Hennepin County Community-Based Infectious Disease Team

Public Health Department and County: Hennepin County Public Health (HCPH) is the largest public health department in Minnesota. Its vision is for all people who live, work, and play in Hennepin County to experience optimal health grounded in health and racial equity. HCPH takes a comprehensive approach that strives to respond to the unique and important needs of all residents. Its dynamic programs promote physical and mental health, reduce chronic diseases, and prevent illnesses and injury associated with communicable diseases and environmental conditions.  

Hennepin County is Minnesota's largest county (anchored by Minneapolis), with 1.27 million people calling it home, or about 23% of the entire state's population. Hennepin County is rich with different cultures, dynamic immigrant groups, arts, and civic engagement. However, Hennepin County also struggles with institutional racism and classism at multiple levels, with the community altering murder of George Floyd in Minneapolis in 2020 bringing local inequities to the national lens.  

Public Health Issue and Response: With a population larger than some states, Hennepin County has unfortunately seen firsthand the rapid spread and devastating consequences that infectious diseases can have on our residents. This is especially true for traditionally marginalized communities with fewer resources, multiple barriers to quality care, and a historic mistrust of the health care system. To reach true health equity, the diseases that most often impact underserved populations must be responded to with resources and zeal. We know crises will happen, and we know they will likely seek out the most vulnerable populations. If anything positive emerged from COVID, it was a better understanding of what could and should have been done to respond better.  

After reflection and review of data, HCPH came to a solution - a response team that can be deployed quickly with an action plan in hand and resources at the ready when new infectious disease emergencies are detected, coupled with a commitment to working side by side with communities. Thus, the Community-Based Infectious Disease team (CBID) was born.  

Goals and Objectives: The CBID team was created with the goal to prepare a rapid, effective, and culturally competent response to emerging infectious disease outbreaks, particularly outbreaks that heavily impact BIPoC and other marginalized communities. This goal would be met with a highly trained team, health equity tracking, and mutually beneficial staffing solutions.  

Timeline: In fall 2021, HCPH leaders reflected on COVID lessons. The department saw staff burnt out from being deployed to cover duties outside of their regular positions, staff shortages created in areas, significant racial disparities in who was vaccinated and infected, and the struggle to simultaneously create and execute action plans. Thus, the CBID team was created. The proposal was approved in January 2022 and after a delay due to Omicron, the team was formed between March and May 2022. Just as soon as it was created came the Mpox outbreak, providing a crucial first experience for the team.  

Results: The CBID team, even in its infancy, was able to quickly respond to the Mpox outbreak, administering 70% of Minnesota's vaccinations. Despite a high MSM population density, the number of cases held at 161, with the last one detected on November 1. The CBID team vaccinated more BIPoC identified people than the general county demographics. However, a significant discrepancy still exists between who was vaccinated and who had Mpox, requiring ongoing work to decrease the gap and assess actions in future outbreaks.  

Important Factors: The most important factor that has set up CBID is in its title community-based. CBID puts community first so those who have been marginalized are now centered with communication, care locations, and strategic partnerships. Additionally, CBID progressively gains experience and knowledge so it can bring improved practices to the next response. CBID also confronts one of the most pressing issues in health care staff shortage and burnout. CBID team members are hired with an understanding of what their job requires, instead of being surprised with an emergency preparedness deployment. Public health staff can continue their normal job duties and even be assisted by CBID team members between outbreaks.  

Public Health Impact: The CBID team was able to respond to Mpox within a day, allowing for rapid dissemination of vaccines. A swift and organized response will be beneficial to any infectious disease outbreak. The responding staff become experts, allowing more localized responses even during national emergencies, again decreasing the lag time and enabling a response that meets the unique community dynamics of Hennepin County. It is never a question of if another outbreak will happen, it's when, and COVID taught us that preparation is key.  

Community Engagement: As community involvement is at the heart of CBID, partnerships are crucial. Because CBID is based in a strong public health department, it could fortunately build on partnerships from previous initiatives. Community partners based on outreach to those experiencing homelessness,  HIV prevention, syringe exchange, and immigrant health efforts were especially beneficial as they were already focused on marginalized groups. These partners gave valuable insight into the needs and concerns of its members, localized space and access, and existing programs that could be extended to include the CBID response.  

Reducing Health Disparities: CBID was created because the cycles of infectious disease outbreaks continue to disproportionally impact marginalized groups. During COVID, significantly more white people were getting vaccinated than BIPoC identified individuals while COVID was proving more serious and deadly for BIPoC communities. It became clear that there were many factors at play, including historical mistrust of health care, access barriers, and lack of trusted messengers. It took months for the government to respond to these differences and even then, the skepticism was real since it was governmental communications.  

After seeing great disparities, HCPH knew it could not have that kind of learning curve again. The disparities cost countless lives. Thus, CBID leads its efforts by connecting with BIPoC and other effected communities first instead of down the line.  

Website: While CBID has not yet created a website, here is the link to HCPH: https://www.hennepin.us/publichealth 

County Population: Hennepin County is Minnesota's largest county, with 1.27 million people calling it home, or about 23% of the state's entire population. Over the next 30 years, the Minnesota Demographic Center estimates that the county's population will increase by an additional 30%. Hennepin County anchors the western side of the Twin Cities metro, the 16th largest metro area in the US and the third largest metro area in the Midwest. Hennepin County's most populous cities include Minneapolis (the largest city in the state), Bloomington, and Brooklyn Park.  

According to the 2020 US Census, of Hennepin County's residents, 21.8% are under the age of 18, 15.1% are over the age of 65, and 50.3% are female. Hennepin County is the most racially diverse county in the state, with 32.3% of residents identifying as BIPoC (14.2% Black/African-American, 1.1% Native American, 7.6% Asian, 7.1% Latino, and 3.5% two or more races). In addition, 13.8% of residents were born outside of the United States, 10% live in poverty, and 18.1% speak a language other than English at home. While there is no official governmental data on the number of LGBTQ+ people that live in Hennepin County, 12.5% of Minneapolis residents identify as LGBTQ+ according to the American Community Survey, making it the fourth highest LGBTQ+ per capita population in the country.  

Population Focus: As the CBID team is designed to respond to any infectious disease outbreaks, the specific target group for each incident will be different. The CBID team understands this and thus secures strong partnerships across the county and communities, so they are prepared to act quickly. Additionally, CBID monitors indications of potential outbreaks and communicates with partners for possible preparation.  

With Mpox, it was clear from national data that the outbreak was disproportionately impacting the MSM community and thus they were the initial focus population. This target group expanded in time to include transgender and non-binary individuals, people who exchange sexual acts for money or basic needs, and people experiencing homelessness.  In the last six months, the CBID team reached over 4,000 people from these communities. As the exact number of individuals meeting these criteria in Hennepin County is unknown, the percentage cannot be calculated. Instead, CBID concentrates on reaching as many people as possible through existing connections with organizations and businesses and outreach efforts. CBID also measures its reach by the demographics of those served to analyze whether the racial demographics mirror the overall population representation.  

The CBID team continues to expand its partnerships and connections to various communities so it can respond to future outbreaks regardless of impacted population.  

Health Equity: Health inequities and infectious diseases are deeply historically intertwined. Devastating diseases can spread easier and faster when they attack those with barriers to care, limited resources, historic mistrust of health care institutions, and higher rates of comorbid conditions. Thus, for the CBID team to be successful, addressing health inequalities must be at its core.  

Nearly half of the team's staff members identify as people of color, mirroring impacted communities and experiences. All staff are highly trained on difficult conversations, trauma-informed care, accessible communication styles, and trust building. As the team is focused on this work, their knowledge and practices only increase over time with each day, disease stage, and outbreak. Community members see their familiar faces, understand they will continue to show up, and know they can address vulnerable concerns.  

Most importantly, the CBID team knows that many community leaders and partners have spent decades building the trust of county residents. To work side by side with these leaders and partners gives the CBID team a stamp of approval so they can more quickly and easily get the care to those who need it the most. Additionally, when the team shows up right at the beginning of an outbreak, the community sees that they are a priority and will have the resources they need if they access them.  

Throughout every outbreak, data is collected on patients which creates an up-to-date dashboard of demographic information. This allows every team member to see what is working, what is not working, and who is being left behind. Within a day, care sites can shift and outreach strategies can change so inequities can be faced immediately instead of well after the outbreak is over.  

Innovative Practice: The CBID team represents an acknowledgement that infectious diseases are an unfortunate constant in our lives and deserve a dedicated team that is not only experienced health care professionals, but also community focused. COVID showed that effective responses to infectious diseases rely on two crucial components – medical tactics and community activation. Community activation includes neighborhood-based care sites, trusted messengers to disseminate accurate information, and staffing that is both prepared and knowledgeable. This all must be paired with health equity practices, which takes significant upfront strategic work that could delay an adequate response if not done beforehand. By pairing prepared professionals with a health equity lens, future infectious disease outbreaks can be quickly hampered.  

Important Factors: The most important factor that has set up CBID as an innovative practice is the community-based” portion. The history of infectious diseases clearly shows that outbreaks seek out communities historically underserved due to racism, sexism, classism, homophobia, and xenophobia. From HIV to COVID to STIs, the trend is clear. Thus, CBID puts community first so those who have been marginalized in the past are now centered with communication approaches, care locations, and strategic partnerships. CBID built on relationships that HCPH already held with non-profit organizations, community centers, businesses, and social gathering spots like LGBTQ+ bars. CBID went to the community with on-site vaccinations at the bars, neighborhood centers, and community clinics. By partnering with organizations that both already had the trust of the community and posed fewer access barriers, CBID went to where the community was.  

In addition, the CBID team is not only designed to respond quickly, but also with the cumulative knowledge it holds from outbreak experiences. The staff who answered the Mpox emergency carried with them their recent lessons from COVID. For the next outbreak, they will take understandings and best practices from both. This continuation of staff, records, procedures, and partnerships builds a stronger team with every emergency.  

COVID also showed how truly difficult it could be for health care workers to show up every day at the front lines of a crisis. Most times, they were not originally hired for such a role. They left behind their everyday jobs, leaving the public receiving less attention in other areas and staff stressed about coverage. Neither the health care workers nor patients are fairly treated in this situation. With the CBID team, the nurses and community health workers join the project because that is where their passion lies. That is their focus. During times where the whole team is not needed to respond to a crisis, members can help fill in for staff in other areas of public health – parental leave, staff shortage, etc. Instead of creating staff shortages during crises, this team flips it and fills in for staff when possible. 

Design Basis: Currently, Hennepin County Public Health is not aware of other counties with this team model. As discussed above, the model was designed based on crucial lessons that the COVID response provided. HCPH used its years of experience and data to evaluate what would make a true difference for future outbreaks and balanced it with both financial and staffing resources available. Thus, while it may not be evidence-based in a traditional sense, it is experience-based.  

Other government agencies and organizations do have similar emergency response teams, but they tend to rely on volunteers. While the CBID team is open to using volunteers in the future, it will always rely on staff so it can move quickly with established procedures and team cohesion. The CBID team is also unique as it enriches public health staff coverage instead of creating shortages during emergencies.  

Goals and Objectives: Following health equity principles and practices, this CBID team of nurses and community health workers will conduct infectious disease outbreak testing, vaccination, medication administration, and coordination in the communities in which they live. The responses will be integrated into existing community structures and institutions to meet people where they are.  

To further expand on the objectives provided in the summary above, the CBID team strives to achieve the following:  

-Highly trained and knowledgeable staff of nurses and community health workers 

-Informative, thorough, and current health equity and outbreak data analytics  

-Staff who are primarily dedicated to infectious disease outbreaks that are prepared to respond at any time without abandoning other essential jobs in the department 

-Coverage for other areas of the public health department during non-outbreak times 

-Strong partnerships with organizations and entities that lifted community voices and allowed responsible access to populations most impacted by outbreaks  

-Existing relationships with community leaders and elders to have a level of established trust from the beginning of an outbreak  

-Preliminary framework and workplan for any outbreak to decrease preparation time  

-Common supplies, material, and paperwork at the ready  

-Education, testing, and vaccinations distributed immediately upon availability  

Timeline: In October 2021, 18 months after COVID hit the Twin Cities and when public health workers could take a moment to reflect, leadership at Hennepin County Public Health asked what could have been done better. Could the response have been faster, were staff fully prepared for what they faced, did HCPH have the right partnerships from the beginning, and why was there such a significant racial disparity in who got vaccinated?. Based on these conversations and feedback from the community, the CBID team was proposed for the 2022 budget year and was passed. However, with the Omicron outbreak in January and February of 2022, the formation of the team was postponed a couple of months. At the end of February 2022, the leadership of the team was identified and the framework began to be built. In May 2022, nurses and community health workers were hired. While the CBID team thought they would have more time to solidify their structure and procedures, infectious diseases follow no timeline.  

In May 2022, the first Mpox case was detected in the USA and while everyone was susceptible, it seemed to be infecting MSM populations the most. At any time of year, this would have been a significant cause of concern. However, Minneapolis is known for many things, including hosting the largest free pride event in the country the last weekend of June. Knowing that transmission seemed to be higher in the LGBTQ+ community, CBID had to act even though it was still in its infancy. The day after Mpox was locally declared an emergency, CBID was administering vaccinations out of the Red Door Clinic in downtown Minneapolis, the state's largest STD and HIV clinic. On June 27, 2022, the PHC team identified the first Mpox case in Minnesota. The CBID team is still working on Mpox to this day, looking closely at who is not getting vaccinated and why. At the same time, they are assisting with an HIV outbreak and are prepared to respond to the next emergency, including a potential measles outbreak. 

Partnerships: Throughout the life of HCPH, strong partnerships have been built after years of trust building and true collaboration. CBID expanded on these partnerships, many previously built around HIV prevention, COVID, and syringe exchange programs. These partners gave CBID two key things. First, access and space to their participants so CBID could truly go to the patients, eliminating access barriers and fear of the unknown. Second, the outbreak response was seen by many participants as simply extensions of programs they already knew and trusted. Some of the primary partners in the fight against Mpox included the following:  

-Pride Institute: An LGBTQ+ focused residential and outpatient program for mental health and substance use issues.  

-CLUES (Comunidades Latinas Unidas En Servicio): The largest Latino-focused non-profit in Minnesota, focused on the social and economic well-being of Latinos.  

-The Saloon: One of the most popular LGBTQ+ bars in Minneapolis.  

-Avivo Village: An indoor community of 100 tiny homes for people experiencing housing instability. 

At each of these locations, CBID set up on-site vaccine events. They also distributed educational material, got to know participants, and held conversations about their concerns and barriers to improve the program. For example, nurses speak to patients who have not returned for their second vaccine dose to figure out the underlying factors and what could be done to improve follow through. 

Costs: The first year of CBID will cost an estimated $1,295,500. The majority of this is salaries and fringe benefits for the eleven team members. Of these expenses, $483,000 is billable. The remainder has come from the county budget, but dedicated funding is always being sought.  

Goals and Objectives: As described above, the CBID team was created with the goal to proactively prepare a rapid, effective, and culturally competent response to emerging infectious disease outbreaks, particularly those outbreaks that heavily impact BIPoC and other marginalized communities. This goal was measured with the following objectives:  

-Form and train a CBID team to effectively and quickly respond to infectious disease outbreaks. 

-Create health equity tracking and accountability practices during outbreaks 

-Minimize disruption to the broader public health's operations by having a team assigned and trained to be first responders 

-During non-outbreak periods, utilize CBID team members to cover staffing gaps in public health 

Evaluation System: Both quantitative and qualitative data were collected. Using the Epic electronic health record system, case progress and patient demographic information were recorded. This included test results, vaccination status, and whether treatment was requirement. Any demographic information they were willing to share was also collected to assess whether health equity goals were met. This information was also communicated to the state for larger scale outbreak monitoring. The data was summarized in epidemiologic curves and customized Power BI dashboards for comprehensive progress analysis. As soon as the data was entered into Epic, it could be included in the dashboards, offering relatively immediate feedback.  

Because this is a community-based health initiative, qualitative data collection is equally as important. This was collected through conversations between nurses or community health workers and patients and through clinic surveys. Patients were asked about barriers to getting their second vaccine dose, concerns they are hearing, and suggestions for additional care sites or times.  

Results: While the CBID team has only existed for six months and long-term data is not yet available, its initial success with the Mpox breakout is significant. To date, the CBID team has distributed 70% of Minnesota's Mpox vaccine. The county experienced 161 total cases this year, with no more than five positive cases a week. Since November 1, 2022 there has only been one positive case. In total, the CBID team led the vaccination of 4,103 Hennepin County residents, including 3,049 residents who are now fully vaccinated. In addition, they distributed tpoxx to 41 patients. While there were several cases detected, the surge seemed to pass within a couple of months, signifying a possible impact of the education, testing, treatment, and vaccination efforts. Considering that Pride was held at the beginning of the outbreak and the large focus population concentrated in a few cities, the outbreak was relatively controlled.  

The clinic surveys also provided much appreciated feedback from patients, demonstrating the individual impact of the initiative:  

-Nurse Heather was absolutely amazing and explained things in a way that made my anxieties about Mpox reduce.”  

-The most fantastic clinic I've ever experienced.” 

-You guys provide such an important public health service to Hennepin County. Thank you.” 

Additionally, no public health staff had to be taken away from their essential job duties to respond to the outbreak as CBID was there to fill the need. This ensured the everyday programs of HCPH could continue interrupted and staff did not face the same level of burn out as they did during COVID emergency deployments.  

To assess whether the CBID initiative was addressing health inequity, racial demographics were monitored. Of the people that CBID immunized, 28% identified as BIPoC. In comparison, 24% of Hennepin County identifies as BIPoC, meaning CBID successfully reached a proportionate percentage of BIPoC individuals in its Mpox response. However, it is important to note that the percentage of immunized BIPoC people increased as the months went on, reflecting strategy changes CBID had to make in order to reach target populations. Additionally, 54% of patients receiving tpoxx identified as BIPoC.  

Despite the proportional representation of BIPoC individuals being immunized, they still made up 52% of reported Mpox cases in Hennepin County, demonstrating the ability of infectious diseases to seek those most marginalized. In future outbreaks, patient demographics must go beyond overall population representation to reflect the reality of infectious disease disparities.  

Adjustments: Based on the discrepancy between who was being immunized and who was being infected, program changes were made. The team is now focused on decreasing this discrepancy. Three immunization events were held at the Saloon and two were held at the Pride Institute. For 2023, there are already four clinics scheduled one at the Saloon, one at the Pride Institute, and two at CLUES.  

Additionally, a concerted effort was required to reach more individuals experiencing homelessness. Part of HCPH is Hennepin County Health Care for the Homeless, a program dedicated to reaching those experiencing housing instability. The CBID team cross-trained Health Care for the Homeless staff to carry and administer Mpox vaccines, including to visits at encampments. Mpox vaccines are also being brought to infectious disease screening events and syringe exchange programming. The vaccine is taken to impacted communities instead of asking communities to come to the vaccine.  

When nurses asked patients about why they might have been hesitant to be vaccinated, many referred to the large red mark that would appear on their forearm from the injection. It became a visible mark of the vaccine and as the vaccine holds the stigma of the impacted communities, it was a significant deterrent. The CBID team was relieved when medical guidance changed to allow for injection in the upper arm and back. This is an example of a barrier that can only be addressed after hearing directly from the community, beyond the data points.  

With CBID entering its third quarter of existence, lessons are still being learned and processed. However, with the intensity of its early days came significant feedback. First, partnerships are key. Partners offer program space, communication channels, accessibility, and direct community engagement. Whenever possible, neighborhood-based care sites should be set up quickly. Second, health equity analysis should focus on the population being infected rather than county demographics. Communities are not equally impacted by infectious diseases and representation measurements must be more complex. Thus, it is vital that current demographic information is available for both case instances and patients. There must be staff assigned to monitor these trends and quickly adjust locations and tactics. Third, having dedicated leadership and staffing for community-based infectious disease response alleviates pressure on other public health staff, offers clear direction and procedures, and adds stability across the department.  

HCPH leadership is interested in doing a cost/benefit analysis after the first year is complete. For costs, this will include staffing, benefits, supplies, transportation, and communication needs. For benefits, multiple factors will need to be examined, including prevention of hospitalizations, retention of staff that would otherwise be deployed, coverage in understaffed areas, and reduction of response labor for new outbreaks. While the analysis will be approximate due to some difficult to measure factors, a general picture should emerge.  

The continuation of this program will rely on county tax revenue, billable services, as well as future grant funding requests. To ensure this experience is the most beneficial, HCPH would also be open to sharing trainings and materials with other counties interested in replicating the model.