Homelessness during COVID-19: Understanding and Preventing Risk of Virus Spread in this Vulnerable Population

Ashley Van Slyke
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On any given night in the U.S., over a half a million individuals experience homelessness.1 Shelters are often a place of respite and relief for homeless individuals.

Yet, amidst the COVID-19 pandemic, shelters have become a breeding ground for transmission of COVID-19.2 The high concentration of individuals staying in close quarters, such as shelters, and lack of facilities and supplies necessary to practice proper hygiene can lead to rapid yet poorly monitored transmission of coronavirus.  

COVID-19 Health Risks for the Homeless Population
Individuals experiencing homelessness are older and have a lower life expectancy compared to the average American.3 Compared to the non-homeless population, those experiencing homelessness are projected to have higher rates of hospitalization, critical care needs, and death across all age ranges due to COVID-19.2  Those experiencing homelessness have less access to health care and are at a high risk of several chronic health conditions that increase risk of death should they become infected with COVID-19, including hypertension, diabetes mellitus, cardiac disease, and respiratory diseases. Additionally, individuals experiencing homelessness often face physical barriers to accessing health care, such as inability to reach emergency rooms and medical facilities. This has resulted in challenges related to isolating those diagnosed with COVID-19 to prevent spread.

COVID-19 and Homelessness in U.S. Cities
Many state and city governments have taken steps to prevent further transmission among homeless populations but face many barriers to progress. In the state of Washington, the first U.S. COVID-19 case was confirmed in January 2020. In March 2020, the Center for Disease Control (CDC) published an article regarding the results of testing individuals experiencing homelessness at three affiliated homeless shelters in Seattle and King County, WA, after the public health department was notified of an active case at a shelter. The public health department quickly mobilized to test 181 homeless individuals and staff at the shelter, finding an additional 19 active cases. This helped the shelters take additional steps to prevent infections, such as supplying face masks, emphasizing proper hygiene, and isolating individuals who tested positive.3 From this experience, the CDC identified several interventions to prevent the transmission of COVID-19 in the homeless population, including rapid testing, infection control measures (e.g., hand washing, wearing masks), and encouraging social distancing in homeless shelters.4  Despite CDC recommendations, access to COVID-19 testing, proper social distancing, and practicing good hygiene remain challenging for the homeless population.

In Boston, Massachusetts, the Massachusetts Department of Public Health and Boston Health Care for Homeless Populations tested individuals for COVID-19 who had been identified and referred by an area hospital, showed symptoms at a local shelter, or who were at identified outbreak points. Across a 15-day span, they diagnosed 182 adults experiencing homelessness with COVID-19, equating to 46.3 cases/1000 individuals. This is compared to only 1.8 cases with 1,000 individuals in the city overall.5

As of January 2019, New York State had over 92,000 people experiencing homelessness, the second highest number in the U.S. after California.1 New York City has borne a large burden of COVID-19 cases and has scrambled to prevent virus spread among individuals experiencing homelessness. New York City is renting hotel rooms to isolate symptomatic individuals and has prioritized sheltering older adults and those with symptoms/positive tests of COVID-19.6 The Department of Homeless Services and the Department of Health and Mental Hygiene in New York City have created guidelines for shelters on how to maintain cleanliness and protect staff and residents. Residents at shelters often share sleeping areas, bathrooms, and meal spaces, which present obvious barriers to preventing COVID-19 transmission. The city government has set up hand washing stations, toilets, tents and food stations, and provided hygiene kits for individuals experiencing homelessness. The fear of COVID-19 has prevented some from feeling comfortable going to shelters.7 Many non-profit organizations, such as the Coalition for Homelessness and the Salvation Army, are working to provide additional resources for individuals experiencing homelessness and advocate to local and state government for increased funding. For example, the Coalition for Homeless and Doctors Without Borders have increased meal production and distribution of hand sanitizer, surgical masks, prepaid cash cards, and cell phones with prepaid plans. Additionally, these organizations have opened more shelter locations to decrease high concentrations of individuals in one place.8

In Syracuse, NY, many nonprofit organizations, such as In My Father’s Kitchen, the Salvation Army, the Rescue Mission, and Catholic Charities have taken action to care for individuals experiencing homelessness. The Salvation Army has stated that before individuals enter the facilities, they must be questioned about their symptoms, and if symptomatic, they will be tested as soon as possible. The Salvation Army has some capacity to isolate and quarantine individuals who test positive, and are working with the Housing and Homelessness Coalition, State Health Department, and Department of Social Services to help expand facilities for quarantine, moving positive patients to motels in the city. While they remain open, they aim to increase sanitation practices and training on proper health precautions. However, these measures do not ameliorate concerns related to pre-existing health conditions that increase susceptibility to COVID-19 and risk of death should one contract the virus. In My Father’s Kitchen, a nonprofit organization in the city of Syracuse, and Upstate Hospital physician Dr. Lehmann have been making “house calls” to individuals experiencing homelessness out in the streets. These personal visits aim to provide basic medical care, monitor the spread of COVID-19, and keep individuals up to date about the pandemic.9

Despite the steps taken by organizations and governmental agencies in these and other cities, there remains a shortage of supplies, such as face masks, personal protective equipment and COVID-19 tests, thus hindering broad and effective prevention efforts.

Protecting Homeless Populations during COVID-19
The COVID-19 pandemic presents a set of issues unique to individuals experiencing homelessness. In order to properly care for all people and prevent further virus spread and deaths, cooperation between the private and public sectors is essential. The CDC encourages a “whole community approach”, involving local and state health departments, street medicine providers, homeless shelters, emergency management/healthcare providers, law enforcement, housing authorities, local government, and individuals with lived experience of homelessness.10

The United States Interagency on Homelessness (USICH) has taken numerous steps to provide health and socioeconomic resources for individuals experiencing homelessness. The CARES Act allocated $4 billion to USICH’s Emergency Solutions Grants which provide housing for individuals experiencing homelessness, often in housing assistance such as Rapid Rehousing. The CARES Act also allocated $5 billion to USICH’s Community Development Block Grants to be given to state and local governments for aiding individuals experiencing homelessness. Funds have been allocated to services such as tenant based rental assistance, tribal housing grants, fair housing, disaster relief funds, and public housing. The CARES Act offers a 120-day delay on evictions. However, it does not protect individuals in private housing.11 The U.S. Department of Veterans Affairs has increased its supportive services to veterans and their families and has been working to provide emergency housing for veterans at high risk of COVID-19.12 The CDC created Interim Guidance for Homeless Shelters10 and advises a coalition of state and local services to care for individuals experiencing homelessness. Guidance includes education for staff and clients regarding proper hygiene practices, social distancing, and infection prevention.

USICH has put together several resources and recommendations for preventing and addressing COVID-19 in the homeless population. For more information, visit: https://www.usich.gov/covid-19/.                  

Reference

  1. State of Homelessness: 2020 Edition (2020). In National Alliance to End Homelessness. Retrieved from https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-2020/.
  2. Culhane, D., Treglia, D., Steif, K., Kuhn, R., & Byrne, T. (2020). Estimated Emergency and Observational/Quarantine Capacity Need for the US Homeless Population Related to COVID-19 Exposure by County; Projected Hospitalizations, Intensive Care Units and Mortality. UCLA: Campuswide Homelessness Initiative. Retrieved from https://escholarship.org/uc/item/9g0992bm
  3. Tobolowsky, F.A., Gonzales, E., Self, J.L., et al. (2020). COVID-19 outbreak among three affiliated homeless service sites- King county, Washington, MMWR, Morb Mortal Wkly Rep, 69, 523-526. doi:10.15585/mmwr.mm6917e2externalicon.
  4. Responding to COVID-19 Among People Experiencing Unsheltered Homelessness (2020). In National Health Care for the Homeless Council. Retrieved from https://bit.ly/2AMqKjT.
  5. Baggett, T. P., Lewis, E., & Gaeta, J. M. (2020). Epidemiology of COVID-19 among people experiencing homelessness: Early evidence from Boston. Annals of Family Medicine COVID-19 collection.
  6. Katersky, A., & Tores, E. (2020, April 15). At least 27 New York City homeless, among hundreds of cases, have died from COVID-19. In ABC News. Retrieved from https://abcnews.go.com/Health/27-york-city-homeless-hundreds-cases-died-covid/story?id=70139748
  7. Crary, D. (2020, May). Homeless in NYC: Scared of Shelters During COVID-19 Crisis. In U.S. News & World Reports. Retrieved from https://www.usnews.com/news/health-news/articles/2020-05-04/homeless-in-nyc-tougher-than-ever-amid-covid-19-pandemic
  8. Coalition for the Homeless COVID-19 Response (2020). In Coalition for the Homeless. Retrieved from https://www.coalitionforthehomeless.org/coalition-for-the-homeless-covid-19-response/
  9. Rubio-Licht, N. (2020, March 19). Coronavirus in CNY: Syracuse homeless shelters prepare for coronavirus outbreak. In Syracuse.Com. Retrieved from https://www.syracuse.com/coronavirus/2020/03/coronavirus-in-cny-syracuse-homeless-shelters-prepare-for-coronavirus-outbreak.html
  10. Interim Guidance on Unsheltered Homelessness and Coronavirus Disease 2019 (COVID-19) for Homeless Service Providers and Local Officials (2020, May 10). In Center for Disease Control . Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/unsheltered-homelessness.html
  11. CARES ACT: What’s In It, And What Do We Still Need? (2020, April 2). In National Coalition for the Homeless. Retrieved from https://nationalhomeless.org/cares-act-whats-in-it-and-what-do-we-still-need/
  12. COVID-19 Funding, Flexibilities, and Waivers (2020, April 20). In United States Interagency Council on Homelessness. Retrieved from https://www.usich.gov/tools-for-action/covid-19-funding-flexibilities-and-waivers

Acknowledgments
The author thanks Shannon Monnat for suggestions on earlier drafts.

About the Author
Ashley Van Slyke is an undergraduate student studying Nursing at the University of Pittsburgh Research Assistant in the Lerner Center for Public Health Promotion at Syracuse University. (ajvansly@syr.edu)