5/21/2020 Interim Guidance on Unsheltered Homelessness and Coronavirus Disease 2019 (COVID-19) for Homeless Service Providers and Local Officials CDC Coronavirus Disease 2019 (COVID-19) Interim Guidance on Unsheltered Homelessness and Coronavirus Disease 2019 (COVID-19) for Homeless Service Providers and Local O cials Interim Guidance This interim guidance is based on what is currently known about coronavirus disease 2019 (COVID-19). The Centers for Disease Control and Prevention (CDC) will update this interim guidance as needed and as additional information becomes available. Printer friendly version  Summary of Recent Changes A revision was made on 5/10/2020 to re ect the following: Revisions to document organization for clarity Description of “whole community” approach Clari cation of outreach sta guidance Clari cation of encampment guidance People experiencing unsheltered homelessness (those sleeping outside or in places not meant for human habitation) may be at risk for infection when there is community spread of COVID-19. This interim guidance is intended to support response to COVID-19 by local and state health departments, homelessness service systems, housing authorities, emergency planners, healthcare facilities, and homeless outreach services. Homeless shelters and other facilities should also refer to the Interim Guidance for Homeless Shelters  . Community and faith-based organizations can refer to the Interim Guidance for Community and Faith-based Organizations for other information related to their sta and organizations. COVID-19 is caused by a new coronavirus. We are learning about how it spreads, how severe it is, and other features of the disease. Lack of housing contributes to poor physical and mental health outcomes, and linkages to permanent housing for people experiencing homelessness should continue to be a priority. In the context of COVID-19 spread and transmission, the risks associated with sleeping outdoors or in an encampment setting are di erent than from staying indoors in a congregate setting such as an emergency shelter or other congregate living facility. Outdoor settings may allow people to increase physical distance between themselves and others. However, sleeping outdoors often does not provide protection from the environment, adequate access to hygiene and sanitation facilities, or connection to services and healthcare. The balance of risks should be considered for each individual experiencing unsheltered homelessness. Community coalition-based COVID-19 prevention and response Planning and response to COVID-19 transmission among people experiencing homelessness requires a “whole community”  approach, which means involving partners in the response plan development, with clearly outlined roles and responsibilities. Table 1 outlines some of the activities and key partners to consider for a whole-community approach. Table 1: Using a community-wide approach to prepare for COVID-19 among people experiencing homelessness https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/unsheltered-homelessness.html 1/5 5/21/2020 Interim Guidance on Unsheltered Homelessness and Coronavirus Disease 2019 (COVID-19) for Homeless Service Providers and Local Officials CDC Connect to community-wide planning Connect with key partners to make sure that you can all easily communicate with each other while preparing for and responding to cases. A community coalition focused on COVID-19 planning and response should include: Local and state health departments Outreach teams and street medicine providers Homeless service providers and Continuum of Care leadership Emergency management Law enforcement Healthcare providers Housing authorities Local government leadership Other support services like case management, emergency food programs, syringe service programs, and behavioral health support People with lived experiences of homelessness People with lived experiences of homelessness can help with planning and response. These individuals can serve as peer navigators to strengthen outreach and engagement e orts. Develop an advisory board with representation from people with current or former experiences of homelessness to ensure community plans are e ective. Identify additional sites and resources Continuing homeless services during community spread of COVID-19 is critical. Make plans to maintain services for all people experiencing unsheltered homelessness. Furthermore, clients who are positive for COVID-19 need to have access to services and a safe place to stay, separated from others who are not infected. To facilitate the continuation of services, community coalitions should identify resources to support people sleeping outside as well as additional temporary housing, including sites with individual rooms that are able to provide appropriate services, supplies, and sta ng. These sites should include: Over ow sites to accommodate shelter decompression and higher shelter demands Isolation sites for people who are con rmed to be positive for COVID-19 by laboratory testing Quarantine sites for people who are awaiting testing, awaiting test results, or who were exposed to COVID-19 Protective housing for people who are at highest risk for severe illness from COVID-19 Depending on resources and sta availability, housing options that have individual rooms (such as hotels/motels) and separate bathrooms should be considered for the over ow, quarantine, and protective housing sites. In addition, plan for how to connect clients to housing opportunities after they have completed their stay in these temporary sites. Communication Outreach workers and other community partners, such as emergency food provision programs or law enforcement, can help ensure people sleeping outside have access to updated information about COVID-19 and access to services. Stay updated on the local level of transmission of COVID-19 through your local  and state health departments. Build on existing partnerships with peer navigators who can help communicate with others. Maintain up-to-date contact information and areas frequented for each person. Communicate clearly with people sleeping outside. Use health messages and materials developed by credible public health sources, such as your local and state public health departments or the Centers for Disease Control and Prevention (CDC). Post signs in strategic places (e.g. near handwashing facilities) providing instruction on hand washing and cough etiquette  . Provide educational materials about COVID-19 for non-English speakers, those with low literacy or intellectual disabilities, and people who are hearing or vision impaired. https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/unsheltered-homelessness.html 2/5 5/21/2020 Interim Guidance on Unsheltered Homelessness and Coronavirus Disease 2019 (COVID-19) for Homeless Service Providers and Local Officials CDC Ensure communication with clients about changes in homeless services policies and/or changes in physical location of services such as food, water, hygiene facilities, regular healthcare, and behavioral health resources. Identify and address potential language, cultural, and disability barriers associated with communicating COVID-19 information to workers, volunteers, and those you serve. Learn more about reaching people of diverse languages and cultures. Considerations for outreach sta Sta training and policies Provide training and educational materials related to COVID-19 for sta . Minimize the number of sta members who have face-to-face interactions with clients. Develop and use contingency plans for increased absenteeism caused by employee illness or by illness in employees’ family members. These plans might include extending hours, cross-training current employees, or hiring temporary employees. Assign outreach sta who are at higher risk for severe illness from COVID-19 to duties that do not require them to interact with clients in person. Outreach sta should review stress and coping resources for themselves and their clients during this time. Sta prevention measures Encourage outreach sta to maintain good hand hygiene by washing hands with soap and water for at least 20 seconds or using hand sanitizer (with at least 60% alcohol) on a regular basis, including before and after each client interaction Advise sta to maintain 6 feet of distance while interacting with clients and other sta , where possible. Require outreach sta to wear cloth face coverings when working in public settings or interacting with clients. They should still maintain a distance of 6 feet from each other and clients, even while wearing cloth face coverings. Advise outreach sta to avoid handling client belongings. If sta are handling client belongings, they should use disposable gloves, if available. Make sure to train any sta using gloves to ensure proper use and ensure they perform hand hygiene before and after use. If gloves are unavailable, sta should perform hand hygiene immediately after handling client belongings. Outreach sta who are checking client temperatures should use a system that creates a physical barrier between the client and the screener as described here. Where possible, screeners should remain behind a physical barrier, such as a car window, that can protect the sta member’s face from respiratory droplets that may be produced if the client sneezes, coughs, or talks. If social distancing or barrier/partition controls cannot be put in place during screening, PPE (i.e., facemask, eye protection [goggles or disposable face shield that fully covers the front and sides of the face], and a single pair of disposable gloves)  can be used when within 6 feet of a client. However, given PPE shortages, training requirements, and because PPE alone is less e ective than a barrier, try to use a barrier whenever you can. For street medicine or other healthcare sta who are providing medical care to clients with suspected or con rmed COVID-19 and close contact (within 6 feet) cannot be avoided, sta should at a minimum, wear eye protection (goggles or face shield), an N95 or higher level respirator (or a facemask if respirators are not available or sta are not t tested), disposable gown, and disposable gloves. Cloth face coverings are not PPE and should not be used when a respirator or facemask is indicated. Healthcare providers should follow infection control guidelines. Outreach sta who do not interact closely (e.g., within 6 feet) with sick clients and do not clean client environments do not need to wear personal protective equipment (PPE). Outreach sta should launder work uniforms or clothes after use using the warmest appropriate water setting for the items and dry items completely. Sta process for outreach In the process of conducting outreach, sta should Greet clients from a distance of 6 feet and explain that you are taking additional precautions to protect yourself and the client from COVID-19. If the client is not wearing a cloth face covering provide them with one https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/unsheltered-homelessness.html 3/5 5/21/2020 Interim Guidance on Unsheltered Homelessness and Coronavirus Disease 2019 (COVID-19) for Homeless Service Providers and Local Officials CDC If the client is not wearing a cloth face covering, provide them with one. Screen clients for symptoms by asking them if they feel as if they have a fever, cough, or other symptoms consistent with COVID-19. Children have similar symptoms to adults and generally have mild illness Older adults and persons with medical comorbidities may have delayed presentation of fever and respiratory symptoms. If medical attention is necessary, use standard outreach protocols to facilitate access to healthcare. Continue conversations and provision of information while maintaining 6 feet of distance. If at any point you do not feel that you are able to protect yourself or your client from the spread of COVID-19, discontinue the interaction and notify your supervisor. Examples include if the client declines to wear a face covering or if you are unable to maintain a distance of 6 feet. Considerations for people experiencing unsheltered homelessness Help clients prevent becoming sick with COVID-19 Consider the balance of these risks when addressing options for decreasing COVID-19 spread. Those who are experiencing unsheltered homelessness face several risks to their health and safety. Continued linkage to homeless services, housing, medical, mental health, syringe services, and substance use treatment, including provision of medication-assisted therapies (e.g., buprenorphine, methadone maintenance, etc.). Use telemedicine, when possible. Some people who are experiencing unsheltered homelessness may be at higher risk of severe illness from COVID-19 due to older age or certain underlying medical conditions, such as chronic lung disease or serious heart conditions. Reach out to these clients regularly to ensure they are linked to care as necessary. Prioritize providing individual rooms for these clients, where available. Recommend that all clients wear cloth face coverings any time they are around other people. Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove the mask without assistance. Provide clients with hygiene materials, where available. Discourage clients from spending time in crowded places or gathering in large groups, for example at locations where food, water, or hygiene supplies are being distributed. If it is not possible for clients and sta to avoid crowded places, encourage spreading out (at least6 feet between people) to the extent possible and wearing cloth face coverings. Help link sick clients to medical care Regularly assess clients for symptoms. Clients who have symptoms may or may not have COVID-19. Make sure they have a place they can safely stay in coordination with local health authorities. If available, a nurse or other clinical sta can help with clinical assessments. These clinical sta should follow personal protective measures. Provide anyone who presents with symptoms with a cloth face covering. Facilitate access to non-urgent medical care as needed. Use standard outreach procedures to determine whether a client needs immediate medical attention. Emergency signs include (this list is not all inclusive. Please refer clients for medical care for any other symptoms that are severe or concerning to you): Trouble breathing Persistent pain or pressure in the chest New confusion or inability to arouse Bluish lips or face Notify the designated medical facility and personnel to transfer that clients might have COVID-19. If a client has tested positive for COVID-19 Use standard outreach procedures to determine whether a client needs immediate medical attention https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/unsheltered-homelessness.html 4/5 5/21/2020 Interim Guidance on Unsheltered Homelessness and Coronavirus Disease 2019 (COVID-19) for Homeless Service Providers and Local Officials CDC Use standard outreach procedures to determine whether a client needs immediate medical attention. If immediate medical attention is not required, facilitate transportation to an isolation site. Notify designated medical facility and personnel that the client has tested positive for COVID-19. If medical care is not necessary, and if no other isolation options are available, advise the individual on how to isolate themselves while e orts are underway to provide additional support. During isolation, ensure continuation of behavioral health support for people with substance use or mental health disorders. In some situations, for example due to severe untreated mental illness, an individual may not be able to comply with isolation recommendations. In these cases, community leaders should consult local health authorities to determine alternative options. Ensure the client has a safe location to recuperate (e.g., respite care) after isolation requirements are completed, and follow-up to ensure medium- and long-term medical needs are met. Considerations for encampments If individual housing options are not available, allow people who are living unsheltered or in encampments to remain where they are. Clearing encampments can cause people to disperse throughout the community and break connections with service providers. This increases the potential for infectious disease spread. Encourage those staying in encampments to set up their tents/sleeping quarters with at least 12 feet x 12 feet of space per individual. If an encampment is not able to provide su cient space for each person, allow people to remain where they are but help decompress the encampment by linking those at higher risk for severe illness to individual rooms or safe shelter. Work together with community coalition members to improve sanitation in encampments. Ensure nearby restroom facilities have functional water taps, are stocked with hand hygiene materials (soap, drying materials) and bath tissue, and remain open to people experiencing homelessness 24 hours per day. If toilets or handwashing facilities are not available nearby, assist with providing access to portable latrines with handwashing facilities for encampments of more than 10 people. These facilities should be equipped with hand sanitizer (containing at least 60% alcohol). COVID-19 Readiness Resources Visit cdc.gov/COVID19 for the latest information and resources Information for health departments Guidance for homeless service providers COVID-19 fact sheets for people experiencing homelessness (at the bottom of the page) Department of Housing and Urban Development (HUD) COVID-19 resources  CDC’s COVID-19 stress and coping information Page last reviewed: May 13, 2020 https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/unsheltered-homelessness.html 5/5