People experiencing homelessness are at increased risk for infection during community spread of COVID-19. This interim guidance includes recommendations for testing strategies and is intended to support response planning by shelters and homeless service providers in coordination with public health authorities and emergency management officials. Early and sustained action to slow the spread of COVID-19 will keep clients, staff, and volunteers healthy, and help shelters and homeless service providers maintain normal operations. It is intended for:
- homeless shelters and homeless service providers
- overnight emergency shelters
- day shelters
- warming centers
- domestic violence shelters
- meal service providers
Recommendations for Maintaining Shelter and Homeless Services
Continuing homeless services during community spread of COVID-19 is critical. Homeless shelters should not close or exclude people who are having symptoms or test positive for COVID-19 without a plan for where these clients can safely access services and stay.
Decisions about whether clients with mild illness due to suspected or confirmed COVID-19 should remain in a shelter or be directed to alternative housing sites, should be made in coordination with the local health department (LHD). Alternative housing sites include:
- Overflow sites to accommodate shelter decompression (to reduce crowding) and higher shelter demands
- Isolation sites for people who are confirmed to be positive for COVID-19
- Quarantine sites for people with known exposure to COVID-19
Infection Prevention Measures
Shelters and homeless service providers should establish the following procedures to minimize transmission of COVID-19 and to assure safety of clients, staff, and volunteers:
- Require staff and volunteers to always wear masks in the facility.
- Require all clients to wear masks or face coverings any time they are not in a single room or on their bed/mat (in shared sleeping areas). Masks should not be placed on young children under age 2 or anyone who has trouble breathing or is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.
- Require all clients, staff, and volunteers to maintain physical distancing of at least 6 feet from others. Create a way to make physical distancing between clients and staff easier, such as staggering meal services or having maximum occupancy limits for common rooms and bathrooms.
- Require clients and staff to perform hand hygiene appropriately and frequently by washing hands with soap and water for at least 20 seconds or using an alcohol-based hand sanitizer with at least 60% alcohol if soap and water are not available.
- Provide alcohol-based hand sanitizers that contain at least 60% alcohol at key points within the facility, including registration desks, entrances/exits, and eating areas.
- Make sure bathrooms and other sinks are consistently stocked with soap and drying materials for handwashing.
- Clean and disinfect frequently touched surfaces at least daily and shared objects between use with an EPA-registered disinfectant.
Facility Layout Considerations
- Use physical barriers to limit the spread of COVID-19 between staff and clients. For example, install a sneeze guard at the check-in desk or place an additional table between staff and clients to increase the distance between them to at least 6 feet.
- In meal service areas, create at least 6 feet of space between seats, and/or allow either for food to be delivered to clients or for clients to take food away.
- In general sleeping areas (for those who are not experiencing respiratory symptoms), try to make sure client’s faces are at least 6 feet apart.
- Align mats/beds so clients sleep head-to-toe.
For clients with symptoms consistent with COVID-19:
- Ensure the client is tested immediately for COVID-19 (see “Testing Strategy”, below)
- Prioritize these clients for individual rooms.
- If individual rooms are not available, consider using a large, well-ventilated room.
- Keep mats/beds at least 6 feet apart.
- Use temporary barriers between mats/beds, such as curtains.
- Align mats/beds so clients sleep head-to-toe.
- If possible, designate a separate bathroom for these clients.
- If areas where these clients can stay are not available in the facility, facilitate transfer to a quarantine site.
For clients with confirmed COVID-19, regardless of symptoms:
- Prioritize these clients for individual rooms.
- If more than one person has tested positive, these clients can stay in the same area.
- Designate a separate bathroom for these clients
Follow CDC recommendations for how to prevent further spread in your facility.
If areas where these clients can stay are not available in the facility, assist with transfer to an isolation site.
Screen clients, staff, visitors, and volunteers daily for symptoms of COVID-19
- Clients who have symptoms may or may not have COVID-19. Make sure they have a place they can safely stay within the shelter or at an alternate site in coordination with the LHD.
- If available, an on-site nurse or other clinical staff can help with clinical assessments.
- Facilitate access to non-urgent medical care as needed.
- Use standard facility procedures to determine whether a client needs immediate medical attention. Emergency signs of COVID-19 infection include:
- Trouble/difficulty breathing
- Persistent pain or pressure in the chest
- New confusion or inability to arouse
- Bluish lips or face
- Notify the designated medical facility and emergency medical personnel transferring/transporting clients that the client might have COVID-19.
- Prepare health care staff to care for patients with COVID-19, if your facility provides health care services, and make sure your facility has an adequate supply of personal protective equipment.
Testing Plan and Response Strategy
The purpose and process of all testing and other public health activities should be clearly communicated to clients and to staff at the homeless service site to promote understanding and acceptability. Testing strategies should be carried out in a way that protects privacy and confidentiality to the extent possible and that is consistent with applicable laws and regulations.
Whenever a positive test result is identified, the facility should ensure that the individual is rapidly and appropriately notified, separated from others, provided appropriate medical care, and linked to appropriate alternative housing for isolation, as necessary. Shelters should ensure that they obtain verbal, informed consent for testing from residents and staff and minimize the use of paper forms to reduce transmission risks.
Local health departments and administrators of homeless service sites, in partnership with health care providers, should decide whether and how to implement these testing considerations to identify cases among persons who are asymptomatic, including both those with and without known exposure to COVID-19. Key components of the testing plan, shown in the COVID-19 Viral Testing Flowchart for Homeless Shelters, below, are:
Immediate testing should be performed on:
- individuals with signs or symptoms consistent with COVID-19
- asymptomatic individuals with recent known or suspected exposure to COVID-19 to control transmission
Facility-wide testing of all clients, staff, and volunteers whenever a case is identified through immediate testing.
Repeat testing of all previously negative clients, staff, and volunteers (e.g., every 3-7 days or as directed by the local health department) until no new cases are identified over a period of at
least 14 days (for a single isolated case) or over a period of at least 28 days (for an outbreak).
COVID-19 Viral Testing Flowchart for Homeless Shelters
Testing for COVID-19
Facilities should perform testing of clients and staff using viral tests approved or authorized by the Food and Drug Administration (FDA) for diagnosing current COVID-19 infection. Approved viral tests include the Real-Time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) and point-of-care (POC) antigen or molecular tests. As described above, shelter administrators should work with their local health department to identify testing resources.
• The RT-PCR molecular test is the “gold standard” for clinical diagnostic detection of SARS-CoV-2, the virus that causes COVID-19 infection.
• While POC molecular and POC antigen tests usually provide more rapid results than the RT-PCR, they have a higher probability of missing an active infection. RT-PCR tests are typically highly accurate and usually do not need to be repeated.
• For antigen tests, confirmatory RT-PCR might be needed for positive or negative results, depending on the level of community transmission and whether the individual has symptoms.
• For considerations on interpreting antigen test results in homeless shelters see the CDC algorithm that is attached to this guidance https://www.cdc.gov/coronavirus/2019-ncov/downloads/homelessness-testing-guidance.pdf
• Procedures for reporting results of rapid POC tests are included in Provider Guidance for Testing
COVID-19 Vaccination Recommendations
Vaccination is an important tool to control the COVID-19 pandemic. The goal is for everyone, including people experiencing homelessness, to be able to easily get a COVID-19 vaccine as soon as possible.
Shelter service staff and volunteers are classified as frontline essential workers and included in Priority Group 1b for receipt of the COVID-19 vaccine. They should be strongly encouraged to receive vaccine as soon as it is available to them. Recommendations for shelter providers and Local Health Departments to improve vaccine accessibility and to build vaccine confidence among clients, staff, and volunteers include:
- Building relationships and providing clear, consistent, transparent information to ensure that individuals feel comfortable receiving the COVID-19 vaccine.
- Making vaccines available on site through partnership with the local health department because people who are experiencing homelessness may have experienced one or more of the following: history of trauma; negative experiences with medical services; and/or difficulty accessing medical services in traditional settings, such as a clinic or pharmacy.
- Holding multiple vaccination events to allow clients time to consider receiving the vaccine.
- Integrating reminders into the process for vaccinating clients to ensure that they receive the second dose of vaccine and conducting outreach to connect with individuals who might otherwise be lost to follow-up.
Vaccination is just one tool to control the COVID-19 pandemic. Therefore, shelter service providers should continue taking all precautions possible, including mask wearing, social distancing, and hand hygiene, to prevent staff, volunteers, and clients from contracting and spreading the virus that causes COVID-19.
Last Updated: 2/8/2021