Interim Guidance on People Experiencing Unsheltered Homelessness

Summary of Recent Changes

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.

COVID-19 is caused by a coronavirus. Vaccination is the leading prevention measure to keep clients, outreach staff, and volunteers from getting sick with COVID-19. COVID-19 vaccines are safe and effective and are available at no cost to everyone 12 years and older living in the United States, regardless of insurance or immigration status. Learn more about the Benefits of Getting a COVID-19 Vaccine. See Interim Guidance for Health Departments: COVID-19 Vaccination Implementation for People Experiencing Homelessness for more information. In encampments or other unsheltered locations, individuals who are fully vaccinated should follow CDC’s Recommendations for Fully Vaccinated People.

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 whole-community approach to prepare for COVID-19 among people experiencing homelessness

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.
• Build on existing partnerships with peer navigators who can help communicate with others.
• Maintain up-to-date contact information and areas frequented for each client.
• 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 information on vaccination, social distancingpdf icon, handwashing, and cough etiquettepdf icon.
  • Provide educational materials about COVID-19 for everyone, including people with limited English proficiency, people with intellectual or developmental disabilities, and people with hearing or vision impairments.
  • 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 and volunteers

Staff and volunteer training and policies

• Provide trainingpdf icon and educational materials related to COVID-19 for staff and volunteers.
• Minimize the number of staff members who are not fully vaccinated 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.
• Prepare to support case investigation and contact tracing activities in collaboration with local health departments.
• Regardless of vaccination status, assign outreach staff and volunteers 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 and volunteers should review stress and coping resources for themselves and their clients during this time.

Staff and volunteer prevention measures

• Encourage outreach staff and volunteers to get vaccinated as soon as they can.
• Advise staff who are not fully vaccinated to maintain 6 feet of distance while interacting with clients, staff and volunteers, where possible.
• Require outreach staff who are not fully vaccinated 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.
• Encourage outreach staff, regardless of vaccination status, 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 outreach staff, regardless of vaccination status, 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.
  • Where possible, screeners should remain behind a physical barrier, such as a glass or plastic window or partition (e.g., 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 physical distancing or barrier/partition controls cannot be put in place during screening, personal protective equipment (PPE, e.g., 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.
• For street medicine or other healthcare professionals, regardless of vaccination status, who are caring for clients with suspected or confirmed COVID-19 should follow Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic.
• Outreach staff, regardless of vaccination status, who do not interact closely (e.g., within 6 feet) with sick clients and do not clean client environments do not need to wear PPE.
• Outreach staff, regardless of vaccination status, 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 (for staff who are not fully vaccinated) and explain that you are taking additional precautions to protect yourself and the client from COVID-19.
  • Wear a mask if not fully vaccinated.
  • Provide the client with a mask if they are not fully vaccinated or have unknown vaccination status.
  • 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 people with underlying medical conditions 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 (for staff who are not fully vaccinated).
  • 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.

Considerations for assisting people experiencing unsheltered homelessness

Help clients from becoming sick with COVID-19

• Recommend strongly that clients get a COVID-19 vaccine. Be prepared to address common questions about COVID-19 vaccination.
• Those who are experiencing unsheltered homelessness face several risks to their health and safety. Consider the balance of these risks when addressing options for decreasing COVID-19 spread.
• Continue linkage to homeless services, housing, medical, mental health, syringe services, and substance use treatment, including provision of medications for opioid use disorder (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 who are not fully vaccinated (or have unknown vaccination status) 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 who are not fully vaccinated (or have unknown vaccination status) from spending time in crowded places or gathering in large groups, for example at locations where food, water, or hygiene supplies are being distributed.

Help link sick clients to medical care

• Regularly assess clients for symptoms.
  • Provide anyone who presents with symptoms with a mask.
  • Clients who have symptoms may or may not have COVID-19. Make sure they have a place they can safely isolate 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.
  • 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 but are not limited to:
    • Trouble breathing
    • Persistent pain or pressure in the chest
    • New confusion or inability to arouse
    • Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone
  • Please refer clients for medical care for any other symptoms that are severe or concerning to you.
  • Notify the designated medical facility and transporting personnel 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 the designated medical facility and transporting personnel that clients might have 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.
  • Coordinate with the local health department and provide locating information for case investigation and contact tracing
  • 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 people 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 other community organizations and offices 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).

Considerations for a Long-Term Infection Prevention Strategy for People Experiencing Unsheltered Homelessness

When community COVID-19 transmission levels change, some communities might consider when to modify the COVID-19 prevention measures described above. Below are several factors to consider before modifying community-level COVID-19 prevention approaches for people experiencing unsheltered homelessness, for example, changing outreach team procedures or approaches to COVID-19 prevention in encampments. These factors should be considered together; no single factor should be used alone to decide changes in approach.

These factors should be discussed with local public health partners, community homeless service providers, and people with lived experience of homelessness. Any modifications to COVID-19 prevention measures should be conducted in a phased and flexible approach, with careful monitoring of COVID-19 cases in the community. Connecting people experiencing homelessness to permanent stable housing should continue to be the primary goal.

Community Transmission Levels: What is the incidence of COVID-19 in the community?

The incidence of COVID-19 in the community will influence the risk of infection for people experiencing unsheltered homelessness. The CDC COVID Data Tracker has a tool that displays the current level of community transmission at the county level. Increasing COVID-19 vaccination coverage in the surrounding community is important to help reduce community transmission, but community vaccination coverage should not be used alone to decide to modify approaches to prevention among people experiencing unsheltered homelessness.

Vaccination Levels: What proportion of people experiencing unsheltered homelessness in the community have been vaccinated against COVID-19?

Vaccination significantly decreases the likelihood of becoming infected with the virus that causes COVID-19. Refer to the Interim Public Health Recommendations for Fully Vaccinated People for the most up-to-date information on individual-level modifications to prevention measures for people who are fully vaccinated. People experiencing unsheltered homelessness who are fully vaccinated do not need to wear masks unless they are accessing services in a homeless service facility. Although we know vaccines help protect individuals, there is not enough information available yet to determine a level of vaccination coverage needed to modify community-level COVID-19 prevention measures. Note: Vaccination status should not be a barrier to accessing homeless services. COVID-19 vaccinations should not be mandatory to receive homeless services unless required by state or local health authorities.

Availability of Housing: What is the housing availability in the community?            

Any modifications to approaches to encampments or people experiencing unsheltered homelessness should be conducted with an awareness of housing availability and homeless service capacity. Closing encampments can lead people to disperse and result in increased crowding at other encampments or in shelters, which can increase the risk of spreading infectious disease, including COVID-19. Encampment disbursement should only be conducted as part of a plan to rehouse people living in encampments, developed in coordination with local homeless service providers and public health partners.

Even if the community decides to modify some infection prevention measures for people experiencing unsheltered homelessness, continue to maintain the following key components of a sustainable approach to disease prevention and response.

1. Monitor community transmission of COVID-19 in the area. For the latest updates on county-level transmission of the virus that causes COVID-19, use this CDC COVID Data Tracker tool.
2. Create flexible quarantine and isolation locations that are scalable, in case the number of COVID-19 cases in the community increases.
3. Keep a minimum set of public health prevention and control procedures in place at all times, including
   1. Working together with community organizations to improve sanitation in encampments.
   2. Ensuring access to handwashing facilities and supplies.
   3. Providing place-based, regular health evaluations and linkages to medical care, including access to COVID-19 vaccination, routine vaccinations, and behavioral health services.

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