Interim Guidance for Syringe Services Programs
Syringe services programs (SSPs) are community-based prevention programs that can provide a range of services, including access to and disposal of sterile syringes and injection equipment, vaccination, testing for infectious diseases such as viral hepatitis and HIV, naloxone distribution, and linkage to infectious disease care and substance use treatment. SSPs prevent infectious diseases, help link clients to treatment for substance use disorders, and have the potential to prevent overdose deaths among people who inject drugs.1
SSPs should be considered by state, local, territorial, and tribal jurisdictions as essential public health infrastructure that should continue to operate during the COVID-19 pandemic. During this time, it is critical that SSPs have the capacity to ensure the safety of staff, volunteers, and clients. This guidance describes actions for jurisdictional public health authorities, as well as SSPs, to support the health and well-being of their staff and the clientele they serve. SSP staff perform a variety of functions, with some staff providing direct patient care services (e.g., drawing blood for infectious disease testing, responding to overdoses, treating injection-related wounds). Considerations for both healthcare personnel and other workers are therefore incorporated into this guidance.
Education, Prevention, and Screening for SARS-CoV-2 infection (the virus that causes COVID-19 illness)
- Provide education to clients and staff (including volunteers) prevent the spread of SARV-CoV-2, including placing informative signage and supplies in highly visible places.
- Ensure all clients, staff, and volunteers wear cloth face coverings at all times to protect others. Cloth face coverings should not be placed on anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.
- For staff providing healthcare services (e.g., nurses), appropriate PPE should be used when interacting with clients with suspected or confirmed COVID-19.
- Ensure all clients, staff, and volunteers maintain physical distancing (staying a minimum of six feet apart) as much as possible during interactions (recognizing that this will not be feasible for all interactions), including staff/client interactions and staff/staff interactions (e.g., during breaks and meals).
- Remind all clients and staff to wash hands with soap and water upon arrival or entry into a facility, or use an alcohol-based hand sanitizer with at least 60% alcohol if handwashing is not possible and to comply with federal, state, and local infection control practices required in that setting.
- Consider providing services outdoors or in an open-air space to minimize risk of transmission if adequate confidentiality for clients can be provided. If SSP services are conducted indoors, all of the above precautions should be followed.
- Screen all clients for possible COVID-19 symptoms and recent history of a close contact to someone with known or suspected COVID-19 upon entering the SSP. Work with your local health department for guidance on where to refer clients who are exhibiting COVID-19 symptoms for diagnostic testing or for further care, or work to arrange/facilitate COVID-19 testing at the SSP if feasible. If someone is showing any emergency warning signs, seek emergency medical care immediately.
- Any clients with suspected or confirmed COVID-19 should ideally be excluded from the facility until they meet the criteria for discontinuation of home isolation.
- Consider alternative methods to provide services and equipment to clients not allowed into the facility or to clients who choose not to enter to avoid exposure (e.g., delivery of equipment to clients’ homes, telehealth service provision).
- Staff and volunteers who report COVID-19 symptoms should be sent home immediately to home isolate. If they experience any of the emergency warning signs for COVID-19, they should seek medical attention immediately. Guidance for when it is safe to return to work should be followed, for healthcare personnel providing care to clients, and for volunteers and other staff not providing direct client care.
- Ensure that staff and volunteers follow guidelines for preventing infection, and clients have access to hygiene supplies such as soap, alcohol-based hand sanitizers that contain at least 60% alcohol, tissues, and trash baskets.
- Provide hygiene supplies such as alcohol-based hand sanitizer with at least 60% alcohol to clients experiencing homelessness or otherwise without regular access to soap and water for handwashing.
- Ensure that sick leave policies are flexible, non-punitive, and consistent with public health guidance. Ensure that employees and volunteers are aware of and understand these policies. Have a contingency plan for staff absences in the event of illness or other emerging issues. For staff who are at higher risk for severe illness, implement specific policies to minimize face-to-face contact, or assign work tasks that allow them to maintain a distance of six feet from other workers, clients and visitors, or to telework if possible.
Additional considerations and procedure adjustments to prevent SARS-CoV-2 transmission:
- Continue to provide sterile injection equipment and methods for disposal, as well as skin cleansing supplies such as alcohol pads and hand sanitizer, to help reduce risk of COVID-19 infection, as well as to prevent skin and soft tissue infections related to unsafe injection practices.
- If necessary, change policies to increase the number of syringes each client can receive per visit to enable longer periods between visits. This practice will minimize the need to access SSPs frequently and can help ensure sterile injection in the event of SSP closure or limited hours.
- Ensure clients have adequate supplies to use sterile equipment with each injection. Dispense enough supplies to ensure continued ability of clients to inject with sterile equipment if SSP closure or limited hours may happen during the pandemic.
- Provide supplies through mobile services, delivery, or mail-order services, whenever possible.
- Provide counseling services and referrals to care by telephone and/or using online tools, where feasible.
- Review existing service provision procedures to identify ways to minimize opportunities for COVID-19 exposure and transmission.
- Consider reducing or eliminating processes that involve non-essential client physical contact with staff or objects (e.g., filling out paper forms, using shared writing utensils).
- Consider ways to shorten the duration of client visits as appropriate (e.g., eliminating redundant administrative processes).
- Reduce grouping of clients if possible (e.g., offer staggered client appointments, reduce the number of clients inside at one time, ensure clients maintain appropriate physical distancing (minimum six feet apart) while waiting outside).
- Consider installing a section of clear plastic at the customer contact area to provide barrier protection (e.g., Plexiglas type material or clear plastic sheet).
- Use or encourage others to use peer-based delivery models (e.g., providing enough supplies to clients so they can distribute to other people who inject drugs who may be unwilling or unable to visit the program) to ensure sterile supplies are reaching people who need them most, even in the event of SSP closure.
- Coordinate services with other nearby SSPs and community health programs to enable:
- Daily operations (e.g., determining if hours of operation will be modified to ensure that some SSP services in the area remain open at all times in all communities);
- Acceptance of new clients (e.g., developing or revising new patient intake process); and
- New procedures for visiting clinics or receiving services (e.g., deciding if new safety measures for facilities, staff, or clients are necessary based on the evolving situation).
- Continue to help link clients with substance use treatment such as medication for opioid use disorder (MOUD). Work with programs offering MOUD and with behavioral health agencies to ensure access to 14-28 days of medication, depending on the stability of the patient. The Substance Abuse and Mental Health Services Administration (SAMHSA) posted COVID-19 guidanceexternal icon providing potential flexibility for Opioid Treatment Programs (OTPs) to allow programs to provide medications for extended periods, and to initiate buprenorphine treatment using telehealth.
- If sterile injection equipment is unavailable or can’t otherwise be provided, provide bleach, sterile water, and instructionspdf icon for cleaning syringes. This does not ensure sterile injection, but may reduce the risk of infectious disease transmission.
1 Centers for Disease Control and Prevention. (2019). Summary of the safety and effectiveness of syringe services programs. https://www.cdc.gov/ssp/syringe-services-programs-summary.html
General guidance to reduce COVID-19 transmission:
Actions to reduce risk of COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/get-ready.html
Recommendation Regarding the Use of Cloth Face Coverings, Especially in Areas of Significant Community-Based Transmission: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html
Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19): https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html?deliveryName=USCDC_2067-DM23796
Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission (CDC): https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdfpdf icon
Guidance for healthcare personnel and other critical workers:
Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19): https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
COVID-19 Resources for Clinics and Healthcare Facilities: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html
COVID-19 Guidelines for Workers Critical to Maintenance of the Infrastructure: https://www.cdc.gov/coronavirus/2019-ncov/community/critical-workers/implementing-safety-practices.html
Guidance for other facilities/groups that are relevant for SSPs:
COVID-19 Resources for Community and Faith-Based Leaders: https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/index.html
COVID-19 Resources for Homeless Shelters: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/homelessness.html
COVID-19 Guidance for People living with HIV/AIDS: https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/hiv.html
COVID-19 Guidance for People with Medical Conditions: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/
Guidance on Preparing Workplaces for COVID-19 (OSHA): https://www.osha.gov/Publications/OSHA3990.pdfpdf iconexternal icon
Harm reduction resources:
How to clean your syringes consumer information sheet: https://www.cdc.gov/hiv/pdf/library/pocket-guides/cdc-hiv-syringe-service-pocket-guide.pdfpdf icon
Summary of the safety and effectiveness of syringe services programs: https://www.cdc.gov/ssp/syringe-services-programs-summary.html
COVID-19 Guidance for People who Use Drugs and Harm Reduction Programs (Harm Reduction Coalition):
Practicing harm reduction in the COVID-19 Outbreak: https://www.vitalstrategies.org/resources/practicing-harm-reduction-in-the-covid-19-outbreak/external icon