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May 5, 2020

CDC Urges COVID-19 Testing at Homeless Shelters after Finding Swift Spread of Infection

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum and JAMA
JAMA Health Forum. 2020;1(5):e200580. doi:10.1001/jamahealthforum.2020.0580

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads rapidly within homeless shelters, and clusters of infection have been identified at homeless shelters. Therefore, testing residents and staff should be considered regardless of symptoms, according to a report on homeless shelters in 4 US cities by the US Centers for Disease Control and Prevention (CDC).

The report, published in the Morbidity and Mortality Weekly Report on April 22, was based on the findings of an investigation launched in late March by CDC researchers collaborating with academic partners, clinicians, and homeless service providers. In this investigation, public health teams responded to clusters of 2 or more cases of coronavirus disease 2019 (COVID-19) at 5 homeless shelters—1 in Boston, 1 in San Francisco, and 3 in Seattle.

When investigators tested a total of 730 residents and 148 staff members at the 5 shelters with COVID-19 clusters, they found overall infection rates of 37% among residents and 21% among staff members. Infection rates were as high as 95 of 143 residents (66%) tested at the San Francisco shelter and 15 of 50 staff members (30%) tested at the Boston shelter.

“Given the high proportion of positive tests in the shelters with identified clusters and evidence for presymptomatic and asymptomatic transmission of SARS-CoV-2, testing of all residents and staff members regardless of symptoms at shelters where clusters have been detected should be considered,” the report said. To facilitate the isolation of individuals with SAR-CoV-2 infection to minimize ongoing spread, the agency also advised regular testing in shelters before clusters are identified, “if testing is easily accessible.”

In addition, the investigators tested 213 residents and 106 staff members at 12 shelters in Seattle where only a single case had been previously identified. They found a much lower prevalence of infection, with 5% of residents and 1% of staff members testing positive for SARS-CoV-2. The researchers also found low rates of infection at 2 homeless shelters in Atlanta with no known COVID-19 cases in the preceding 2 weeks, finding that 10 of 249 residents (4%) and 1 of 59 staff members (2%) had the infection.

The authors noted that the tests represent only a single point. Additional limitations to the study’s findings included having some residents or staff members unavailable or unwilling to undergo testing and lacking symptom information for some individuals who were tested.

Homeless shelters pose considerable challenges that allow COVID-19 to spread rapidly. They are often crowded, making social distancing difficult. Furthermore, many residents are at higher risk for severe COVID-19–related illness because they are older or have underlying medical conditions.

In a related article in the Morbidity and Mortality Weekly Report, CDC investigators and other public health researchers described a COVID-19 outbreak at 3 affiliated homeless shelters in King County, Washington. After 1 person was found to be infected on March 30, SARS-CoV-2 testing was immediately offered to all residents and staff members of that shelter and 2 other shelters that used the first location’s day services. A second round of testing was offered approximately a week later to those not tested initially or those who had negative test results. In all, 35 of 195 residents (18%) and 8 of 38 staff members (21%) who were tested had COVID-19.

“Interrupting COVID-19 transmission in homeless shelters is challenging,” the report noted. “In settings with known COVID-19 outbreaks, assistance with enforcement of shelter-in-place orders, testing of residents and staff members, and prompt isolation of symptomatic [individuals] or residents with confirmed disease are needed to prevent further transmission in homeless shelters.”

Cities are struggling with the challenges posed by COVID-19 in their homeless populations. In some cases, local authorities are trying to find alternatives to homeless shelters, such as hotel and motel rooms for housing these individuals. In cases where individual housing units are unavailable, CDC guidance advises against clearing homeless encampments when COVID-19 is spreading in the community.

“Clearing encampments can cause people to disperse throughout the community and break connections with service providers,” the CDC cautions. “This increases the potential for infectious disease spread.” However, despite such advice, newspapers in Denver and Philadelphia have reported that officials have shut large homeless encampments in those cities.

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Open Access: This is an open access article distributed under the terms of the CC-BY License.

1 Comment for this article
Shared Housing Space is the Achilles Heel of the Pandemic
Dana Ludwig, MD, MS | UCSF
It used to be that warehousing inmates, SNF residents, homeless people, migrant farm workers and meat packers with multiple people to a single room was an ethical failing of our social structure. We would write that it is wrong, but we would tolerate it because it didn't affect the rest of us. What we seem unable to realize now is that our reality has changed. We will all suffer and die because of this failing. Staff come home at night or work multiple jobs. Outbreaks spread to the larger community and beyond. The Army Corps of Engineers has plans and materials for mass isolation units, including negative air pressure, that can be assembled in stadiums or large hotels. The states need to commit to these real solutions or own the consequences of massive morbidity and mortality that will follow.