Responding to Coronavirus Disease 2019 (COVID-19) among People Experiencing Unsheltered Homelessness

Interim Guidance

This interim guidance is based on what is currently known about coronavirus disease 2019 (COVID-19). The Centers for Disease Control and Prevention (CDC) will update this interim guidance as needed and as additional information becomes available.

This guidance is intended to provide key actions that local and state health departments, homelessness service systems, housing authorities, emergency planners, healthcare facilities, and homeless outreach services can take to protect people experiencing homelessness from the spread of COVID-19.

Background

People experiencing unsheltered homelessness (those sleeping outside or in places not meant for human habitation) may be at risk for infection when there is community spread of COVID-19. This interim guidance is intended to support response planning by local and state health departments, homelessness service systems, housing authorities, emergency planners, healthcare facilities, and homeless outreach services. Homeless shelters and other facilities should also refer to the Interim Guidance for Homeless Shelters. Community and faith-based organizations can refer to the Interim Guidance for Community and Faith-based Organizations for other information related to their staff and organizations.

COVID-19 is caused by a new coronavirus. There is much to learn about the transmissibility, severity, and other features of the disease. Everyone can do their part to help plan, prepare, and respond to this emerging public health threat.

Lack of housing contributes to poor health outcomes, and linkage to permanent housing should continue to be a priority. In the context of COVID-19, the risks associated with sleeping outdoors in an encampment setting are different than with staying indoors in a congregate setting such as an emergency shelter or other congregate living facility. Outdoor settings may allow people to increase distance between themselves and others. However, sleeping outdoors often does not provide protection from the environment, quick access to hygiene and sanitation facilities, or connection to healthcare. The balance of risks should be considered for each individual experiencing unsheltered homelessness.

Partnerships

Reaching and protecting people experiencing unsheltered homelessness during the COVID-19 outbreak will require coordination across several local sectors. To prevent negative outcomes from lack of services, community leaders should continue activities that protect people experiencing homelessness, including supporting continuity of homeless services, healthcare, behavioral health services, food pantries, and linkages to permanent housing. Plans need to be clearly communicated to all stakeholders.

  • Homeless outreach teams and public health outreach workers will often be the front lines. These workers need to be prepared to protect themselves and their clients, provide health education information, and help direct their clients to care as necessary (see box).
  • State and local health departments, homelessness service systems, housing authorities, and emergency planners will need to identify where people without housing can be isolated and receive care if they are suspected to have COVID-19, are awaiting COVID-19 testing results, or are confirmed to be positive COVID-19 cases. These plans should also include transportation protocols.
  • Hospitals and healthcare facilities should ensure that they are involved in planning the logistics for safely discharging COVID-19 patients to a designated location if they do not require hospitalization but lack housing.
  • Law enforcement should be apprised of plans related to protecting people experiencing unsheltered homelessness from COVID-19 in order to best work in coordination with homelessness service systems and state and local health departments.
  • People experiencing homelessness themselves are an important resource to help navigate their communities and keep their friends and family members safe. Consider developing an advisory board with representation from people experiencing homelessness to ensure plans are implementable in the community.

Prevention measures

Encampments:

  • Unless individual housing units are available, do not clear encampments during community spread of COVID-19. Clearing encampments can cause people to disperse throughout the community and break connections with service providers. This increases the potential for infectious disease spread.
  • Encourage people staying in encampments to set up their tents/sleeping quarters with at least 12 feet x 12 feet of space per individual.
  • Ensure nearby restroom facilities have functional water taps, are stocked with hand hygiene materials (soap, drying materials) and bath tissue, and remain open to people experiencing homelessness 24 hours per day.
  • If toilets or handwashing facilities are not available nearby, provide access to portable latrines with handwashing facilities for encampments of more than 10 people.

Communications:

Provide straightforward communications to people sleeping outside in the appropriate language. Identify people who are influential in the community who can help communicate with others. Post signs in strategic locations to provide information on hand hygiene, respiratory hygiene, and cough etiquette. Request up-to-date contact information for each person.

Information to share includes:

  • The most recent information about COVID-19 spread in their area
  • Advice to avoid crowded areas if COVID-19 is circulating in their community
  • Social distancing recommendations
  • Hand hygiene instructions, cough etiquette instructions, and advice not to share personal items
  • How to recognize the symptoms of COVID-19 and what to do if they are sick
  • What to do if their friends, family, or community members are sick
  • How to isolate themselves if they have symptoms
  • Updated information on where to find food, water, hygiene facilities, regular healthcare, and behavioral health resources if there have been local closures or changes

People at Higher Risk of COVID-19

Some people who are experiencing unsheltered homelessness may be at higher risk of moderate to severe disease because of certain conditions. Pay particular attention to preventing disease among these individuals.

Isolation housing

Local partners should plan for where individuals and families with suspected or confirmed COVID-19 experiencing unsheltered homelessness can safely stay. These should include places where people who are confirmed to be positive and those awaiting test results can be isolated. Additionally, if a person needs to be hospitalized, a plan should be in place for how they will safely recover after discharge. Ideally, these individuals will be housed for the duration necessary, as outlined in the recommendations for discontinuation of isolation. Isolation housing could be units designated by local authorities or shelters determined to have capacity to sufficiently isolate these individuals. If medical care is not necessary and if no other options are available, advise the individual on how to isolate themselves while efforts are underway to provide additional support. In each scenario, identify how to safely transport patients to and from healthcare and housing facilities.

Behavioral health teams should be involved in the planning for these sites to facilitate continued access to support for people with substance abuse or mental health disorders. In some situations, for example due to severe untreated mental illness, an individual may not be able to comply with isolation recommendations. In these cases, community leaders should consult local health authorities to determine alternative options.

A local surge in the need for medical care may require jurisdictions to establish isolation sites and alternate care sites (ACS) where patients with COVID-19 can remain for the duration of their isolation period. These are typically established in non-traditional environments, such as converted hotels or mobile field medical units. Isolation sites are intended to be locations for patients who do not require medical care, while ACS are intended be locations for patients who require some degree of medical care. Isolation sites can be used for people with COVID-19 who are currently experiencing homelessness and cannot be discharged to a congregate setting. For more information, please see Alternate Care Sites and Isolation Sites.

Homeless services outreach staff

When COVID-19 is spreading in your community, assign outreach staff who are at higher risk for severe illness to other duties. Advise outreach staff who will be continuing outreach activities on how to protect themselves and their clients from COVID-19 in the course of their normal duties. Instruct staff to:

  • Greet clients from a distance of 6 feet and explain that you are taking additional precautions to protect yourself and the client from COVID-19.
  • Screen clients for symptoms consistent with COVID-19 by asking them if they have a fever, new or worsening cough, or shortness of breath.
    • If the client has a cough, immediately provide them with a surgical mask to wear.
    • If urgent medical attention is necessary, use standard outreach protocols to facilitate access to healthcare.
  • Continue conversations and provision of information while maintaining 6 feet of distance.
  • Maintain good hand hygiene by washing your hands with soap and water for at least 20 seconds or using hand sanitizer (with at least 60% alcohol) on a regular basis.
  • Wear gloves if you need to handle client belongings. Wash your hands or use hand sanitizer (>60% alcohol) before and after wearing gloves.
  • If at any point you do not feel that you are able to protect yourself or your client from the spread of COVID-19, discontinue the interaction and notify your supervisor. Examples include if the client declines to wear a mask or if you are unable to maintain a distance of 6 feet.
  • Provide all clients with hygiene products, when available.
  • Street medicine and healthcare worker outreach staff should review and follow recommendations for healthcare workers.
  • Review stress and coping resources for yourselves and your clients during this time.