ON A GIVEN single night in 2019, about 568 000 people experienced homelessness in the United States, and each year about 1.4 million individuals access emergency shelters or transitional housing.1 Despite interventions, all-cause mortality among people experiencing homelessness (PEH) under the age of 65 years is 5 to 9 times higher than in the general population.2 The widespread COVID-19 outbreak among PEH might further increase this mortality inequity.3 PEH are at high risk for contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to issues such as lack of shelter, low access to hygiene/sanitation, and congregate living situations.4 Homelessness may also exacerbate the severe effects of the coronavirus disease that emerged in 2019 (COVID-19), especially among older adults.5 In addition to highlighting the health inequities among PEH, the COVID-19 pandemic has magnified the disparities in COVID-19 prevention efforts and treatment.

INEQUITIES IN PREVENTION AND TREATMENT

Access to reliable recommendations to prevent SARS-CoV-2 infection requires health literacy skills to decipher the COVID-19 infodemic.6 In other words, health literacy skills allow one to untangle between misinformation and science-based literature. Unfortunately, health literacy is a significant challenge for PEH, which makes them vulnerable to inaccurate information.7 Furthermore, low health literacy can negatively influence behavioral health beliefs by diminishing perceived susceptibility and severity of COVID-19 and pose a barrier to engaging in preventive practices as outlined by the Centers for Disease Control and Prevention (CDC) and local governments.8 The CDC has recommended frequent hand washing or the use of hand sanitizer when soap is not available to prevent the transmission of SARS-CoV-2.9 However, maintaining recommended hygiene is difficult for individuals who have unstable housing or those who shelter in their cars. Accessing clean and effective face masks is also difficult for residents of a homeless encampment.

Furthermore, local government recommendations underscore the inequities in prevention guidelines. Many counties around the United States have recommended shelter-in-place/stay-at-home measures to curb transmission. Local government officials did recognize that it is impossible to shelter in place or stay at home when one does not have a stable shelter or home and attempted to find PEH temporary shelter.10 However, temporary living accommodations, along with sheltering in cars, can make social distancing difficult, resulting in close contact to be inevitable. While there may be low rates of infection within a community, shelters have been described as a location where superspreading can occur.11 Consequently, for some, the streets may feel safer in terms of exposure to SARS-CoV-2 than congregate living accommodations.

While the shelter-in-place requirements were created to curtail the pandemic, the consequential lockdowns reduced resources that PEH need.4 For example, some shelters are only open during the night and close their doors during the day. This requires residents to congregate in public places; however, with public places such as public parks and libraries shutting down during shelter-in-place orders, PEH did not have a place to go.12 Relatedly, many meal distribution sites closed during this time, resulting in hot meals to be unavailable until service was altered to abide by social distancing guidelines. It is also notable that one of the early testing methods for COVID-19 was done at drive-through testing centers, suggesting that individuals had to have a car to be tested. While some city health departments have teamed up with public transportation to provide individuals with disabilities access to testing, this service may not work for transient individuals, such as PEH.

Just as inequities in prevention exists, so do inequities in treatment should a PEHs be diagnosed with COVID-19. PEH are vulnerable to discrimination13 and often face barriers to accessing health care services and health care providers,14 which presents multiple barriers to receiving treatment of COVID-19. If tested positive, isolating or quarantining in shelter settings might also not be available. Relatedly, PEH may resort to underreporting their symptoms for fear of losing their space within a shelter. Once an individual is diagnosed with COVID-19, the transient nature of PEH might make it challenging to carry out contract tracing and accurately inform diagnosed individuals.4 Furthermore, shelters have resorted to person-based tracing, but that has limited utility due to the vague descriptions provided by the infected individual,11 hence creating the need for specific plans that address the needs of PEH during a pandemic.

RECOMMENDATIONS

The aforementioned fact suggests that recommending frequent hand washing and shelter-in-place/physical distancing, encouraging testing and reporting of symptoms, along with participating in contact tracing can be difficult to implement among PEH. With that in mind, partnerships between homeless serving agencies, city health departments, and federally qualified health clinics are critical to the development of interventions necessary to prevent transmission and provide access to treatment pertaining to COVID-19. The general recommendation is the wide and frequent dissemination of proper protective equipment, hygiene kits, and testing kits to shelters, homeless encampments, and people living in cars. Testing PEH who are in shelters, homeless encampments, and living in cars on a consistent and frequent basis is necessary. In addition, testing asymptomatic individuals is especially important since this population is not able to easily practice social distancing and proper protective equipment is not sustainable due to living conditions.15

To further prevent the transmission of SARS-CoV-2, partnership with hotels is recommended. Specifically, hotels can be used as a shelter in place for individuals who are not sick or have recovered from COVID-19, in addition to those who have been exposed to COVID-19 or are symptomatic or presumed infected. Likewise, shelters should not be denied on the basis of symptoms or positive COVID-19 test. To assist with sheltering in place and decrease panhandling for food, it is recommended that meals be provided for individuals residing in hotel rooms, in addition to provision of access to regular outreach services.15 Some PEH will want to continue sheltering with other PEH with whom they are familiar and will be reluctant to leave their encampments. To prevent the spread of SARS-CoV-2 infection, it is recommended that tents at homeless encampments be spaced out at least 6 ft. The installation of publicly available hand washing stations and toilets at homeless encampments is another prevention recommendation.15

CONCLUSION

The COVID-19 pandemic is an eye-opening event that recognizes the need, even more so now, for empathy, care, and provision of services to PEH. Significant attention to PEH during the COVID-19 pandemic may help reduce health inequities and lead to the design of prevention and intervention strategies that can be applied postpandemic.

REFERENCES