Health workers in Nashville have turned their focus to homeless people amid a growing outbreak of hepatitis A and some of the first diagnosed cases among people living on the streets. They're finding it takes some convincing to get many to agree to a vaccination.
Anyone living without running water is at risk and encouraged to get a vaccine. The virus affecting the liver spreads easily through fecal matter. And there's no getting around it when you live outside.
Joseph Carpenter, 29, has a makeshift toilet in his tent where he lives under Ellington Parkway.
"I've got a bucket system set up," he says. "After a few uses, I'll go take the bag and there's an old man hole back off in the woods and I'll drop the bags off in it."
Even Carpenter had to be bribed with a treat to get the vaccine, saying he's usually not too concerned about his health.
Outreach worker Haley Spigner with Open Table has been wearing down people she's most worried about.
"Here we are. You finished your cigarette. That was our deal," she tells one young man, who agrees to get his shot at a weekly lunch served by Loaves and Fishes, a program of Catholic Charities of Tennessee in East Nashville.
Many haven't heard the first thing about the outbreak, made public nearly a month ago. But there's also a stigma to get over.
Those most at risk include intravenous drug users, men who have sex with men, and homeless people — who might not want to be associated with those groups or even acknowledge they're truly homeless. Spigner says she has to make the case.
"You may feel like you're very clean, but what about other people who are not as clean as you and touch the same door handle as you?" she tells them. "I've been really trying to destigmatize the whole thing."
So far, just about 10 percent of the 2,000 people inoculated in Nashville are homeless, mostly through Neighborhood Health's downtown clinic.
Of the 26 hepatitis A diagnoses locally, just two have "unstable housing." But in other cities that are more than a year into their local outbreaks, the homeless populations were hard hit. In San Diego, the city set up 100 hand-washing stations outside and even bleached the streets in some areas.