Vaccinating Hamilton’s homeless, one block at a time

I used to have an enviable life—travelled to Europe a couple of times a year, several trips to the states, a few courses here and there. You see, I have a little business on the side. I’m a chocolatier. I designed and had manufactured a novel piece of equipment for working with chocolate and I sell it around the world. In 2018, was invited by Ramon Morato, Creative Director for Cacao Barry (and really amazing chocolatier) to be a sponsor for the World Chocolate Masters in Paris. Back then, on Saturdays, if I wasn’t travelling the world, I worked a 24-hour shift in the ER, perhaps one or two 12-hour shifts during the week. Friday mornings, I saw drop-in clients at the Men’s Mission in Hamilton, Ont. Lots of days off during the week to get things done, to have lunch with my BFF, to bake, cook, work with chocolate and to teach people how to work with chocolate. Read: How to love patients with chronic pain For the last 20 years I spent about six weeks a year locuming in Little Current on Manitoulin Island. Called it my paid vacation. Rented a wonderful condo on the water from one of the docs, baked goodies every day to take into work. In September of 2019, I overcame an entire lifetime of avoiding responsibility, moving on from any job when things stopped being fun, and allowed myself to be voted in as the lead physician of the Shelter Health Network Physicians Group: 26 physicians who provide low-barrier care for homeless and marginally housed individuals in Hamilton. Shelter Health partners with a huge number of agencies in Hamilton: Good Shepherd, Mission Services, Wesley Urban Ministries to name just a few. It will be a couple of hours a week they said, no big deal they said . . . We reach the year 2020. In January, I returned from Rimini in northern Italy. February, I returned from Amsterdam. And in March, I returned from Michigan all in advance of their first outbreaks. Read: You used to buzz me on my pager The Michigan trip was a course in the home studio of a delightful chocolatier, Luis Amado, who does amazing chocolate work and teaches all over the world. I drove to this course even though it was March because I was concerned about flying due to COVID. Luis expressed concerns about his elderly mother and was very happy that she was with him in Michigan rather than in Guadalajara because he felt confident that she was better protected from COVID there with him. Her death in May was the first non-patient death from the virus that affected me deeply. The return from Michigan was March 9, 2020 and I was immediately immersed in COVID. That’s actually the last real day off that I’ve had. I’ve stayed at home a couple of days here and there (one of them while waiting for a swab result on myself) but there is COVID work to be done each and every day. I have become a swabbing and vaccinating automaton. I’d worked for 20 years in the STD clinic in Hamilton, so I’ve worked with everyone who is anyone in public health in Hamilton. Realizing early on during COVID that any symptomatic Shelter Health clientele wouldn’t be able to go to testing centers safely (i.e. they don’t drive, can’t put them on the bus or in a cab) we spoke with Dr. Marek Smiejk who runs the virology lab and arranged to have our swabs get priority there. One of a small group of SHN docs went out each day and collected NP swabs from our symptomatic clients, ran them to the lab and I would look up results later that same day. Each of the Shelter Health docs looked at the shelter where their clinic was located and looked to see if they could determine appropriate isolation spaces where a client could be housed while awaiting results. We also looked at the layout in the shelters and gave advice on spacing out clients and what hygiene measures should be introduced. Fortunately before long public health started up their IPAC assessments and we were able to turn it over to the experts. Read: The bitter irony of a patient putting their doctor on mute Early on, I became involved with staff from the city to help set up Hamilton’s first isolation centre for homeless individuals in a north-end recreation center. It could not have been done without SHN’s partnerships. The laundry service in town that provides and cleans isolation gowns for the nursing homes and hospitals was unable to provide them to our isolation center. But the truly amazing procurement officer from the Good Shepherd arranged to have them made. My hubby built us three UV boxes we used in the isolation center and clinics to sterilize goggles and small equipment. Our isolation facilities have changed over time, moving from the rec center into two separate locations, one run by Wesley Urban Ministries and the other by Good Shepherd. We also place families in two townhouses when family size dictates. Isolation centres are staffed by non-medical shelter staff and while Dr. Tim O’Shea handles most of the addiction questions, I get twice daily O2 sats and temperatures on all occupants. As necessary, a SHN doc will go in to deal with medical issues that don’t require hospital transfer. We went from a few swabs a day to joining a research project run through the McMaster Health Lab, run by Dr. David Bulir (who’s dermatology residency is on hold while COVID reigns). The initial project compared different swabbing methods and quickly concluded that if you were going to successfully do surveillance swabs week after week on shelter clientele and staff – NP swabs weren’t going to cut it. From the adoption of buccal-nasal swabs the next step was to scale up, determine a way to efficiently register large numbers of clients, quickly run PCR on them, and report in batches. So every evening I get batched results from the staff and clients of the shelters. Each location swabs from once to up to three times a week if they are in outbreak. We are doing up to 1,500 swabs a week. Having repetitive surveillance swabs means that when someone shows a potentially early positive result we can move them into isolation and repeat the swabs daily until we determine they are either becoming more positive or may just be showing some residual virus particles after a previous infection. It hasn’t yet been written up yet but I’m convinced that our strategy has averted some significant outbreaks in our shelters and prevented deaths. Read: Stop blaming family doctors In January and February of this year, a collection of docs, nurses and NPs from throughout Ontario who care for the homeless attended weekly meetings pulled together by Dr. Isaac Bogosh, who was on the Ontario Vaccine Distribution Taskforce. The discussion centered around when and how we would start vaccinating our clientele. My previous connections with public health gave me the audacity to start bugging everyone as soon as vaccines were available, arguing the case that congregate settings such as shelters were high risk, just like LTC facilities. Hamilton public health allowed us to start vaccinations for our shelter population early, so in late February we set up over a couple of weekends and gave the first Pfizer vaccines to about 625 clients and staff. Second vaccines were to have followed in 3 weeks—but you all know what happened there! When there was sufficient supply for second vaccines for shelter staff (who were classed as healthcare workers) to be received ahead of the four-month delay, I again went after my public health connections to get a supply of vaccine for these staff to have their second shots. Showing again the importance of good partnerships, when my vaccine fridge packed it in last fall, that same Good Shepherd procurement officer had found me the ‘ne plus ultra’ of office vaccine fridges, so I was golden for public health to allow me to have vaccine. Read: Frustrating vax-hesitancy conversations inspired me to do better Very shortly after second vaccines were approved for staff, homeless clients were approved and SHN ran another round of clinics in the shelters. A small group of us set out to mop up and came up with a variety of strategies. We ran ‘vaccine among the vines,’ in the garden out back of the hospice next door to my office. We vaccinated staff and clients who were able to come to us. I invested a small fortune in one of the mobile battery operated printers that public health uses to print out receipts so we could provide proper documentation to those who don’t have e-mail addresses or health cards, and so can’t download their receipt from the Covax site. I put together a number of small carryall baskets with everything needed to vaccinate so we could go to where clients are located and vaccinate them in situ. We drop into encampments, outside the various day centers where folks living rough hang out, outside of the supervised injection site and drop into the various shelters. The skate park has recently proved to be a good source of arms for extra doses left over after vaccinating at one of the food banks or outside St Patrick’s Church’s BBQ on a Friday afternoon. But I want my enviable life back! These days the alarm goes off at 6:30 am. I’ve generally been tossing since 5:00 am or so. I check and forward the results of EMS and nursing home staff swabs then head off to the office for a meeting or two, a few calls to various public health folks about the outbreaks and stray positives that don’t fit into any outbreak—out for several hours vaccinating in various locations, then hit the streets to get rid of any extra doses with iPads, printers and our vaccinating baskets loaded up. If I’m lucky, I get home between 5:00 and 6:00 pm, stuff a little food in my face, then await my evening results for the swabs done on shelter clients and staff. On a good day, I see them start to come in around 8:00 pm. And on a really good day, none of them are positive! Then I start calling in results to the various locations, arranging transport to isolation for any client positives, calls to the public health inspector for any positives that might generate an outbreak. I want my enviable life back! Kerry Beal is the lead physician of the Shelter Health Network (SHN) in Hamilton, Ont. She previously worked locums and emerg around Southern Ontario and for 20+ years spent part of each summer and fall working locums and ER in Little Current on Manitoulin Island. In addition to her work with SHN, Kerry works in the ER at Haldimand War Memorial Hospital in Dunnville.

Vaccinating Hamilton’s homeless, one block at a time

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