Interim Guidance for Homeless and Emergency Shelters on the Novel Influenza A (H1N1) Virus

December 21, 2009, 12:30 PM ET

Note: Emergency shelter components have been updated.

This document provides interim guidance specific for homeless shelters during the outbreak of novel influenza A (H1N1) virus and suggested means to reduce the spread of influenza in these settings and communities. Recommendations may need to be revised as more information becomes available.

Background

Shelters that serve homeless persons can help protect the health of their clients, staff and volunteers during this outbreak of novel influenza A (H1N1) by taking actions to prevent the spread of influenza. The homeless population is diverse, transient, and includes single adults, children and families. Much of the homeless population is sheltered, but over 40% of them are unsheltered. In addition, events such as acts of nature (e.g., hurricanes), reduced access to everyday resources, or a disease outbreak may contribute to a rapid increase in emergency shelter usage. Interim recommendations to reduce transmission of novel influenza A (H1N1) virus in this group setting are addressed below.

Influenza-like Illness (ILI) and Novel Influenza A (H1N1)

Novel influenza A (H1N1) virus is likely to spread from person to person in the same way as seasonal flu. The main way that influenza is thought to spread is through the coughing or sneezing of people infected with the influenza virus. People may also become infected by touching something with flu viruses on it and then touching their mouth, nose, or eyes.

Symptoms

Symptoms of influenza-like-illness (ILI) include fever and either cough or sore throat. In addition, illness may be accompanied by other symptoms including headache, tiredness, runny or stuffy nose, chills, body aches, diarrhea, and vomiting. Like seasonal flu, novel influenza A (H1N1) infection in humans can vary in severity from mild to severe. For more information on the symptoms of novel influenza A (H1N1), please see CDC What to Do If You Get Flu-Like Symptoms.

Transmission

Spread of this novel influenza A (H1N1) virus is thought to occur in the same way that seasonal flu spreads. Flu viruses are thought to spread mainly from person to person through coughing or sneezing by people with influenza. In addition, people may become infected by touching something with flu viruses on it and then touching their mouth or nose.

General Prevention Recommendations

• Encourage all persons within the shelter to cover their cough or sneeze with a tissue. Throw all tissues in the trash after use. Maintain good hand hygiene by washing with running water and soap, or using an alcohol-based hand sanitizer*, especially after coughing or sneezing. Avoid touching eyes, nose and mouth. For more information on how to prevent the spread of novel influenza A (H1N1), please see the CDC Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Novel Influenza A (H1N1) Virus Infection in a Healthcare Setting.
• Make the means for appropriate hand cleansing readily available within the shelter, including common, food preparation and dining areas. Ideal means for hand cleansing include, running water, soap, and hand drying machines. Paper towels and waste baskets should be made available. Shelter staff, volunteers and clients should frequently wash their hands with soap and water, or use a hand sanitizer* if hand washing with soap and water is not possible.
• Shelters should follow standard precautions in the shelter settings. This includes training staff in the control of infectious diseases, providing access to personal protective equipment and apparel, and encouraging proper hand washing. For more information on standard precautions in health care settings, please see Shelter Health: Essentials of Care for People Living in Shelter. Items that are often in contact with respiratory droplets and hands (e.g., doorknobs, faucets, etc.,) should be cleaned and disinfected regularly. For more information, please see CDC Clean Hands Save Lives!
• Clean all common areas within the shelter routinely and immediately, when visibly soiled, with the cleaning agents normally used in these areas. Eating utensils should be washed either in a dishwasher or by hand with detergent and water. Cups and utensils should not be shared until after washing.
• Educational materials and information should be provided to clients in a way that can be understood by non-English speakers. Spanish-language materials are available at CDC H1N1 Flu Espanol. Materials and information in other languages are available at CDC Other Languages and Illinois Department of Public Health H1N1 Flu Other Languages

Reducing Exposure and Spread of Novel Influenza A (H1N1) Within Shelters

Shelter management should contact their state, local, tribal, or territorial health departments for more specific guidance and development of protocols for homeless and emergency shelters in their areas. Shelters that provide service to individuals and families living in single room occupancies (SROs) and transitional housing should also refer to the CDC Interim Guidance for H1N1 Flu (Swine Flu): Taking Care of a Sick Person in Your Home. Shelters that have pregnant women should refer to What Pregnant Women Should Know About H1N1 (formerly called swine flu) Virus.

Reduction of Risk of Introduction

• Shelter clients, staff and volunteers should be instructed to immediately inform shelter management if they have an influenza-like illness (ILI) or if they have had one in the previous 7 days.
• Direct persons with ILI symptoms to facilities or alternative care sites (ACS) where they can receive proper care, if such alternatives are available. Please see Pandemic Flu Healthcare Planning.
• Staff and volunteers with ILI should stay home (or be sent home if they develop symptoms while at the shelter), and remain at home for at least 24 hours after their fever is gone except to get medical care or for other necessities (their fever should be gone without the use of a fever-reducing medicine). They should keep away from others as much as possible. This is to keep from making others sick.
• Follow current vaccination recommendations and encourage staff and volunteers to take the upcoming season’s influenza vaccine, when it is available. For more information please see the CDC Infection Control Guidance for the Prevention and Control of Influenza in Acute-Care Facilities.

Rapid Detection of Cases

• Shelter staff and volunteers should be diligent about early recognition of illness and placing those with ILI symptoms away from others. For more information please see the CDC Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus Transmission and the Interim Guidance for H1N1 Flu (Swine Flu): Taking Care of a Sick Person in Your Home.
• Instruct existing clients, staff and volunteers to report symptoms of ILI to the shelter management at the first sign of illness.
• Plan for how persons with ILI may be evaluated and treated, if necessary. Please see the CDC Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Novel Influenza A (H1N1) Virus Infection in a Healthcare Setting and CDC Antiviral Drugs and H1N1 Flu (Swine Flu) for more information.
• Consider daily temperature checks with shelter clients who had contact with persons with ILI.

Management and Isolation of Suspect and Confirmed Cases

• Minimize the number of personnel directly exposed to ill people. Staff members who have contact with sick clients should follow the CDC Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Novel Influenza A (H1N1) Virus Infection in a Healthcare Setting.
• For proper techniques in caring for an ill person, refer to the CDC Interim Guidance for H1N1 Flu (Swine Flu): Taking Care of a Sick Person in Your Home. Pregnant staff member(s) and others at high risk of severe illness from influenza should not be designated as caregivers for sick clients who are staying in the shelter.
• Refer to the CDC Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus Transmission.
• Actively monitor the number and severity of cases of ILI and inform the state, local, tribal, or territorial health departments of cases at the shelter.
• Ideally, sick persons should be confined to individual rooms and should avoid common areas. If individual rooms for sick clients are not available, consider using a large, well-ventilated room specifically for sick persons with beds at least 6 feet apart and the use of temporary barriers between beds, when possible.
• Designate staff to care for the sick persons and limit client movement between different parts of the institution to decrease the risk of spreading influenza to other parts of the shelter.
• Pre-exposure antiviral chemoprophylaxis should only be used in limited circumstances, and in consultation with local medical or public health authorities. Interim guidance for antiviral use can be found at the CDC Interim Guidance on Antiviral Recommendations for Patients with Novel Influenza A (H1N1) Virus Infection and Their Close Contacts.
• Provide sick clients with access to fluids, tissues, plastic bags for the proper disposal of used tissues, and a means to wash their hands or alcohol-based hand sanitizers as an adjunct.
• Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned separately, but they should not be shared without thorough washing. Linens (such as bed sheets and towels) should be washed using laundry soap and tumbled dry on a hot setting. Individuals should wash their hands with soap and water or use alcohol-based hand sanitizer immediately after handling dirty laundry.

Caring for Persons at High Risk

The shelter should be aware of the special health needs of persons at increased risk of severe illness from influenza.
Persons at high risk for complications from novel influenza A (H1N1) infection may be similar to those who are at high risk for seasonal influenza complications and include the following: children 5 years and younger, persons age 65 years and older, pregnant women, persons of any age with chronic medical conditions (such as asthma, diabetes, or heart disease), and persons who are immunocompromised (for example, taking immunosuppressive medications or infected with HIV). Information on the aforementioned high risk populations can be found at the following links:
Pregnant Women and Novel Influenza A (H1N1) Considerations for Clinicians

H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease and Stroke)

Interim Guidance—HIV-Infected Adults and Adolescents: Considerations for Clinicians Regarding Novel Influenza A (H1N1) Virus

If severe symptoms of novel influenza A (H1N1) infection are identified, persons should be taken to receive medical attention from a physician or hospital. Severe symptoms include:

• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with fever and worse cough

For more information about the signs and symptoms of severe illness, please read: What to Do If You Get Flu-Like Symptoms

Additional Information Regarding H1N1 and Influenza Preparedness

• Key Facts About Swine Influenza.
• Questions and Answers about novel H1N1 are available.
• An Influenza Pandemic Planning Guide for Homeless and Housing Service Providers, Seattle-King County, WA, 12/06

Additional Information Regarding Resources for Homeless Shelters

• The HUD Homeless Resource Exchange.
• The National Health Care for the Homeless Council.
• Disaster Planning for People Experiencing Homelessness, National Health Care for the Homeless Council.
• Healing Hands: Disaster Planning Requires Time, Resources, Collaboration, Health Care for the Homeless Clinicians’ Network, August 2005.
• National Health Care for the Homeless Council
• Shelter Health: Essentials of Care for People Living in Shelters, December 2005.
• Pandemic Influenza Guidance for Homeless Shelter and Homeless Service Providers, October, 2009.

If you have additional questions, please contact the Centers for Disease Control and Prevention’s (CDC) Hotline at 1-800-CDC-INFO, available in English and Spanish, 24 hours a day, 7 days a week.