Introduction to The Manual

We have attempted to make this book easy to navigate and read. Most chapters are designed to be informative for clinicians and readable for shelter staff. This second edition of the manual acknowledges the profound effects that homelessness has on health; in addition to common communicable diseases, we have added several other illnesses and conditions confronted frequently by clinicians working on the streets and in the shelters. Esoteric “zebras” have been left for the more complete medical textbooks.
The manual is divided into seven parts.

Part One contains discussions of 28 communicable diseases and 3 infections (cellulitis, pneumonia, and sinusitis) seen frequently among homeless populations. Each chapter has been written by clinicians experienced in the prevention and control of these infections and infestations in shelter settings. An attempt has been made to inform health care clinicians while also making these chapters readable to a more general audience, especially the staff and workers in shelters who are also exposed to these diseases. Each chapter briefly discusses the prevalence, transmission, diagnosis, treatment, and prevention of a particular communicable disease. A brief summary of the salient points concludes each chapter, followed by a few selected references for those who wish more in-depth knowledge.

A new feature of this edition is a list of the major medications in each chapter. Many clinicians bemoan the confusion caused by the interchangeable use of the generic and brand names of various medications, particularly with HIV medications, antibiotics, and antihypertensive medicines. A list appears at the end of each chapter that includes the generic name of each medicine, the most common brand name products, and the relative cost. We have adopted the scale of $ to $$$$$ as utilized in the Tarascon 2004 Pocket Pharmacopoeia, in which:
$ = $25
$$ = $25-$49
$$$ = $50-$99
$$$$ = $100-$199
$$$$$ = $200 or more.

The relative costs were included in response to requests by clinicians concerned about judicious and cost-effective prescribing practices, particularly with poor and uninsured populations. Two caveats must be underscored with these medication lists: (1) the most common brand-name products are listed in alphabetical order, and the authors do not in any way endorse the use of any specific brand-name medications in this manual; (2) the relative costs are based on average wholesale costs for a month of maintenance therapy, such as diabetes and hypertension medications, or a course of short term treatment, such as antibiotics. These should be seen as rough guidelines only, as the cost of each medication can vary from state to state and from time to time, and can be dramatically influenced by the buying strategies of health plans, Medicaid and Medicare.

Part Two is new to this edition. Survival on the streets exposes homeless persons to the extremes of weather and the elements. This section discusses accidental hypothermia and frostbite, as well as hyperthermia and heat stroke.

Part Three is another new addition to this manual and attempts to respond to an array of bewildering future and present challenges in shelter and street medicine. The emerging menace of bioterrorism is highlighted, as well as the perplexing array of nosocomial infections that can be spread easily in shelters. Recommendations on the proper use of antibiotics are offered in a chapter, while the two final chapters are designed to help clinicians manage chronic pain and recognize the subtle and debilitating consequences of traumatic brain injury.

Part Four addresses the management of chronic illnesses in a population without housing or a safe place to heal and store medications. The Chronic Care Model, developed through the Health Disparities Collaboratives of the Bureau of Primary Health Care, has some exciting new approaches to the organization and delivery of care for illnesses such as diabetes and depression. Several health care for the homeless projects have participated in this endeavor.

Part Five details the immunization schedules for children and adults, as well as some of the illnesses rendered rare by widespread vaccination programs, such as polio, diphtheria, mumps, rubella, and tetanus. Other resurgent or persistent vaccine-preventable infections, such as measles, pertussis, Haemophilus influenzae type b, and hepatitis B, are included with the common communicable diseases in Part One.

Food management in shelters and soup kitchens is the topic of Part Six, which includes practical suggestions for the proper handling, storage, and preparation of food in those settings. Periodic outbreaks of hepatitis A, including a recent one here in Boston, continue to make us aware of the critical importance of this topic.

Fact sheets for shelter guests are compiled in Part Seven. Now in Spanish as well as English, these simple instructions for families and individuals are intended to be photocopied and given to shelter guests during outbreaks of communicable diseases. These were very popular in our first edition, and we hope you will find them useful once again.

Our recommendations and suggestions are obviously not dogma. Most of our approaches are based on practical experience over these past two decades and have worked well in the shelters. We fully acknowledge that other approaches abound, many of which are perhaps better. We also understand that shelters differ in size, layout, staffing, rules for entry, and a host of other variables that are generally out of the control of health care clinicians. Our hope remains that this book, as the previous edition over a decade ago, will generate an open discussion among the growing number of clinicians in this field and will lead us all to more effective strategies for preventing and managing these illnesses and conditions in shelters and on the streets.
The pace of medicine has accelerated dramatically, and new treatments and approaches will inevitably supercede many of our current recommendations. We urge you to maintain a dialogue with your local health departments, hospitals, and community health centers in order to keep abreast of the most current methods of prevention, control, and treatment of communicable diseases in your cities and neighborhoods.