Homeless Users Research Articles

Community outbreak of COVID-19 among people who use drugs attending a harm reduction centre in Barcelona, Spain

BackgroundThe COVID-19 pandemic particularly affected the health of vulnerable population, such as people who use drugs. Due to compromised baseline health status, certain drug uses and settings and socioeconomic deprivation related to poverty and homelessness, drug users faced higher risk of COVID-19 infection. They had difficulty in adhering to the public health measures (i.e. physical distancing, hand hygiene and mask use). Also, the struggle to implement non-pharmaceutical actions (i.e. test–trace–isolate–quarantine strategy) among SARS-COV-2-infected drug users and their close contacts challenged the public health response. Therefore, this study aimed to describe a community COVID-19 outbreak and its approach among drug users of a harm reduction programme in an outpatient drug treatment centre in Barcelona, Spain.MethodsWe conducted an observational descriptive study of an outbreak of COVID-19 among people who use drugs attending the harm reduction programme of an outpatient drug treatment centre in the city of Barcelona, between July and October 2021 (n = 440). A passive search for cases was carried out with rapid antigens tests targeting symptomatic users who attended the facilities.ResultsNineteen positive COVID-19 cases were identified among symptomatic drug users, between July and October 2021, with an attack rate of 4.3%. Specific measures were taken to control the outbreak, such as offering accommodation to self-isolate in a low-threshold residential resource to homeless drug users who tested positive and intensifying the vaccination strategy. The management of the outbreak was carried out in close collaboration between the outpatient centre and the main public health stakeholders in the city of Barcelona.ConclusionsThis study shows the complexity of managing and investigating COVID-19 outbreaks in vulnerable population groups. Epidemiological control measures, such as the test–trace–isolate–quarantine strategy, were challenging to implement due to technology-related barriers and socioeconomic vulnerabilities, especially homelessness. Community-based interventions, cooperation among stakeholders and housing-related policies were helpful in tackling outbreaks among people who use drugs. When addressing vulnerable and hidden populations, the perspective of inequalities should be included in epidemiological surveillance and outbreak control strategies.

Drug policy or lack of it, from users' view: ADAW on site in San Francisco

Last week, we were in San Francisco for the 2023 annual meeting of the American Psychiatric Association (APA), and for a visit to the Tenderloin — the part of the city that is home to the homeless drug users, mainly fentanyl users. We spent a sunny Monday morning walking through the streets of the Tenderloin. One of our main goals was to find out whether the users there had been offered, or wanted, treatment. We passed the OTP (opioid treatment program), which is in the midst of it all. But we did get one response that treatment was too much trouble. It's hard to see how it would be more trouble than the lives that these drug users, most of whom are homeless, currently live.

New Psychoactive Substances in the Homeless Population: A Cross-Sectional Study in the United Kingdom

The last few years have seen the emergence of new psychoactive substance among the homeless population, specifically synthetic cannabinoid receptor agonists. The purpose of this study is to investigate the knowledge and experiences of new psychoactive substances amongst users from the homeless population. An explanatory research design was applied using a semi-structured questionnaire with the focus on gaining insights on the prevalence, motivations and effects. Participants were recruited through convenience sampling from support organisations and charities UK-wide. Descriptive statistics and logistic regression were applied to analyse the data obtained from participant surveys. A total of 105 participants met the inclusion criteria and were in the age range of 18 to 64 years old. Almost 70% consumed new psychoactive substance products, which “Spice” was the most prevalent substance. Homeless users had consumed new psychoactive substance to escape reality and to self-treat themselves and stopped consumption due to the adverse effects. Adverse events were reported from the majority of the participants and led to more than 20% of the participants requiring medical treatment following hospitalisation. Findings from this study can contribute to the development of guidelines and policies that specifically address the needs of the homeless population who use new psychoactive substances.

Challenges and Prescriptions for Homeless Drug Users’ Social Reintegration; An Experience of Partnerships Between Iran and Europe NGOs

The research addressed challenges and prescriptions for reintegration of homeless people who use drugs. Data were collected through conducting semi-structured interviews. Twenty-nine participants were recruited. The primary codes were extracted and divided into two main categories of challenges and prescriptions; the former included becoming homeless after a long term recovery, workplace stigma, service users’ different cultural backgrounds, dismissing the 12-Step Program, message fatigue, negative effect of relapse on groups and cyberspace overuse; and the latter included connection by hook or by crook, abstinence-harm reduction orientation, organizational service collection, pushing boundaries of interventions, and expanding services umbrella.

Housing characteristics of crack cocaine users in Northeast Brazil, 2011-2013.

We compared sociodemographic characteristics, substance use patterns, sexual behavior, use of health services, and criminal records of homeless vs. domiciled users. Data are from the Brazilian National Survey on Crack Use. A discriminant model and correspondence analysis cross-compared characteristics of users according to their housing status. The logistic model revealed associations between "living in the streets" and female gender and intermittent work. "Homelessness" was also associated with the use of tobacco and "oxi" in the previous 30 days, reliance on soup kitchens, low access to public mental health services, and arrests in the previous year. Correspondence analysis highlighted the spatial proximity of the variables as follows: "having traded sex for drugs", "informal work", "age 31 years or older", "access to public mental health services", "problems with law enforcement", and female gender with homeless crack users. People who smoke crack cocaine in Northeast Brazil are seldom studied. Their profiles, stratified according to their housing conditions, show subgroups with specific characteristics. While domiciled users have access to specialized clinics, homeless users basically reported access to free food and harm reduction services.

The homeless injection drug users and crack smokers in Montréal: different levels of attachment and uses of the place Émilie-Gamelin

The homeless injection drug users and crack smokers in Montréal: different levels of attachment and uses of the place Émilie-Gamelin

The impact of the 2016 Psychoactive Substances Act on synthetic cannabinoid use within the homeless population: Markets, content and user harms.

On 26 May 2016, the UK introduced the Psychoactive Substances Act. The Act made it an offence to produce, supply, or offer to supply, any psychoactive substance likely to be used for its psychoactive effects. While a Home Office review of the Act in 2018 proclaimed that the Act had been successful in achieving its main goal of preventing the open sale of psychoactive substances, significantly, the review acknowledged that high levels of synthetic cannabinoid use remain amongst vulnerable user groups, in particular the homeless population. The research adopted an innovative interdisciplinary approach drawing on sociology and chemistry. The sociological element involved 82 face-to-face qualitative semi-structured interviews with 37 homeless synthetic cannabinoid users, 45 stakeholders, and over 100h of fieldwork observations. The chemical analysis element involved the testing (using Gas Chromatography-Mass Spectrometry) of 69 synthetic cannabinoid street samples obtained by a local police force. The introduction of the Act was associated with a number of significant changes to the synthetic cannabinoid market, including the integration of synthetic cannabinoids into the existing illicit street market, new dealers, the adoption of more targeted and aggressive supply practices, and variability in the content and potency of synthetic cannabinoids. Combined, these changes have increased the risk of harm to homeless users and homeless sector staff and resulted in a concomitant increase in the demand on emergency services. The foreseen concerns that the Act would result in detrimental market changes and increased harms to vulnerable user groups have been manifested in the homeless population. The failure of the Act to reduce synthetic cannabinoid use within this group, combined with the increased risk of individual and societal harm, highlights the importance of reducing the demand for synthetic cannabinoids.

When policy and opportunity meet: Barcelona's first gender responsive shelter for homeless drug users

Issue/problemDrug policies in Barcelona have been guided by the Barcelona City Drug Action Plan (PADB). This four-year plan aims to prioritise and evaluate drug policies. The need to have a low-threshold residential resource for homeless people using drugs (HPWUD) is an objective that had been present in successive plans, but unfortunately could not be realised so far. In Spain, the covid-19 pandemic led to a total country lockdown. A great intersectoral coordination effort involving Barcelona City Council and the Public Health Agency of Barcelona together with third sector organisations resulted in the opening of the first gender responsive low-threshold residential resource for HPWUD in Barcelona.Description of the problemPending a broader evaluation, quantitative indicators are available for 6 months (3 April to 3 October 2021), informing about: How many people were accommodated? What are their profiles? What drugs do they use? How many overdoses were reverted? How many successful discharges? How many people confined/isolated due to covid-19? What are the challenges?ResultsPreliminary results showed that during first 6 months, 120 people (74 men, 42 women and 4 non-binary) were accommodated. All places reserved for women were covered. About 44% were Spaniards; being opioids and alcohol, the main used in the HPWUD. Thirty overdoses reverted (60% due to stimulants). There were 39 people confined and 2 residents isolated due to covid-19. The challenges are to continue to improve the new alcohol harm reduction program, work on adherence and mainstreaming gender.LessonsBarcelona PADB is instrumental to guide evidence-based interventions to reduce health and social inequalities in highly vulnerable and underserved population. This new gender-responsive residential setting for HPWUD with a comprehensive harm reduction program together with health and social care is unique in Barcelona.Key messages Drug policy to guide evidence-based interventions to reduce health and social inequalities in highly vulnerable and underserved population.First low-threshold gender responsive residential resource for homeless people using drugs has opened in Barcelona.

An online home for the homeless: A content analysis of the subreddit r/homeless

There is currently a little observational work exploring homeless peoples’ digital networking behaviors, with previous research relying on limited self-report data. This study fills this gap through a qualitative thematic analysis of the public subreddit r/homeless. We analyzed the 30 most commented posts on the subreddit from each month of 2019, examining a total of 360 posts. We find that r/homeless contributions primarily center around (a) commentary on social issues, (b) communication of needs and concerns, (c) offering of care and support, and (d) online community management and engagement, suggesting that homeless individuals not only leverage the r/homeless subreddit to gain support and information, but to generate discourse around larger societal issues. Evidence of both bridging and bonding ties was present on the subreddit, with bonding ties being especially valued and sought after by homeless users, contributing to the growing literature on the relationship between social capital, social media, and homelessness.

Precários e sobrantes: os sentidos do trabalho para usuários de drogas em situação de rua

A população em situação de rua (PSR) apresenta-se hoje como expressão máxima da questão social. O objetivo deste artigo é analisar os sentidos do trabalho entre pessoas em situação de rua usuários de drogas. Foi realizada uma investigação etnográfica que se valeu de observação participante e entrevistas em profundidade realizadas com 6 homens em situação de rua, que vivem próximos de instituições que prestam serviços voltados para a PSR em Juiz de Fora (MG). Os resultados encontrados foram sintetizados a partir das seguintes categorias: a) o trabalho como valor central; b) o não reconhecimento de si como trabalhador; c) a reprodução do discurso precarizado. A partir desses resultados, refletimos como a centralidade da categoria trabalho e a inserção nele de forma precária têm impactos nocivos e específicos na saúde mental.

Developing and Testing the Populi Needle Exchange Point Finder: An App to Reduce Harm Associated With Intravenous Drug Consumption Among Homeless and Non-homeless Drug Users.

The spread of viral infections remains a serious public health problem. People who inject drugs represent one of the highest-risk groups. eHealth and mHealth have been shown to be effective in improving individuals' management of their own health and their access to health care and to contribute to reducing the costs associated with certain medical interventions. People who inject drugs, including homeless people, tend to have access to technology. Young homeless people in particular are likely to use smartphones and social networking sites in ways that are similar to the general population. Despite this widespread use of technology, there are no apps designed specifically to reduce harm in people who inject drugs. The objective of this study is to analyze the development and usability testing process for an application for mobile devices, designed to complement the Needle Exchange Program. This app—the first of its kind—was developed by a public health agency, specialized professionals and people who inject drugs. We analyzed the differences in how health providers and drug users experienced the usability of the app. The participants were 61 members of multidisciplinary professional group and 16 people who inject drugs. We used a cross-sectional quantitative, observational design. First, we created and administered a questionnaire to collect the sociodemographic characteristics that could mediate the use of technology. Next participants tried the app and filled out a second questionnaire in which they rated their experience on a Likert scale from 1 to 7 in the following dimensions: overall attractiveness of the app, ease/difficulty of use, the extent to which they believed the app could improve access to injection materials, the extent to which they thought it would improve PWID's participation in the needle exchange program, overall utility, the degree to which they thought PWID would use the app, and the need for the app. To analyze the answers, we used contingency tables and compared means using a Student's t test. Finally, we conducted six audio-recorded focus groups about how the participants experienced the usability of the app. The objective of this part of the study was to classify and quantify the contributions of individuals and the group according to three predefined categories: potential benefits and positive aspects, potential obstacles or difficulties in carrying out the project, and concrete suggestions for improving the interface. There were not significant differences between the sociodemographic variables and the variables related to use of the app between professionals and PWID. Both professionals and PWID rated the app as intuitive and useful, especially the geolocation function for NEPs. Both groups also thought that the interface contained too much information and that this excess could be confusing for users. Both groups also had similar opinions about the app and its uses. An important difference between the two groups is that PWID reported that they would use the app, while professionals reported that they didn't think PWID would use it. All participants proposed improvements on the prototype, suggestions that will be applied in the creation of the definitive interface. Including professionals and patients in this sort of usability test enables researchers and developers to detect the needs of potential app users.

Using Blockchain Technology to Mitigate Challenges in Service Access for the Homeless and Data Exchange Between Providers: Qualitative Study.

BackgroundIn the homeless population, barriers to housing and supportive services include a lack of control or access to data. Disparate data formats and storage across multiple organizations hinder up-to-date intersystem access to records and a unified view of an individual’s health and documentation history. The utility of blockchain to solve interoperability in health care is supported in recent literature, but the technology has yet to be tested in real-life conditions encompassing the complex regulatory standards in the health sector.ObjectiveThis study aimed to test the feasibility and performance of a blockchain system in a homeless community to securely store and share data across a system of providers in the health care ecosystem.MethodsWe performed a series of platform demonstrations and open-ended qualitative feedback interviews to determine the key needs and barriers to user and stakeholder adoption. Account creation and data transactions promoting organizational efficiency and improved health outcomes in this population were tested with homeless users and service providers.ResultsPersons experiencing homelessness and care organizations could successfully create accounts, grant and revoke data sharing permissions, and transmit documents across a distributed network of providers. However, there were issues regarding the security of shared data, user experience and adoption, and organizational preparedness for service providers as end users. We tested a set of assumptions related to these problems within the project time frame and contractual obligations with an existing blockchain-based platform.ConclusionsBlockchain technology provides decentralized data sharing, validation, immutability, traceability, and integration. These core features enable a secure system for the management and distribution of sensitive information. This study presents a concrete evaluation of the effectiveness of blockchain through an existing platform while revealing limitations from the perspectives of user adoption, cost-effectiveness, scalability, and regulatory frameworks.

The use of synthetic cannabinoid receptor agonists (SCRAs) within the homeless population: motivations, harms and the implications for developing an appropriate response

Background Synthetic cannabinoid receptor agonists (SCRAs) have become increasingly associated with a range of physical, mental health and societal harms. In response, several countries have introduced legislation aimed at restricting their supply and use. While these legislative changes have led to a decrease in SCRA use within the general population, SCRAs remain popular within vulnerable populations, in particular the homeless. This article presents the findings from the first in-depth qualitative study of SCRA use within the homeless population. It makes an important and timely contribution to the current evidence base and discourse on how governments and service providers should respond to SCRA use within the homeless population. Methods The research on which this article is based was undertaken in Manchester, UK. Qualitative interviews were undertaken with 53 homeless users of SCRAs and 31 stakeholders. Results The motivations for SCRA use are broadly similar to those associated with traditional drugs; namely to escape from the reality of life on the streets, and to provide relief from the physical conditions of a street-based lifestyle. However, the combination of their low cost, the ease with which they can be accessed, their high potency, and their non-detectability explains their particular appeal to the homeless population. Alongside these motivations, the research identified a range of physical, mental health, and societal harms that were directly attributable to SCRAs. Conclusions The most appropriate way to address the continued use of SCRAs within the homeless population is through the development of a more appropriate service response rather than further legislative change.

Exploring the ‘Spoiled’ and ‘Celebrated’ Identities of Young and Homeless Drug Users

Young people experiencing homelessness and who use drugs are vulnerable to being attributed with ‘spoiled identities’ due to stigmatising attitudes by wider society. This article is underpinned by a symbolic interactionist account of self-identity and stigma. It draws upon ethnographic research in a UK-based supported accommodation hostel for young people and explores how the residents in the hostel related to the labels of ‘homeless,’ ‘drug user’ and ‘youth’ and how these were expressed through their self-identities. Over a period of seven months, in-depth participant-observation, semi-structured interviews and a focus group were conducted involving 22 hostel residents, aged 16 to 21 years old. The data highlight how the residents engaged in processes of ‘distancing’ or ‘othering’ by making disparaging remarks about other people in similar situations based on stereotyping. These processes reinforced spoiled identities while enabling the residents to disassociate from them. However, residents also appeared to embrace and celebrate certain features of each label, indicating an acceptance of these more positive features as forming a part of their self-identities. The article concludes by arguing for a nuanced approach to understanding stigma and identity among homeless people, one that accounts for more than just a person’s housing situation.

Underground Inscriptions

This essay examines the politics of home in underground Bucharest, and the ways relationships of care among homeless drug users emerge amid everyday violence and exclusion, illuminating the unconventional practices of belonging that take shape in transient communal spaces such as underground electric, transportation, and waste-management systems. The traces of systemic exclusion in these experiences converge in makeshift forms of kinship and care, provoking questions of solidarity, fragility, and the political potential of recognizing such forms through ethnographic collaboration.

Being ‘in place’, being ‘out of place’: Problematising marginalised drug users in two cities

Socially marginalised drug users when congregating in the public space on so-called 'open drug scenes' are often problematised, especially in post-industrial cities which increasingly are engaged in attempts to attract those that are considered to be promoters of economic activity through processes of 'beautification' and 'gentrification'. The different punitive practices that target homeless and marginalised drug users in the public space have been rendered visible in a range of influential accounts since the 1990s. However, these accounts have mostly been based on the US context and it has been argued that, in a European context, responses from local governments have been more variegated and ambivalent. Two case studies of the response to homeless and marginalised drug users in public space were investigated in the two major cities of Denmark, Aarhus and Copenhagen. In order to account for the differences in responses to marginalised drug users between the two cases, the different problematisations of their presence were investigated through document analysis and interviews with key stakeholders. The marginalised drug users were seen as 'out of place' in the open drug scene in Aarhus, while the marginalised drug users in the open drug scene in Copenhagen repeatedly were discursively constructed as being 'in place' and having a historical 'right' to be in this particular neighbourhood. The study illustrates that, by using the concept of 'problematisation', it is possible to reveal the assumptions about the proper use of the public space that underlies responses to the presence of marginalised drug users. Comparisons of such problematisations render us able to see how similar issues of marginalised drug users and the use of the public space can be problematised differently in different urban spaces and how this can legitimise specific governmental responses.

The digitization of advice and welfare benefits services: re-imagining the homeless user

Digitization is transforming the way in which people in England access advice and welfare benefits. Face-to-face advice provision is being increasingly replaced by telephone and online services, whilst the online application and management of benefit claims have become mandatory within the introduction of Universal Credit. This paper argues that the current shift to digitization fails to recognize the variation and complexity surrounding homeless people’s use of technology, with homeless people as technology users often placed into homogenizing categories. Based on findings from qualitative interviews and observations carried out with homeless people and voluntary sector organizations, this paper discusses the social and contextual factors affecting homeless people’s use of technology for advice and benefit purposes. The paper highlights the need for a more nuanced understanding of homeless people’s use of technology.

Empathy at Knifepoint: The Dangers of Research and Lite Pedagogies for Social Justice Movements

AbstractIn this paper, I discuss the ways I have fallen short as a participatory geographer and activist both in my teaching and research practices. I use three critical moments in the development of our PAR collective in Colombia to push debates in geography on participatory research and pedagogy further through reflection on my struggles in the streets and in the university. Additionally, I connect these experiences and previous discussions in participatory geographies with Orlando Fals Borda's discussion of sentipensar (a concept that engages feeling and thinking simultaneously). I draw attention to the Latin American origins of PAR philosophy by placing Fals Borda into dialogue with the protagonists of our social movement in Colombia including human rights activists, homeless drug users and sex workers. In a general sense, this paper is an examination of the challenges I have faced in the contact zones of PAR inside and outside the classroom.

Everyday Substance Insecurity Among Homeless Injection Drug Users in Israel’s Largest Open Drug Scene

Limited attention has been given to Homeless Injection Drug Users (HIDUs) perceived need for illegal substances. This study assessed self-perceived illegal drug need in HIDUs based on their experiences. Observations and in-depth qualitative interviews were conducted with 11 HIDUs and with four treatment professionals. The findings revealed three findings concerning the unique experiences and perceptions of HIDUs: (a) Everyday Substance Need caused fear and anxiety, (b) Substance Need was experienced as more urgent than basic survival needs, and (c) HIDU participants attributed misunderstanding and denial of Substance Need to the authorities. It was found that HIDUs suffer from “Substance Insecurity,” which may be defined as the uncertain availability of quality substances (or their substitutes) and uncertain ability to acquire substances/substitutes and safe injection equipment in socially acceptable (or not) ways. Increased awareness of Substance Insecurity for HIDUs as a Substance Security First (SSF) model should be adopted.

Evaluation of Syndromic Surveillance in Detecting Hepatitis A in Los Angeles County

ObjectiveTo create a hepatitis A virus (HAV) syndrome category with which to monitor emergency department (ED) visits for situational awareness during a currently emerging Hepatitis A community outbreak in Los Angeles County (LAC), and to evaluate its usefulness.IntroductionIn early 2017, HAV outbreaks were identified in San Diego County (490 cases)1 and Santa Cruz County (73 cases)2 in California, affecting primarily the homeless and/or illicit drug users. As of October 10, 2017, LAC had identified 12 outbreak-related HAV cases. Due to LAC’s proximity to San Diego County, and its own large homeless population, the syndromic surveillance team of the LAC Department of Public Health created a syndrome category and began querying its ED data to monitor for any increase in HAV-related visits.MethodsED data from 1/1/2017 to 10/10/2017 (CDC weeks 1-41) from all participating syndromic EDs in LAC were queried for patients who reported symptoms and signs of HAV. For comparison, ED data from calendar year 2016 was also queried. The query consisted of key word searches primarily within the chief complaint field, and, if available, the diagnosis and triage note fields. Based on the Centers for Disease Control and Prevention (CDC) clinical description of hepatitis A3, the HAV syndrome category was defined as: Jaundice (or elevated liver function tests) AND nausea or vomiting. Any ED visit that mentioned a diagnosis of hepatitis A also met the syndrome criteria. The resulting line lists were reviewed, and the query was periodically refined to exclude visits unrelated to hepatitis A (e.g., previous history of or vaccination for hepatitis A, other forms of hepatitis, and neonatal jaundice). The syndromic system was also queried for records that matched the 12 LAC cases by hospital and admission date. In addition, the chief complaint, diagnosis, and triage note fields were reviewed for any mention of homelessness or intravenous drug use.ResultsThe syndromic system detected 158 ED patients meeting the HAV syndrome category criteria. Of these, 12.7% had a diagnosis of HAV, 53.8% had jaundice, 36.7% had elevated liver enzymes, 65.2% had nausea, and 65.8% had vomiting. In 2016, 170 ED patients who met the syndrome criteria were detected: 8.2% had a diagnosis of HAV, 64.1% had jaundice, 32.4% had elevated liver enzymes, 63.5% had nausea, and 71.2% had vomiting. In both years, no indications of homelessness or IDU were found.Of the 12 LAC confirmed HAV outbreak-related cases, three did not go to a hospital, and thus did not have any syndromic data. Two went to non-participating syndromic EDs, but medical chart review showed that they would not have met the syndrome criteria. Of the remaining seven, all went to a participating syndromic ED, and three met the syndrome criteria, but none had any mention of homelessness or IDU.ConclusionsNo major change was seen in the trend of HAV syndrome visits in 2017 compared to 2016 (Figure 1). One of the challenges in monitoring HAV incidence is that the clinical signs and symptoms are very general, and may be shared with many other conditions. An emerging outbreak may not be detected above background levels unless the increase in ED patients with HAV is large, or consolidated over time. Variability in data quality in the free text fields such as chief complaint and triage notes may be problematic. Cases will be missed if data fields are not fully and accurately documented, and also if patients didn’t go to a participating syndromic hospital, or to a hospital at all. Though many syndromic hospitals now report diagnosis information, such information may be delayed, waiting for lab results. Using a stricter syndrome definition, such as requiring a specific diagnosis of HAV, may result in underreporting, but may provide a more accurate baseline for detecting increases and monitoring trends.While the query relied primarily on ED chief complaint, diagnosis and triage notes also proved useful in detecting HAV syndrome visits. None of the confirmed HAV cases that were known to be homeless had any mention of homelessness. The lack of any records indicating homelessness or IDU may indicate that these conditions are not currently reliably captured in the syndromic extract of ED patient records.LAC will continue to monitor for increases in HAV syndrome ED visits as a surrogate measure of HAV spread in the community. Syndromic surveillance, despite its limitations, remains a valuable complement to electronic lab reporting and other traditional reporting mechanisms.