating to address this gap in infectious disease prevention.  The One Health MMU’s goal was to increase access to veterinary care for animals owned by homeless persons and to provide an opportunity for gateway conversations with homeless persons regarding issues such as their own preventive medical care, diet, and mental health.  Another goal was to decrease the population’s exposure to rabies and gastrointestinal parasites (i.e. hookworms) over time by decreasing the prevalence of such pathogens in this population.    The One Health effort would provides each animal a physical exam, administration of a gastrointestinal dewormer, ectoparasite control application, and a rabies vaccination.   The DOH-Pasco has a significant contingent of veterinarians in their West Central Florida Medical Reserve Corps (WCFMRC) and a great working relationship with the local veterinary medical Association, the Pasco Hernando Veterinary Medical Association (PHVMA).  Providing a One Health MMU is more complex than just having veterinarians report for work!  The State of Florida regulates such activity through issuance of “Limited Service Permits” and costs are incurred for a biannual renewal of the permit and for the registration of each location.  The WCFMRC purchases the biannual permit, with a WCFMRC member and the President of the PHVMA listed as the “Responsible veterinarian” on the permit and the PHVMA purchases each location registration.  Several pharmaceutical companies were solicited by the PHVMA to provide vaccines for zoonotic diseases, gastrointestinal dewormers, ectoparasite prevention/treatments, and complete healthy diets to be distributed to each animal seen by the One Health MMU.  The WCFMRC deploys member veterinarians to each One Health MMU event, occurring roughly 4-5 times annually, and provides equipment such as canopies, exam tables, chairs, and consumables.  The veterinarians only deploy in conjunction with the original MMU and staff so that any human medical problems that might be discovered by the veterinarians can be addressed immediately by the medical provider on board the unit.   Overall, the cost of the effort is relatively low.  Labor is provided by volunteers with the WCFMRC, the PHVMA purchases necessary consumables and provides pharmaceuticals, the WCFMRC and DOH-Pasco provide standard equipment such as tables, chairs, canopies, etc., and the PD’s office advertises the outreach via word of mouth among homeless service providers.  Ongoing costs for pharmaceuticals are borne by the PHVMA and permitting costs are split by PHVMA and DOH-Pasco.  This truly is a collaborative community effort so that the cost to any single partner does not become prohibitive.  
The One Health MMU program has produced large amounts of information related to providing for the public health of the homeless in Pasco County. For example, initial data confirmed that even those homeless not currently owning animals have frequent contact with wildlife and free-roaming domestic animals. Prior to this program many in local public health programs dismissed this possibility. Additionally, many of the homeless-owned animals do not receive minimum preventive veterinary care nor do the homeless persons access medical services at the MMU. With the trust and rapport that has been carefully cultivated since the addition of veterinary services to the MMU, more members of this vulnerable and difficult-to-reach population are accessing both. Initial goals of this program were to 1) provide access to preventive veterinary care for animals owned by the homeless, 2) improve zoonotic disease risk perception among the homeless 3) provide education on safe hygiene practices and their importance, 4) decrease the burden on public health regarding response to animal bites from animals owned by homeless persons. All these objectives were achieved within the first 14 months of the program. The majority of the animals seen at the One Health MMU events have not seen a veterinarian in the last 12 months or ever. At the one year mark, the One Health MMU saw the first annual “repeater.” Spike, a chihuahua owned by Beverly, was seen June 20, 2013 at the first One Health MMU event and received his first-ever rabies vaccine and flea prevention. On June 19, 2014, Beverly brought Spike to a One Health MMU event for his first-ever annual rabies vaccine booster and more flea prevention. In fact, Beverly had lived unsheltered for the intervening year, and managed to keep Spike’s original vaccine certificate issued by the One Health MMU in 2013 and bring it with her on June 19, 2014. Many more annual “repeaters” followed in subsequent events in 2014. Many of the homeless are unaware of the risk of handling wildlife, hunting and eating wildlife, and the risk of disease exposure to their animals that live with them. Many discussions regarding these issues and their importance were conducted by personnel at every One Health event. This is the beginning of health education for this population that addresses their particular vulnerabilities. In September 2014, “Cujo,” a dog owned by a homeless man named Francisco, was the subject of a bite report from local animal control to the DOH-Pasco epidemiology program. Ordinarily, this would result in the victim potentially receiving post-exposure prophylaxis (PEP) for rabies or the dog being euthanized and decapitated for rabies testing since quarantine compliance would not be possible for a homeless owner. In this case, “Cujo”’s current vaccine status was verified with a certificate from the One Health MMU and by photo taken at the time of vaccination, and rabies was ruled out as a possible zoonotic issue. This amounted to a huge win: no loss of canine life, strengthening the owner’s trust of DOH-Pasco, a cost-savings of ~$7,000 (PEP administration), and a better outcome for all involved. Overall, the evaluation of the introduction of this program is a wild success.
The Florida Department of Health in Pasco County (DOH-Pasco) is a mostly rural county north of Tampa and has one of the highest populations of homeless individuals in the state of Florida. Of the ~475,000 citizens of Pasco, 3,305 were homeless on any given day in 2013 and ~3200 of those were “unsheltered” homeless. This unsheltered population are living and sleeping in a car, abandoned building, or makeshift campground. Approximately 25% of unsheltered homeless in Pasco are chronically homeless, meaning they have been homeless for >1 year or experienced >4 episodes of homelessness in the past three years. With such a high percentage of people living in undeveloped areas for extended periods of time, interactions with wild animals are inevitable. Such interactions could be harmful for the individual, especially for those who live in the woods and invade territories of wild animals. Since many homeless people do not have medical insurance or ready access to routine medical care, it is possible that many injuries may go unchecked and in time result in serious complications such as infection, sepsis, and even death. Additionally, most homeless people lack access to routine preventive health care such as standard vaccinations. Moreover, their compromised living circumstances hinder routine hand washing, a simple, universal precaution that protects against zoonotic diseases that are prominent in Florida, such as rabies, leptospirosis, and brucellosis. Another factor influencing the homeless’ vulnerability to zoonotic diseases is the ownership of animals, typically dogs. The percent of animal caretakers among the homeless varies from group to group, but is estimated to be 10-24%. Access to routine preventive veterinary care is also very uncommon, increasing the vulnerability of the pet and the owner to zoonotic disease transmission.Since 2012, the Sixth Circuit Public Defender’s Office (PD) has operated a Mobile Medical Unit in Pasco County under Medical oversight of DOH-Pasco that provides basic medical care and outreach services to homeless people. People come to the Mobile Medical Unit to receive treatment for minor injuries/illnesses, vouchers for prescriptions/medication, physicals for work/school, and referrals for other services. In late 2012, the PD, DOH-Pasco and the Pasco Hernando Veterinary Medical Association (PHVMA) began collaborating to address this gap in infectious disease prevention. The One Health MMU’s goal was to increase access to veterinary care for animals owned by homeless persons and to provide an opportunity for gateway conversations with homeless persons regarding issues such as their own preventive medical care, diet, and mental health. Another goal was to decrease the population’s exposure to rabies and gastrointestinal parasites (i.e. hookworms) over time by decreasing the prevalence of such pathogens in this population. The One Health effort provides each animal a physical exam, administration of a gastrointestinal dewormer, ectoparasite control application, and a rabies vaccination. The DOH-Pasco has a significant contingent of veterinarians in their West Central Florida Medical Reserve Corps (WCFMRC) and a great working relationship with the local veterinary medical Association, the Pasco Hernando Veterinary Medical Association (PHVMA). Providing a One Health MMU is more complex than just having veterinarians report for work! The State of Florida regulates such activity through issuance of “Limited Service Permits” and costs are incurred for a biannual renewal of the permit and for the registration of each location. The WCFMRC purchases the biannual permit, with a WCFMRC member and the President of the PHVMA listed as the “Responsible veterinarian” on the permit and the PHVMA purchases each location registration. Several pharmaceutical companies were solicited by the PHVMA to provide vaccines for zoonotic diseases, gastrointestinal dewormers, ectoparasite prevention/treatments, and complete healthy diets to be distributed to each animal seen by the One Health MMU. The WCFMRC deploys member veterinarians to each One Health MMU event, occurring roughly 4-5 times annually, and provides equipment such as canopies, exam tables, chairs, and consumables. The veterinarians only deploy in conjunction with the original MMU and staff so that any human medical problems that might be discovered by the veterinarians can be addressed immediately by the medical provider on board the unit. Overall, the cost of the effort is relatively low. Labor is provided by volunteers with the WCFMRC, the PHVMA purchases necessary consumables and provides pharmaceuticals, the WCFMRC and DOH-Pasco provide standard equipment such as tables, chairs, canopies, etc., and the PD’s office advertises the outreach via word of mouth among homeless service providers. Ongoing costs for pharmaceuticals are borne by the PHVMA and permitting costs are split by PHVMA and DOH-Pasco. This truly is a collaborative community effort so that the cost to any single partner does not become prohibitive. The cost/benefit analysis for DOH-Pasco is certainly heavy in the benefit side – minimal staff time, great engagement of non-traditional partners, cultivation of relationship with difficult to reach vulnerable population, and overall prevention of significant diseases in the community. The PHVMA has really taken this project up as their major service project for the last 2 years and their growing pride in the program and the unique collaboration with public health helps to ensure their commitment to sustainability of the project and use of peer pressure to help it continue. From the DOH-Pasco perspective, a lesson in engaging professionals to join the WCFMRC and then take on leadership roles was that DOH-Pasco personnel need to have face-to-face contact. Attendance, upon invitation, at routine monthly association meetings were critical in engaging the veterinary association at the very beginning and ensuring that services did not compete or conflict with local practices.  This project has become really entrenched in the community now and will certainly sustain for the next few years.  Sharing outcomes and data with the partners is key to their continued commitment to making a difference in this effort.
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