COVID-19 presents challenges to many vulnerable and underserved communities. This is particularly true of individuals living homeless, a population that faces unique challenge to disease mitigation, testing and disease management. King County, WA, which includes Seattle, experienced the first outbreak of COVID-19 in the United States. With more than 11,000 individuals experiencing homelessness, approximately 1/3 of whom live in shelters, King County also has one of the largest homeless populations in the country. As a result, it was imperative that the region develop a clear strategy and actionable plan as it pertains to this highly vulnerable population. Here, we briefly describe some of the key considerations and actions taken in the region as a means of providing insight to other communities considering how to create a multi-faceted, regional strategy to address the distinct needs of a heterogeneous homeless population.

Learn more in our new commentary “Addressing the Needs of People Living Homeless During the COVID-19 Pandemic” published in the Journal of Public Health Management and Practice.

Prevention/Mitigation

Congregant facilities need to consider opportunities for social distancing and prevention. Opening new shelters and redistributing clients to reduce crowding has the potential to mitigate disease transmission. Seattle homeless providers are nothing if not advocates for their clients, and worked quickly with partners at Public Health – Seattle & King County to depopulate shelters, moving many individuals to single unit dwellings. Further, allowing individuals who live in tents and recreational vehicles to continue staying in locations where they are able to self-isolate serves a similar purpose. This requires that communities immediately stop encampment removals, as Seattle has done. Providing additional sanitation and hygiene access through portable washing stations is also critical, particularly as counties like ours also attempt to address Hepatitis A outbreaks and other communicable diseases.

Testing

Health care institutions and providers need to ensure that they are prioritizing the testing of homeless populations and developing aggressive outreach campaigns. Individuals living homeless have much higher rates of comorbid conditions such COPD, diabetes, and hypertension, often poorly controlled due to a lack of access to medical care. Given what we know about COVID-19, where comorbidities are associated with higher mortality rates, this is particularly important. These patients may also place others at risk if they reside in congregant settings, leading to rapid outbreaks as documented in Boston and other cities. In order to meet patients where they spend time, outreach testing has been a priority of King County, with a wide-ranging program that includes mobile testing units at shelters and day centers. Additionally, individuals living homeless who present for testing in any location should be prioritized for these same reasons. With persistent and increasing concerns about limited testing capacity, defining priority populations remains an undesired, but important, aspect of the COVID response.

Management

Local and regional entities need to consider how best to house individuals diagnosed with COVID-19, yet medically stable enough for outpatient management. Developing isolation and quarantine (I&Q) facilities that serve the homeless community poses many challenges. Public health agencies and other service providers must keep in mind that many people living homeless also suffer from substance use disorders and psychiatric diseases. When designing and deploying I&Q sites, sufficient wraparound services should be readily available on site in order to meet the needs of those who require I&Q. Equally important, ensuring rapid and efficient access to these facilities through a common call center, such as the one developed in King County, is incredibly helpful for busy emergency departments, clinics, shelters, and other homeless service providers.

Despite agreement on the principles outlined above, and the tireless efforts of those on the front lines in King County, we still face many challenges in creating a system that efficiently and effectively responds to the unique needs of our homeless patients. Fortunately, the proactive work of public health, social service, and health care providers has resulted in fewer cases than seen in many cities. Continued learning, both from our own experience and the experience of others will be critical as the pandemic shows no signs of abating in the near future.

Recommended Reading in the Journal of Public Health Management and Practice:

• Addressing the Needs of People Living Homeless During the COVID-19 Pandemic