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 Communities of Faith for other information related to their staff 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 different 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”external icon 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

table 1 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 efforts. Develop an advisory board with representation from people with current or former experiences of homelessness to ensure community plans are effective. 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 staffing. These sites should include: Overflow sites to accommodate shelter decompression and higher shelter demands

Isolation sites for people who are confirmed 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 increased risk for severe illness from COVID-19 Depending on resources and staff availability, housing options that have individual rooms (such as hotels/motels) and separate bathrooms should be considered for the overflow, 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 external icon and state health departments.

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 pdf icon . 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. 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 staff

Staff training and policies

Provide training and educational materials related to COVID-19 for staff.

Minimize the number of staff 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 staff who are at increased risk for severe illness from COVID-19 to duties that do not require them to interact with clients in person.

Outreach staff should review stress and coping resources for themselves and their clients during this time.

Staff prevention measures

Encourage outreach staff 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 staff to maintain 6 feet of distance while interacting with clients and other staff, where possible.

Require outreach staff to wear masks 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 masks.

Advise outreach staff to avoid handling client belongings. If staff are handling client belongings, they should use disposable gloves, if available. Make sure to train any staff using gloves to ensure proper use and ensure they perform hand hygiene before and after use. If gloves are unavailable, staff should perform hand hygiene immediately after handling client belongings.

Outreach staff 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 staff 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 effective than a barrier, try to use a barrier whenever you can.

For street medicine or other healthcare staff who are providing medical care to clients with suspected or confirmed COVID-19 and close contact (within 6 feet) cannot be avoided, staff 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 staff are not fit tested), disposable gown, and disposable gloves. Masks are not PPE and should not be used when a respirator or facemask is indicated. Healthcare providers should follow infection control guidelines.

Healthcare providers should follow infection control guidelines. Outreach staff 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 staff should launder work uniforms or clothes after use using the warmest appropriate water setting for the items and dry items completely.

Staff process for outreach

In the process of conducting outreach, staff 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 mask, 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 mask 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 increased 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 masks any time they are around other people. Masks 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 staff to avoid crowded places, encourage spreading out (at least6 feet between people) to the extent possible and wearing masks.



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 staff can help with clinical assessments. These clinical staff should follow personal protective measures. Provide anyone who presents with symptoms with a mask. 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. 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 efforts 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 sufficient space for each person, allow people to remain where they are but help decompress the encampment by linking those at increased 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