Homeless Shelters Guidance

People experiencing homelessness are at increased risk for infection during community spread of COVID-19. Vaccination is the leading prevention measure to keep clients, staff, and volunteers healthy and help shelters maintain normal operations. COVID-19 vaccines are safe and effective, widely available, and provided at no cost to people living in the United States. While it’s important for all homeless services staff, volunteers, and clients to get vaccinated as soon as possible, USICH stresses that being fully vaccinated should not be treated as a prerequisite to receive shelter, housing, or services; and regardless of vaccination status, all homeless services staff, volunteers, and clients should continue wearing masks and physically distancing.

At this time, everyone should continue to follow prevention measures, including physical distancing and wearing a well-fitted mask in shelters even if they are fully vaccinated. The guidance that follows applies to both vaccinated and unvaccinated people in a shelter setting.

This interim guidance includes recommendations for layered prevention approaches, including vaccination, universal masking, and testing strategies and is intended to support response planning by shelters and homeless service providers in coordination with public health authorities and emergency management officials.

Early and sustained action to slow the spread of COVID-19 will keep clients, staff, and volunteers healthy, and help shelters and homeless service providers to maintain normal operations. It is intended for:

• homeless shelters and homeless service providers
• overnight emergency shelters
  
• day shelters
  
• warming centers
  
• domestic violence shelters
  
• meal service providers
  

Continuing homeless services during community spread of COVID-19 is critical.  Homeless shelters should not close or exclude people who are having symptoms or test positive for COVID-19 without a plan for where these clients can safely access services and stay. Clients with mild illness due to suspected or confirmed COVID-19 should not remain in a shelter if they cannot be appropriately isolated from others.  Decisions about alternative housing sites should be made in coordination with the local health department (LHD). Alternative housing sites include:

• Overflow sites to accommodate shelter decompression (to reduce crowding) and higher shelter demands
• Isolation sites for people who are confirmed to be positive for COVID-19
  
• Quarantine sites for people with known exposure to COVID-19
  

Shelters and homeless service providers should establish the following procedures to minimize transmission of COVID-19 and to assure safety of clients, staff, and volunteers:

• Strongly encourage shelter clients, staff, and volunteers to get vaccinated, complete the vaccine series, and obtain vaccine booster shots (if they are eligible) as soon as they can. Additional information about vaccination resources is provided below.
• Require all shelter clients, staff, and volunteers to always wear masks in the facility, regardless of vaccination status, in accordance with Governor Pritzker’s August 26, 2021, COVID-19 Executive Order 2021-20 No. 87.
  
• Provide training and educational materials related to COVID-19 for staff and volunteers.
  
• Ensure staff members and volunteers who have face-to-face interactions with clients with respiratory symptoms have access to well-fitted face masks and appropriate PPE. This may require repeated and frequent trainings on PPE use. Minimize face-to-face interaction of unvaccinated volunteers with clients with respiratory symptoms.
  
• For situations where staff are providing 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), a fit-tested N95 or higher-level respirator (or a surgical mask if respirators are not available or staff are not fit tested), disposable gown, and disposable gloves. Cloth masks are not appropriate for these situations and should not be used when a respirator or face mask is indicated. Contact your Local Health Department (LHD) to obtain supplies of N95 respirators and resources for performing fit testing.
  
• Staff and volunteers should avoid handling client belongings, regardless of vaccination status. If staff or volunteers are handling client belongings, they should use disposable gloves, if available. Make sure to train staff or volunteers using gloves to ensure proper use and to ensure they perform hand hygiene before and after use. If gloves are unavailable, staff should perform hand hygiene immediately after handling client belongings.
  
• Require clients to wear masks or face coverings any time they are not in a single room or on their bed/mat (in shared sleeping areas). Masks should not be placed on children under age 2 or anyone who has trouble breathing or is unconscious, incapacitated, or otherwise unable to remove the mask without assistance. (COVID-19 Executive Order 2021-20 No. 87).
  
• Require clients, staff, and volunteers to maintain physical distancing of at least 6 feet from others.  Create a way to make physical distancing between clients and staff easier, such as staggering meal services or having maximum occupancy limits for common rooms and bathrooms.
  
• Require clients and staff to perform hand hygiene appropriately and frequently by washing hands with soap and water for at least 20 seconds or using an alcohol-based hand sanitizer with at least 60% alcohol if soap and water are not available.
  
• Provide alcohol-based hand sanitizers that contain at least 60% alcohol at key points within the facility, including registration desks, entrances/exits, and eating areas.
  
• Make sure bathrooms and other sinks are consistently stocked with soap and drying materials for handwashing.
  
• Clean and disinfect frequently touched surfaces at least daily and shared objects between use with an U.S. Environmental Protection Agency (EPA)-registered disinfectant.
  

Ensure ventilation systems operate properly and provide acceptable indoor air quality for the current occupancy level for each space. Consider increasing air exchanges occurring per hour for enhanced ventilation.

Increase the indoor delivery of outdoor air as much as possible. Do not open windows and doors if doing so poses a safety or health risk (such as risk of falling, triggering asthma symptoms) to clients, to staff, to volunteers, or to visitors using the facility.

Ensure exhaust fans in kitchens and restroom facilities are functional and operating at full capacity when the building is occupied. Consider running exhaust fans for several hours before and after occupied times when possible.

• Consider using portable high-efficiency particulate air (HEPA) fan/filtration systems to help enhance air cleaning, especially in higher-risk areas, such as nurse offices or screening rooms. Increase total airflow supply to occupied spaces, if possible. HEPA filters should be graded per room size as per the EPA.

Note: This chart is for estimation purposes. The CADRs are calculated based on an 8-foot ceiling. If you have higher ceilings, you may want to select a portable air cleaner with a higher CADR.

• Consider using natural ventilation (i.e., opening windows if possible and safe to do so) to increase outdoor air dilution of indoor air when environmental conditions and building requirements allow.
  • If temperatures outside make it difficult to leave multiple windows open, consider safely securing window fans or box fans (sealing the perimeter around the box fan) to blow air out of selected windows. The resulting make-up air will come into the building via multiple leak points and blend with indoor air as opposed to a single unconditioned incoming air stream.
    
• Improve central air filtration. Consider using air filters graded at MERV 13 or higher.
  

Collaborate with local health departments and other community partners to identify resources for improving ventilation and air quality.

Use physical barriers to limit the spread of COVID-19 between staff and clients. For example, install a sneeze guard at the check-in desk or place an additional table between staff and clients to increase the distance between them to at least 6 feet.

In meal service areas, create at least 6 feet of space between seats, and/or allow either for food to be delivered to clients or for clients to take food away.

In general sleeping areas (for those who are not experiencing respiratory symptoms), try to make sure client’s faces are at least 6 feet apart.

• Align mats/beds so clients sleep head-to-toe.
  

For clients with symptoms consistent with COVID-19:

• Ensure the client is tested immediately for COVID-19 (see “Testing Strategy”, below).
• Prioritize these clients for individual rooms.
  
• If individual rooms are not available, consider using a large, well-ventilated room.
  
• Keep mats/beds at least 6 feet apart.
  
• Use temporary barriers between mats/beds, such as curtains.
  
• Align mats/beds so clients sleep head-to-toe.
  
• If possible, designate a separate bathroom for these clients.
  
• If areas where these clients can stay are not available in the facility, facilitate transfer to a quarantine site.
  

For clients with confirmed COVID-19, regardless of symptoms:

• Prioritize these clients for individual rooms.
• If more than one person has tested positive, these clients can stay in the same area.
  
• Designate a separate bathroom for these clients.
  

Follow CDC recommendations for how to prevent further spread in your facility.

If areas where these clients can stay are not available in the facility, assist with transfer to an isolation site.

Staff or volunteers who are checking client temperatures should use a system that creates a physical barrier between the client and the screener.

• Screeners should stand behind a physical barrier, such as a glass or plastic window or partition that can protect the staff member’s face 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., respirator, 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 training requirements and because PPE alone is less effective than a barrier, try to use a barrier whenever possible.
  

Clients who have symptoms may or may not have COVID-19. Make sure they have a place they can safely stay within the shelter or at an alternate site in coordination with the LHD.

If available, an on-site nurse or other clinical staff can help with clinical assessments.

Facilitate access to non-urgent medical care as needed.

Use standard facility procedures to determine whether a client needs immediate medical attention. Emergency signs of COVID-19 infection include:

• Trouble/difficulty breathing
• Persistent pain or pressure in the chest
  
• New confusion or inability to arouse
  
• Bluish lips or face
  

Notify the designated medical facility and emergency medical personnel transferring/transporting clients that the client might have COVID-19.

Prepare staff to care for patients with COVID-19, if your facility provides health care services, and ensure your facility has an adequate supply of personal protective equipment.

Refer to the IDPH monoclonal antibody webpage for the most up-to-date information.

Shelters should identify a source for providing monoclonal antibody (mAb) treatment for clients who develop COVID-19, regardless of vaccination status, to reduce the risk of severe illness and hospitalization.

Persons who may benefit from mAb treatments include those who are older or who have chronic respiratory, cardiac, or renal disease; are overweight or obese; have immunosuppressive disease or treatment; have diabetes; and have other medical conditions or risk factors, including race and ethnicity associated with increased risk of severe COVID-19 disease.

Monoclonal antibody (mAb) treatments can be administered either by intravenous or subcutaneous routes.

• Have had a positive COVID-19 test within the past 10 days and
• are experiencing mild-to-moderate symptoms (i.e., not hospitalized for COVID-19) and
  
• are at high risk for developing severe COVID-19 and
  
• are not requiring oxygen and
  
• are 12 years of age or older (and at least 88 pounds)
  

Monoclonal antibodies may also be administered to prevent individuals from developing COVID-19 after exposure (known as “post-exposure prophylaxis”).

(consistent with the CDC's close contact criteria) and who are:

• High risk for developing severe COVID-19 and
• 12 years of age or older (and at least 88 pounds) and
  
• not fully vaccinated or vaccinated but immunocompromised
  

Clients, staff, and volunteers who meet the criteria for monoclonal antibody (mAb) treatments should present or be referred to a medical provider. Shelters and homeless service providers are encouraged to consult with their local health department (LHD) for information on mAb treatments.

More information about mAb treatment is available from IDPH, CDC, CMS, and from the U.S. Department of Health and Human Services (HHS).

The purpose and process of all testing and other public health activities should be clearly communicated to clients and to staff at the homeless service site to promote understanding and acceptability. Testing strategies should be carried out in a way that protects privacy and confidentiality to the extent possible and that is consistent with applicable laws and regulations.

Whenever a positive test result is identified, the facility should ensure that the individual is rapidly and appropriately notified, separated from others, provided appropriate medical care, and linked to appropriate alternative housing for isolation as necessary. Shelters should ensure that they obtain verbal, informed consent for testing from residents and staff and minimize the use of paper forms to reduce transmission risks.

Local health departments and administrators of homeless service sites, in partnership with health care providers, should decide whether and how to implement these testing considerations to identify cases among persons who are asymptomatic, including both those with and without known exposure to COVID-19.  Key components of the testing plan, shown in the COVID-19 Viral Testing Flowchart for Homeless Shelters are:

Immediate testing should be performed on:

• Individuals with signs or symptoms consistent with COVID-19
• Asymptomatic individuals, regardless of vaccination status, with recent known or suspected exposure to COVID-19 to control transmission
  

Testing should be performed whenever a staff member or client is identified with COVID-19.  After consultation with the local health department (LHD), shelters should conduct one of the following two outbreak testing options:

• Contact-tracing testing option: Targeted testing of all clients, staff, and volunteers, regardless of vaccination status, who were close contacts to the COVID-19 case.
• Facility-wide testing option: Testing of all clients, staff, and volunteers, regardless of vaccination status.
  

Repeat testing of all previously negative clients, staff, and volunteers (e.g., every 3-7 days or as directed by the local health department) until no new cases are identified for 14 days.

Facilities should perform testing of clients and staff using viral tests approved or authorized by the Food and Drug Administration (FDA) for diagnosing current COVID-19 infection. Approved viral tests include the Real-Time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) and point-of-care (POC) antigen or molecular tests. As described above, shelter administrators should work with their local health department to identify testing resources.

• The RT-PCR molecular test is the “gold standard” for clinical diagnostic detection of SARS-CoV-2, the virus that causes COVID-19 infection.
• While POC molecular and POC antigen tests usually provide more rapid results than the RT-PCR, they have a higher probability of missing an active infection. RT-PCR tests are typically highly accurate and usually do not need to be repeated.
  
• For antigen tests, confirmatory RT-PCR might be needed, depending on the level of community transmission and whether the individual has symptoms.
  
• For considerations on interpreting antigen test results in homeless shelters see the CDC algorithm that is attached to this guidance.  Additional information is available from CDC.
  
• Procedures for reporting results of rapid POC tests: Interim Guidance on Testing for COVID-19 in Community Settings and Schools
  

Vaccination is an important tool to control the COVID-19 pandemic. The goal is for everyone, including people experiencing homelessness, to be able to easily get a COVID-19 vaccine as soon as possible. Shelter clients, service staff and volunteers should be strongly encouraged to receive and complete the vaccine series, including booster shots as soon as possible. Recommendations for shelter providers and local health departments to improve vaccine accessibility and to build vaccine confidence among clients, staff, and volunteers include:

• Build relationships and providing clear, consistent information to ensure that individuals feel comfortable receiving the COVID-19 vaccine.
• Make vaccines available on site through partnership with the local health department or other provider, because people who are experiencing homelessness may have experienced one or more of the following: history of trauma; negative experiences with medical services; and/or difficulty accessing medical services in traditional settings, such as a clinic or pharmacy.
  
• Holding multiple vaccination events to allow clients time to consider receiving the vaccine and to catch up on second doses, additional doses or boosters.
  
• Integrating reminders into the process for vaccinating clients to ensure that they receive all required vaccine doses, including booster vaccinations, and conducting outreach to connect with individuals who might otherwise be lost to follow-up.
  

Last Updated:  12/10/2021