Investigating and responding to COVID-19 cases at homeless service provider sites

Considerations for state and local health departments

Updated April 18, 2020

Purpose: Homeless service provider sites (such as sites for overnight emergency shelters, day shelters, and meal service providers) can present unique challenges for COVID-19 investigation and public health action. Because homeless service provider sites can be crowded settings, the virus may spread easily. Additionally, clients at homeless service provider sites are often older adults or have underlying medical conditions, making it more likely for them to have severe illness from COVID-19.

To help prepare homeless service providers to prevent spread of the virus that causes COVID-19, review CDC guidance specific to homeless service providers and people experiencing homelessness. The following considerations are for public health response to cases at homeless service provider sites, which is not outlined in the other guidance documents.

Decision-making based on community transmission levelpdf icon and health department capacity

When overall community transmission is none to minimal:

Goal – to prevent transmission within the homeless service site.

  • Coordinate with the local emergency management structure to identify necessary resources, including isolation and quarantine sites, supplies, staff, and testing.
  • Facilitate data collection and sharing between state and local health department epidemiology teams to enable timely interventions.
  • Align with “optimal” actions outlined in Table 1.

When overall community transmission is moderate to substantial:

Goal – to minimize transmission and ensure clients can access care.

  • Consider setting a threshold for initiating an on-site investigation and response. Depending on local circumstances, a threshold for investigation might be a facility with any single case of COVID-19-like illness, >2 cases of COVID-19-like illness among residents or staff within 7 days, or a threshold that aligns with decision-making for a long-term care facility in your jurisdiction.
  • Consider prioritizing on-site investigation and response for homeless service provider sites that serve large numbers, serve primarily people at higher risk for severe illness from COVID-19, or that have difficulty accomplishing infection prevention and control (e.g., bed spacing, availability of hand washing supplies, or other items necessary for infection prevention and control).
  • Align with at least the “minimum” actions outlined in Table 1.

Table 1: Public health actions in response to identification of COVID-19 at a homeless service provider site

Action*

Optimal

Minimum

Optimal

Minimum

Optimal

Minimum

Optimal

Minimum

Optimal

Minimum

Consider

Action*

Limit movement

Optimal

Minimum

Consider

Optimal

Minimum

Action*

Support staff

Optimal

Minimum

Optimal

Minimum

Consider

Optimal

Minimum

Action*

All staff and clients

Optimal

Minimum

Consider

Action*

Symptomatic clients and staff

Optimal

Minimum

Action*

Those at high risk for severe illness from COVID-19

Optimal

Minimum

*See below for descriptions of each action

Description of public health actions in response to identification of COVID-19 at a homeless service provider site

Communicate with the facility

  • Alert the facility that a case has been identified, if it does not already know.
  • Communicate that the role of a public health investigation is to work together with the homeless service provider to protect clients and staff.
  • Establish regular communication between the homeless service site, health department, and healthcare facilities.

Encourage enhanced infection prevention and control

  • Provide the facility with guidance on cleaning and disinfection. The facility does not need to close to complete this cleaning and disinfection.
  • Depending on availability, recommend that all clients and staff wear disposable masks to prevent pre-symptomatic/asymptomatic spread. Educate about the potential for contact transmission from touching the mask and how to appropriately remove the mask and when it needs to be replaced.
    • If disposable masks are not available, advise shelter staff and clients on the use of cloth face coverings.
  • Establish regular communication between the homeless service site, health department, and healthcare facilities.
  • Evaluate whether the facility is aligned with public health guidance for homeless service provider sites. Help it identify changes it can make to its current processes and facilitate access to necessary supplies. Check on:
    • Bed spacing
    • Infection control supply availability
    • Communication materials (e.g., signs, posters, and fact sheets)
    • Availability of handwashing stations with adequate soap and water or hand sanitizer (ideally touchless) with at least 60% alcohol if soap and water are not available.
    • Areas for people who are symptomatic
  • Consider additional recommendations to increase physical distancing and decrease contamination in the context of COVID-19 transmission.
    • If possible, increase physical distancing (6 feet or more) in communal areas
    • Assign beds/mats and linens to reduce sharing
    • Discourage handshaking and encourage the use of other non-contact methods of greeting
    • Stagger food services to reduce crowding during meals
  • If the facility is too crowded, help identify methods to reduce crowding. However, be sure to maintain potentially exposed individuals as a cohort. For those who test negative or who are not exposed, consider:
    • Collaborating with local officials to establish an additional homeless service site
    • Identifying overflow locations in other facilities

Isolate persons with confirmed COVID-19

  • Those who have tested positive for the virus that causes COVID-19 should wear disposable masks at all times.
  • Per CDC guidance, ensure that the homeless service site has capacity to isolate people with positive results who are not hospitalized, or facilitate transportation of those with positive test results to a designated isolation area.
  • Ensure that transportation to off-site isolation areas limits exposure to the driver and the public.

Investigate persons with confirmed COVID-19

(Note, a traditional contact-tracing investigation is not necessarily recommended. Rather, identifying other homeless service provider sites visited by persons with confirmed cases of COVID-19 during the time they were considered infectious can help reveal additional facilities that might need to take action).

  • Interview persons with COVID-19 about locations where they have been, starting 48 hours before symptom onset or specimen collection date of an asymptomatic positive case.
  • Consider using Homeless Management Information Systems (HMIS) and other information systems used by homeless service providers to identify where the person with confirmed COVID-19 has checked-in over the past 2 weeks.
  • If staff members have been exposed or have tested positive, identify whether they worked at other homeless service provider sites (or elsewhere) over the past 2 weeks to identify whether investigation and response might be necessary at other locations.
  • When possible, ask person with confirmed COVID-19 if they have a partner, family members, or other close friends with whom they spend a lot of time to identify “closest” contacts who might be of concern.
  • As necessary, use bed maps, social groups, and job/program involvement to identify other contacts.

Limit movement

  • It may be necessary to limit movement in and out of the facility to decrease the possibility of spread. Define a cohort of those exposed who require movement limitations. This may be the entire facility
  • If possible, consider requesting the facility to close to new admissions for 14 days.
    • If individuals have already left the facility, consider allowing readmission of those who were there in the 48 hours prior to symptom onset so that they do not need to seek alternate shelter arrangements.
  • Consider providing increased entertainment options that avoid close contact, including television, to encourage clients to stay in place.
  • Discourage public transportation use.
  • If clients have individual rooms, recommend that they stay in their rooms as much as possible.
  • If clients need to be in public or shared spaces, recommend that homeless service providers require that clients wear disposable or cloth face coverings if appropriate (excluding children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance).
  • Identify services needed to assist clients to stay at the facility such as support for behavioral health and treatment for substance use disorders.

Relocate those at higher risk of severe illness to individual rooms

  • If possible, consider individual room or housing options for older adults or those with serious underlying medical conditions to decrease exposure potential.
  • Avoid moving those at higher risk of severe illness into shared settings.

Encourage enhanced monitoring for illness

  • Ensure there is routine clinical care and a provider on-call if symptoms or medical issues arise.
  • Recommend twice daily temperature and symptom checks for all staff and clients. A shelter intake screening tool can be used for these symptom checks. Keep a log of symptoms.

Support staff

  • Facilitate surge staff support (e.g., clinical, behavioral health, substance use counseling, medication assisted treatment (MAT), janitorial).
  • Address staff anxiety and concerns through clear communication.
  • Ensure staff have necessary personal protective equipment (PPE) in alignment with their duties and that they have completed training on putting PPE on and taking PPE off.
  • If PPE supplies are insufficient, assist staff in identifying methods to optimize the supply, such as extended use of face masks and eye protection.
  • If staff have been exposed (i.e., have had close contact for a prolonged period of time with an individual with COVID-19 symptoms) instruct them about how to proceed based on the CDC Public Health Recommendations for Community-Related Exposure. If they become ill, they should notify their supervisor and follow CDC guidance for what to do when sick.
  • Staff who have tested positive for the virus that causes COVID-19 or who are experiencing those symptoms should follow guidance on isolation found here.
  • If a staff member has tested positive for the virus that causes COVID-19 but is asymptomatic, they should also follow the guidance for isolation found here.

Link to resources

  • Engage community partners for support if there are supply issues related to food or other resources such as hand washing supplies, PPE, or other items necessary for infection control.
  • Identify ways to support bringing handwashing stations, showers, and laundry to the facility if these are not already available.

Test clients and staff

  • Upon notification of a case or cluster of cases, testing all clients and staff at a single point in time will help with immediate isolation efforts and can define the scope of transmission by identifying asymptomatic clients with infection. A repeat set of tests after two weeks can help identify ongoing transmission or need for additional intervention.
  • If it is not possible to test everyone, consider testing those at highest risk and/or those who are symptomatic.
  • Protect staff collecting specimens using CDC guidance for specimen collection.
  • Manage those who have a positive viral test for the virus that causes COVID-19 in accordance with CDC recommendations related to care and discontinuation of isolation.