COVID-19 and people experiencing homelessness: challenges and mitigation strategies

How has COVID-19 affected the homeless population and its service providers?

Homeless individuals are at increased risk of infection with SARS-CoV-2 owing to their lack of safe housing and conditions in shelter and drop-in facilities.1^,6 In a shelter population, spread of SARS-CoV-2 may be rapid and the detection of illness delayed because of limited access to health care and social services.7^,8 The risk of severe COVID-19 is increased for people experiencing homelessness owing to the high prevalence of medical comorbidities including heart disease, respiratory conditions, liver disease and high rates of smoking in homeless populations.9^–11 An increasing proportion of people experiencing homelessness are older than 65 years, a factor that also exacerbates the risk of developing severe COVID-19.12

Given these factors, modelling of the potential effect of SARS-CoV-2 among the US homeless population showed a potential peak infection rate of 40%, with an estimated 4.3% of individuals who experience homelessness likely to require admission to hospital.6 Among 408 individuals experiencing homelessness who were in shelters in Boston, Massachusetts, 36% tested positive for SARS-CoV-2.13 Rapid transmission has also been reported among staff at shelters, with 1 study showing that 30% of staff working in a Boston shelter tested positive for COVID-19.14 Projected COVID-19 mortality rates among individuals experiencing homelessness range from 0.3% to 1.9%, which is higher than population averages.6

Staff and organizations that provide services for people experiencing homelessness have identified the following particular problems: lack of timely and ongoing public health communications, difficulties in maintaining adequate infection control measures because of limitations in staffing and physical facilities, lack of sufficient personal protective equipment, and challenges to achieving effective screening of clients.1 Furthermore, the obvious difficulty of maintaining self-isolation or quarantine in shelters or drop-in sites makes it essential to plan early and proactively to create isolation sites for people experiencing homelessness.1

What changes to the homeless services sector may reduce the spread of COVID-19?

A framework created by the Canadian Network for Health and Housing for People Experiencing Homelessness notes 6 essential pillars in response to this pandemic: enhanced screening methods, sentinel surveillance, coordination of health and shelter systems, COVID-19 risk stratification, isolation shelters for persons under investigation and cohorting SARS-CoV-2-positive cases for community-based shelter care.15 Given that homeless people represent a group that is particularly vulnerable to COVID-19, it is prudent to offer homeless people priority testing for SARS-CoV-2.

In keeping with general public health recommendations to prevent the spread of SARS-CoV-2, shelters, meal programs and other organizations that serve individuals experiencing homelessness must create conditions that enable physical distancing. Opening new shelter spaces and increasing spacing between beds has the potential to reduce the risk of spread of SARS-CoV-2.7^,16 Additional strategies to allow for physical distancing in shelters and drop-in sites include moving individuals who experience homelessness into hotels and motels, which has been implemented by government and shelter personnel in locations such as Montréal, Calgary, Los Angeles and the Region of Peel in Ontario.17^–20 Such efforts require commitment to additional funding and human resources.

Seattle reportedly created 1893 new spaces in shelter services to address the unique needs of individuals experiencing homelessness, 16 including increased number of beds in emergency shelters (95 beds), access to areas for physical distancing (709 expansion spaces), areas for isolation or quarantine (432 beds) and areas designed for recovery (612 beds).16 A dedicated site for individuals with COVID-19 and experiencing homelessness was created in the Region of Peel and in Toronto, Canada, to allow for isolation along with health and social support care.7^,20

What special challenges arise in the management of people who are suspected of having or confirmed to have COVID-19?

Intersecting factors such as mental illness, substance use, involvement in sex work and distrust of service providers may contribute substantially to difficulties faced by individuals in engaging with pandemic-specific protocols.4, Additional challenges include limited access to health or social services.4 Screening and treatment services such as primary care clinics may have been less accessible for individuals experiencing homelessness. The transient nature of homeless populations adds further complexities with respect to contact tracing to contain the spread of SARS-CoV-2 and reduce community transmission. 4 Additionally, the limited availability of services relative to the needs of the population poses major constraints on control efforts, as inadequate resources (e.g., space and personal protective equipment) make enforcing public health protocols extremely difficult at many shelters.7^,8

Individuals experiencing homelessness who do not adhere to advice to self-isolate or quarantine pose a particular challenge. When individuals with SARS-CoV-2 re-enter the community, risk of disease transmission is high. Absent legal and restrictive measures to address this issue, health and social homeless service providers must focus on building relationships and rapport, and take a trauma-informed approach to care, to persuade individuals to follow advice.

As discussed, individuals experiencing homelessness are likely to be at high risk for clinically severe COVID-19 yet are also unlikely to have engaged in any advance care planning. However, as a result of alienation from the health care system, many individuals experiencing homelessness may resist transfer to hospital if their condition deteriorates. Work is under way to establish consistent protocols for advance care planning for homeless people before admission to COVID-19 sites. Clinicians caring for this population should be trained and equipped to provide pandemic palliative care, including compassionate and trauma-informed end-of-life care.21

How might physical distancing and isolation interventions negatively affect individuals experiencing homelessness?

Physical distancing has substantial negative implications for individuals who are homeless or precariously housed. Abrupt closure of drop-in services and community centres, and resulting disruption in social relationships and support, may lead to deterioration in mental health for many. Similarly, reduced access to public spaces such as libraries, community centres and malls, and a reduction in resources such as peer counselling services, disproportionately affect individuals experiencing homelessness.

Among individuals who are experiencing homelessness and have substance use disorders, the added stress imposed by the closures of related services may contribute to increased alcohol or drug use and high rates of substance-related morbidity or mortality.22^,23 For individuals who are opioid dependent, experiences of physical distancing and the resulting limited supply of opioid products may increase risks of overdose because of intermittent use and loss of drug tolerance. Reduced access to supervised consumption services increases risk of harms associated with unsafe drug use, including acquisition of blood-borne infections such as HIV and hepatitis C.23

For many individuals who experience homelessness, sources of income include activities such as panhandling or sex work. Among women, girls and gender-diverse people, engaging in sex work or survival sex is often necessary to maintain shelter or to avoid intimate partner violence.24 With physical distancing in place, individuals may have a reduced ability to engage in these activities and therefore may suffer substantial loss of income. Furthermore, homeless women and gender-diverse people may be at increased risk of experiencing intimate partner violence during the pandemic.

Individuals who experience homelessness are also likely to face criminalization of their daily life. For example, it is difficult, if not impossible, for homeless individuals to avoid infractions of physical distancing orders when they line up to enter a shelter or meal program or when they sit on a park bench. Homeless people in both Canada and the US have reportedly received fines ranging from $500 to $10 000 for such violations,25 which is highly problematic.25

How can COVID-19 care for individuals who experience homelessness be made more equitable?

As described above, interventions that are designed to house, isolate and treat people experiencing homelessness can begin to address the challenges, yet gaps remain. Programs and policies for addressing COVID-19 should be developed with and by Indigenous organizations to ensure that stigmatization, racism and ongoing colonialization experienced by Indigenous people is not compounded by public health approaches to the pandemic and that the unique needs of Indigenous people experiencing homelessness are met.

Health, social and government agencies must collaborate in a coordinated approach when developing and implementing services within the homeless sector. Funding is needed to ensure adequate supply of resources such as personal protective equipment, to enhance shelter space and to ensure harm reduction approaches in isolation and quarantine facilities for individuals experiencing homelessness. The latter includes providing managed alcohol programs, overdose prevention support and access to opioid antagonist therapy or safer supply.

Finally, as the pandemic wanes and is ultimately controlled, governments and service providers should take the opportunity to overhaul the way that people experiencing homelessness are treated and sheltered, and to transition to approaches that focus on long-term recovery through permanent housing and supports. 8^,25 The feasibility of the latter approach will be influenced by ongoing shifts in the housing market, public priorities and government budgets as a result of the COVID-19 pandemic.