Symptom Screening, Isolated Spaces Could Reduce COVID-19 at Homeless Shelters

By Carolyn Crist

January 04, 2021

NEW YORK (Reuters Health) - Daily symptom screening and testing of people with symptoms could reduce SARS-CoV-2 infections at homeless shelters, where crowded conditions increase the risk of contracting the virus, according to a new study.

Homeless shelters also need a dedicated space to isolate and monitor people with mild COVID-19 to ensure they receive treatment and avoid overwhelmed hospitals, researchers write in JAMA Network Open.

"More than any crisis in our lifetimes, the COVID-19 pandemic has underscored how interconnected we all are. Research from colleagues here in Boston showed how a COVID-19 outbreak at a large biotech conference early in the pandemic seeded outbreaks at a large homeless shelter in Boston and then spread worldwide," said lead author Dr. Travis Baggett of Harvard Medical School.

More than 1.4 million people in the U.S. stay at homeless shelters each year, according to the Department of Housing and Urban Development, with about 356,000 people in shelters each night. The Centers for Disease Control and Prevention has issued guidance for preventing COVID-19 infections in shelters, including symptom screening and isolation areas.

"We won't overcome this pandemic unless we're committed to addressing it everywhere, including - and especially - in our most vulnerable populations," Dr. Baggett told Reuters Health by email.

He and his colleagues ran a simulation of several COVID-19 surveillance and management strategies to understand the costs and clinical outcomes for people in homeless shelters. The model included 2,258 adults in shelters in Boston and used costs based on the Boston Health Care for the Homeless Program. They analyzed the effects of daily symptom screening, regular testing, hospital-based care, alternative care sites and temporary housing options.

The research team found that daily symptom screening was associated with 37% fewer infections and 46% lower costs, as positive COVID-19 cases could be found sooner and isolated outside of hospitals.

Testing residents every two weeks was associated with an additional decrease in infections, and costs dropped by $1,000 per case. The most effective scenario included biweekly testing and temporary housing, which was associated with 81% fewer infections, though it was substantially more expensive. Every alternative care strategy was associated with lower costs than hospital-based care or no care at all.

"We had a sense that certain interventions - such as proactive symptom screening, routine testing and use of non-hospital alternate care sites for mild to moderate cases - would be effective," said senior author Dr. Kenneth Freedberg of Massachusetts General Hospital.

"What we didn't expect was that these strategies would be associated with such major healthcare cost savings relative to a scenario without these interventions," he told Reuters Health by email.

The research team ultimately recommended a combined strategy that would reduce infections and also save costs - daily symptom screening with testing of those who have symptoms, as well a dedicated space for positive cases.

"In people with housing, those with mild to moderate COVID-19 can isolate and recuperate at home. People experiencing homelessness cannot do this," said co-author Dr. Jessie Gaeta, chief medical officer for the Boston Health Care for the Homeless Program.

"Without dedicated spaces for isolation and recovery, hospitals have to be the setting for COVID-19 care," she told Reuters Health by email. "As we all know, hospitals are now overflowing with people who need to be in them, and hospitals are a very expensive solution to a problem that can be better solved in other ways."

The strategies could become increasingly important as the pandemic - and its ramifications - continue into next year.

"It is important to recognize the COVID-19 pandemic has led to high rates of unemployment and possible increases in homelessness, so there may be more individuals experiencing homelessness for the first time," said Dr. Jack Tsai of the University of Texas Health Science Center at Houston. Dr. Tsai, who wasn't involved with this study, has written about COVID-19 and homelessness this year.

"There is the virus, but also the social, economic, and political climate that must be considered in serving vulnerable populations like individuals experiencing homelessness," he told Reuters Health by email. "These issues may influence how COVID-19 spreads, best containment procedures, how to engage homeless individuals and ways to increase uptake of vaccines."

SOURCES: JAMA Network Open, online December 22, 2020.