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

Summary of Changes

Homeless service provider sites have many different designs and capacities. Some may have individual apartments or rooms, while others use shared sleeping areas. Some have medical staff on site, while others do not. The investigation, support needed, and public health actions to be taken will depend on the setting and the local context of the outbreak. Consider the following options when COVID-19 has been reported among clients or staff in homeless service provider sites.

Communicate with the facility

• Alert the facility as soon as a COVID-19 in client or staff member has been identified.
• Communicate the goal of working together with the homeless service provider to protect clients and staff.
• Establish regular communication and facilitate data sharing between the homeless service site, health department, and healthcare facilities.

Isolate persons with confirmed COVID-19

Quarantine and isolation duration in homeless shelters

Following close contact to someone with COVID-19, clients and staff of homeless shelters, regardless of their vaccination and booster status, should quarantine for 10 days from the date of their last known close contact. Clients and staff who have been exposed should be tested at least 5 days after the last known close contact regardless of vaccination and booster status or symptoms.

All clients and staff of homeless shelters who receive a positive test result, regardless of their vaccination and booster status or symptoms, should isolate for 10 days. Multiple clients testing positive may be cohorted together in isolation, irrespective of the date of their positive test.

Clients and staff may follow general population guidance in other community settings. For example, if a client is working in a setting other than the homeless service site (and it is not a congregate setting at higher risk for transmission), they may return to work in accordance with the general population guidance. Similarly, staff can follow general population guidance for activities other than returning to work, such as grocery shopping.

Shortening quarantine or isolation duration in crisis situations

During crisis situations (examples below), facilities may need to consider short-term alternatives to the 10-day quarantine or isolation periods for clients or staff. Decisions to shorten duration should be made independently for staff and for clients. Once the period of crisis-level operations has passed, facilities should return to the recommendations for periods of routine operations.

The following are guiding principles for reducing quarantine or isolation periods during crisis-level operations:

• Before reducing the duration of quarantine or isolation, consider alternatives (e.g., shift from individual to cohorted isolation).
• Consider the risk of transmission within the facility (e.g., improvements made to the ventilation system, ability to maintain physical distance), risk profile of the facility’s population, and local context before making modifications.
• Consider reducing quarantine or isolation duration for groups at lower risk of infection first (e.g., those who are up to date on their COVID-19 vaccines).
• If infected staff return to work before 10 days of isolation, risk of transmission can be reduced by assigning staff to work exclusively in isolation units or in assignments where they have minimal contact with others for the duration of the 10 days.

Examples of when quarantine/isolation durations might be shortened:

• Staffing shortages threaten to compromise the continuity of essential operations.
• There is insufficient space to quarantine or isolate all residents who have been exposed or infected for the full recommended 10-day periods.
• Resources are constrained and the facility has been deemed to be at lower risk for transmission based on facility or client characteristics (e.g., a shelter where individual rooms are available and clients are not at high risk for severe outcomes).

Additional isolation considerations:

• Per guidance for homeless service providers, ensure that the homeless service site has capacity to isolate clients with positive results who are not hospitalized, or facilitate safe 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.
• Ensure appropriate accommodation for families if parents or children require isolation.
• Clients who have tested positive should be provided masks to wear (unless contraindicated) whenever they leave their rooms or their designated areas.

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.
• Recommend that all clients and staff wear well-fitting masks or respirators, regardless of vaccination or booster status, to prevent spread of the virus from people who do not know that they are infected. Provide education about the potential for contact transmission from touching masks, how to appropriately remove masks, how to clean masks, and when masks need to be replaced.
• Conduct a site assessment to evaluate whether the facility is aligned with public health guidance for homeless service provider sites. Help identify changes to the current layout, operations, necessary supplies. Check:
  • Bed spacing
  • Infection control supply availability, including necessary personal protective equipment
  • Communications materials about COVID-19, that are culturally and linguistically appropriate, for staff and clients (e.g., signs, posters, and fact sheets)
  • Availability of handwashing stations with adequate soap and water, disposable paper towels, and touch-free trash receptacles
  • Hand sanitizer (ideally touchless), with at least 60% alcohol, located at key points within the facility (e.g., registration desk, entrances/exits, and eating areas)
  • Separate areas for people who are symptomatic and pending testing, including separate bathrooms if possible
  • Separate rooms onsite (ideally with separate bathrooms) or offsite locations for people who are confirmed to be positive for COVID-19
• Develop a plan to support infection prevention and control activities after the site assessment is complete.
• Consider additional recommendations to maintain physical distancing between all clients and staff and decrease contamination in the context of COVID-19 transmission.
  • If possible, maintain social distancing (6 feet or more) in communal areas
  • Assign beds/mats and linens to reduce sharing
  • Encourage the use of non-contact methods of greeting
  • Stagger food services to reduce crowding during meals
  • Allow food to be delivered to clients or for clients to take food away
• If the facility is too crowded, help identify methods to reduce crowding. However, be sure to maintain potentially exposed individuals as a cohort. Collaborate with local officials to establish an additional homeless service site.

Test clients and staff

• Facility-wide testing of asymptomatic individuals with recent known or potential exposure to SARS-CoV-2 is recommended for certain settings, like homeless shelters or encampments, where a case of COVID-19 has been identified.
  • Work with partners to offer diagnostic testing as soon as possible to all clients and staff who were at the site during the time period from 48 hours before symptom onset of the person diagnosed with COVID-19 until they were isolated.
  • Where possible, try to broadly offer testing to anyone who might have been exposed.
• Repeat testing of all previously negative or untested clients and staff (e.g., once a week) is recommended until the testing identifies no new cases of COVID-19 over at least 14 days since the most recent positive result.
• Follow-up testing is recommended for anyone who was not tested or tested negative if they develop symptoms of COVID-19 at any time.
• Protect health department and healthcare staff collecting specimens using CDC guidance for specimen collection.
• Ensure that individuals who have tested positive receive appropriate medical care.
• Follow-up can be difficult among people experiencing homelessness. To facilitate location-based contact tracing (see below), consider interviewing all clients at the time of testing to identify common locations the person visited starting from 48 hours before their symptoms began (or before the date their specimen was collected, if they did not have symptoms).

Contact tracing

• Case investigation and contact tracing are fundamental activities that involve working with a patient (symptomatic or asymptomatic) who has been diagnosed with an infectious disease to identify and provide support to others who may have been infected through exposure to the patient. However, in homeless service sites, crowding, mixing of clients and staff, difficulty ascertaining contacts, client mobility, and other constraints can limit the effectiveness of traditional person-based contact tracing.
• Location-based contact tracing involves identifying sites visited by persons with confirmed COVID-19 during the time they were considered infectious, which can help identify additional facilities that might need investigation and testing. To conduct location-based contact tracing:
  • Communicate the purpose of your interview clearly so that clients and staff will understand that the goal is to protect friends, family, and community members from future potential COVID-19 infections.
  • Interview persons with COVID-19 who are experiencing homelessness about locations where they have been, starting 48 hours before their symptoms began (or before the date their specimen was collected, if they did not have symptoms). Locations that are likely to have more people in close contact for extended periods of time may warrant additional follow-up.
  • Work with homeless service providers to use Homeless Management Information Systems (HMIS) and other data collection systems to identify where the person with confirmed COVID-19 checked-in during the time they were infectious.
  • If staff members have been exposed or have tested positive, identify whether they worked at other homeless service provider sites or elsewhere (e.g., encampments) during the time they were infectious.
  • For other sites that have been identified in location-based contact-tracing, conduct investigation and facility-wide testing as resources allow.
• When possible, ask persons with confirmed COVID-19 if they have a partner, family members, or other friends with whom they spend a lot of time to ensure “closest” contacts have access to medical care and testing.
• As feasible, use bed maps, social groups, and job involvement to identify other contacts.

Limit movement

• It may be necessary to limit movement in and out of the facility while cases are being identified to decrease the possibility of spreading the virus. Define a cohort of those exposed who require movement limitations. This may be the entire facility.
• If possible, consider asking the facility to close to new admissions if new cases have been identified within the past 14 days.
• Work with community partners to ensure those seeking shelter have alternate options.
• For clients who use public transportation, encourage them to follow the CDC guidance on how to protect themselves when using transportation, travel during less busy times, limit touching their eyes, nose, or mouth, and wash their hands or use hand sanitizer with at least 60% alcohol before using public transportation and as soon as they arrive at their destination.
• 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 masks (excluding children under age 2 or anyone who has trouble breathing or is unconscious, incapacitated or otherwise unable to remove the mask without assistance) and maintain 6 feet of distance from others, regardless of vaccination or booster status.
• Identify activities and services needed to help clients stay at the facility, such as activities to pass time, support for behavioral health, and treatment for substance use disorders, medical care, and other social services. 

Relocate clients at increased risk for 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 increased risk for severe illness into shared settings.

Encourage enhanced monitoring for illness

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

Staff support

• 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 facemasks and eye protection.

Link to resources

• Coordinate with the local emergency management structure to identify necessary resources, including isolation and quarantine sites, supplies, staff, and testing.
• Engage community partners for support if there are supply issues related to food or other resources such as handwashing supplies, PPE, and other items necessary for infection prevention and control.
• Identify ways to support bringing handwashing stations, showers, and laundry to the facility if these are not already available.
• Post easily understandable graphics around the facility to help staff and clients identify the symptoms of COVID-19 and practice proper hand hygiene and other behaviors to prevent the virus’s spread.
• Identify and address potential barriers related to language, culture, and disability associated with communicating COVID-19 information to workers, volunteers, and clients.