Addressing COVID-19 Among People Experiencing Homelessness: Description, Adaptation, and Early Findings of a Multiagency Response in Boston

Abstract

People experiencing homelessness are at high risk for coronavirus disease 2019 (COVID-19). In March 2020, Boston Health Care for the Homeless Program, in partnership with city and state public health agencies, municipal leaders, and homeless service providers, developed and implemented a citywide COVID-19 care model for this vulnerable population. Components included symptom screening at shelter front doors, expedited testing at pop-up sites, isolation and management venues for symptomatic people under investigation and for people with confirmed disease, quarantine venues for asymptomatic exposed people, and contact investigation and tracing. Real-time disease surveillance efforts in a large shelter outbreak of COVID-19 during the third week of operations illustrated the need for several adaptations to the care model to better respond to the local epidemiology of illness among people experiencing homelessness. Symptom screening was de-emphasized given the high number of asymptomatic or minimally symptomatic infections discovered during mass testing; contact tracing and quarantining were phased out under the assumption of universal exposure among the sheltered population; and isolation and management venues were rapidly expanded to accommodate a surge in people with newly diagnosed COVID-19. During the first 6 weeks of operation, 429 of 1297 (33.1%) tested people were positive for COVID-19; of these, 395 people were experiencing homelessness at the time of testing, representing about 10% of the homeless adult population in Boston. Universal testing, as resources permit, is a focal point of ongoing efforts to mitigate the effect of COVID-19 on this vulnerable group of people.

Homeless people hospitalized with COVID-19 in Brussels

“…Our results illustrate the urgent need for implementing strategies to stop the spread of COVID-19 in the homeless population. Strategies based on wide-scale prevention, screening and management of COVID-19 infection have been shown to be efficient in reducing SARS-CoV-2 transmission among homeless people [ 5 , 6 ].…”

Harm reduction in the time of COVID-19: Case study of homelessness and drug use in Dublin, Ireland

“… Development of a command structure amongst the health professionals involving daily meetings and reviews and also ensuring regular communication with staff working in the sector to respond to emerging issues and allay concerns. This command structure worked with municipal leaders and public health agencies ( Baggett et al., 2020 ). …”

“…Boston had to expand their COVID-19 care facility from 17 to 52 beds and construct a 500-bed field hospital. Ten percent of the homeless population in Boston were eventually infected (compared to 2% of the general population) ( Baggett et al., 2020 ). Possible reasons why Dublin had better outcomes than Boston include: Dublin did not abandon its testing and isolation of symptomatic clients; The Dublin response involved shielding those who were the most vulnerable clients.…”

“…The expansion of housing provision seemed to have limited the direct effects of COVID-19 transmission and infection. The infection rates in Dublin (2%) compared favourably to Boston (10%) where shielding units were not developed ( Baggett et al., 2020 ). The above appeared to represent a relatively swift and decisive approach from all sectors with coordination from public servants.…”

“…It was recognised early on in the COVID-19 Pandemic that both homeless and drug-using populations were particularly vulnerable to the effects of coronoavirus infection. This is due to the high morbidity burden of these populations; the poor living conditions they experience and their lack of access to health services ( Alexander, Stoller, Haffajee & Saloner, 2020 ; Baggett et al., 2020 ; Dubey et al., 2020 ; Kar et al., 2020 ; López-Pelayo et al., 2020 ; Marsden et al., 2020 ; McCann Pineo& Schwartz, 2020 ; Mosites et al., 2020 ; Ornell et al., 2020 ; Reece, 2008 ; Tobolowsky et al., 2020 ; Volkow, 2020 ). For example, Albon et al.…”