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Sites and Settings Associated with

People Experiencing Homelessness

B73 COVID-19 - Procedural Guidance for DPH Staff



Sites and Settings Associated with People Experiencing Homelessness

Forms / Quick Links

  • COVID-19 Outbreak Form: Persons Experiencing Homelessness (PEH) Settings PDF
  • DPH PEH Data Collection Template Excel
  • COVID-19 Death Report Form PDF

REPORTING PROCEDURES

Outbreak Definitions:

Under Title 17, Section 2500, California Code of Regulations all suspected outbreaks are reportable.

Outbreak definitions are determined based on risk of transmission in particular sites, and are as follows:

Congregate and semi-congregate residential sites associated with PEH (i.e., shelters, encampments, single room occupancy housing or outdoor congregate areas):

At least one laboratory-confirmed case (symptomatic or asymptomatic) of COVID-19 has been identified in residents or staff

OR

A sudden increase of acute febrile respiratory illness (e.g. Fever measured or reported as >100.4° F and either a cough, sore throat, or shortness of breath, etc.) in the setting of community transmission of COVID-19 — a minimum of 2 Persons Under Investigation (PUI) in residents or staff within a 14-day period.

Non-congregate residential sites associated with PEH (i.e. Project Roomkey Hotels/Motels. This does NOT include apartment complexes with discrete units):

At least 3 or more cases and/or PUIs, and at least 1 of those must be a lab-confirmed case in either residents or staff, within a 14-day period.

Non-congregate, apartment-style residential sites associated with PEH (i.e SROs or domestic violence shelters for which the layout is discrete apartments):

At least 3 or more lab-confirmed cases from at least 3 different apartment units within a 14-day period.

Non-residential sites providing homeless services (i.e. hygiene centers, food distribution, case management or other services centers associated with PEH):

At least 3 or more laboratory-confirmed  cases (symptomatic or asymptomatic) of COVID-19 have been identified in staff or PEH utilizing services within a 14-day period.

 

Medical shelters for isolation of persons diagnosed or suspected of COVID-19 or for quarantine of contacts (IQ sites):

At least three confirmed cases of symptomatic or asymptomatic COVID-19 in staff within a 14-day period.

Residents are not included in the outbreak definition because they are there specifically for isolation or quarantine due to COVID-19.

Epidemiologic Data for Outbreaks

  1. Confirm etiology of outbreak using laboratory data. All symptomatic residents or staff are recommended to be tested for COVID-19.
  2. Determine the onset date of the outbreak. The onset date of the outbreak is the date of the first laboratory-confirmed case. Given the incubation period of SARS CoV2s is 14-days, the outbreak investigation should include investigation of cases occurring 14 days prior to onset date.
  3. If earlier cases are found, investigation of prior cases should continue until a first index case can be determined, and the  outbreak onset date should be updated to reflect the new findings.
  4. Complete the line list for the site (see Report Forms) after each round of testing, and final list prior to outbreak closure.
  5. It is important to include everyone who was exposed at the site on the line list, whether they are present on the date of testing or not, whether they agree to testing or not. Please consider infectious period of each case: 2 days before symptoms or test date if asymptomatic, through 10 days since symptoms started or test date if asymptomatic, AND 24 hours without fever. Once a case has been relocated to a medical shelter, exposure from that case can be considered ended on that date.
  6. Exposed people include residents, staff, and volunteers. For the purposes of outbreak management, volunteers will be considered staff.
  7. Assessment of refusal of testing numbers is only possible with complete line lists.
  8. The line list information includes identifying information for exposed people, demographics, location information, entry and exit dates, and health information including vaccination status. Please refer to the line list and accompanying instructions on the line list.
  9. Note dates of entry and exit of residents and staff in and out of the facility during the outbreak period.
  10. Obtain site floor plan, if appropriate.
  11. Maintain surveillance for new cases until no new cases for at least 2 weeks from last exposure. Last exposure refers to the last date a person with COVID-19 was at the site while infectious.
  12. If a new case or symptomatic person is identified within two incubation periods (i.e. 28 days) of the date that the last symptomatic or lab confirmed case was identified, then outbreak investigation will be re-opened for further investigation of epi linkages and ongoing transmission.
  13. Ensure epidemiologic data documented in IRIS and in line lists are consistent. Upload forms and line lists into IRIS.
  14. Complete COVID-19 OUTBREAK FORM: CONGREGATE RESIDENTIAL SETTINGS form at the conclusion of investigation (see Report Forms).
  15. Create an epi-curve, by date of onset. Only put those that meet the case definition on the epi-curve. (Optional, but recommend for complicates or extensive outbreaks)

CONTROL OF CASES & CONTACTS

Cases

Mask PUI/confirmed case(s). Rapidly separate PUI or case whenever possible into a separate sick area that is isolated from the rest of the facility (ideally in an area with an accessible designated bathroom) or to a medical shelter site (IQ site). All PUIs should be tested for COVID.

PUI/cases who are staff should be directed to go home right away.

If ill person has severe symptoms, call 911. Notify emergency medical staff and the receiving healthcare facility of COVID suspicion.

Follow Droplet and Contact precautions in addition to Standard Precautions for all interactions:

    1. Maintain 6 feet or greater distance.
    2. Perform hand hygiene for at least 20 seconds before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. If soap and water are not available, use alcohol-based hand sanitizer that contains at least 60% alcohol.
    3. Wear a surgical mask or higher level of protection, eye protection (e.g., goggles, face shield), gloves, and fluid resistant gown as needed, depending on the planned interaction.
    4. Carry a plastic waste bag for collection of used or contaminated PPE to dispose of later in a clinic or other designated location. Waste bag should be double knotted prior to disposal. Biohazard disposal is not necessary.

Contacts

A close contact is defined as follows:

Being within approximately 6 feet of a person with COVID-19 for a prolonged period (greater than 15 minutes, cumulative over or 24 hours) without PPE (surgical mask or higher level of protection);

OR

Having unprotected direct contact with infectious secretions or excretions of a person with confirmed or suspected COVID-19 (e.g., being coughed on, touching used tissues with a bare hand).

For all interactions:

    1. Maintain 6 feet or greater distance.
    2. Avoid direct physical contact with any person, but if direct contact is necessary, use protective gear, such as surgical masks and gloves.
    3. Do not rub eyes or nose or touch face until proper hand hygiene has been performed.

 

For high-risk congregate settings, accurate contacts may be difficult to determine, and mass testing of the residents is often warranted and appropriate.

Definition of Fully Vaccinated

For the purpose of this guidance, per CDC, fully vaccinated refers to individuals who are:

  • ≥ 2 weeks from following receipt of the second dose in a 2-dose series (e.g. Moderna or Pfizer, OR
  • ≥ 2 weeks following receipt of one dose of a single-dose vaccine (e.g. Johnson & Johnson's Janssen).

Isolation of Cases and Quarantine of Contacts

Cases

Persons with symptomatic COVID-19 can be released from isolation after at least 10 days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms have improved. Asymptomatic persons with COVID-19 who never developed symptoms may be released from isolation 10 days after the date of collection of their initial positive viral test.

Contacts

Contacts who are not fully vaccinated residents and remain asymptomatic should stay in quarantine for either 14 days or for 10 days with a negative molecular test (specimen collected after day 7), starting after last exposure to a PUI or confirmed case. Not fully-vaccinated staff contacts who are asymptomatic should be instructed to stay home in quarantine for either 14 days or for 10 days with a negative molecular test (specimen collected after day 7), starting after last exposure to a PUI or confirmed case.

Fully vaccinated asymptomatic residents or staff of non-healthcare residential high-risk congregate settings (e.g., shelters) may need to quarantine or may be placed on work restriction following close contact with a person with laboratory-confirmed COVID-19. The need for quarantine or work restriction will be determined by the DPH outbreak investigator based on the results of testing and transmission patterns at each outbreak location.

Post-exposure testing is needed for fully vaccinated asymptomatic residents and staff of high-risk residential congregate settings.

A negative COVID-19 test result collected at least 3 days AFTER the last exposure with the infected case may release the asymptomatic vaccinated resident from quarantine and the staff from work restriction.

Contacts should be instructed to self-monitor for symptoms twice a day for 14 days regardless of vaccination status.

If contacts test positive or develop symptoms of respiratory illness (fever and cough or shortness of breath), then they should begin self-isolation and the timing of isolation resets based on symptoms or test dates.

Only contacts who are healthcare personnel and first responders (e.g. Emergency Medical Services (EMS) and Fire Department) may continue to work if there is critical staffing shortage and they remain asymptomatic. Note that this guidance is more restrictive than CDC guidance.

Additional guidance and resources:

GENERAL OUTBREAK INVESTIGATION GUIDELINES

  1. Investigation can be initiated over the phone and whenever possible, contact with the site should be made on the same day the outbreak investigation is opened. A site visit should be made within 24 hours. A testing strategy should be discussed and developed with the Community and Field Services (CFS) physician leading the investigation within 24 hours and communicated with the site.
  2. The frequency of follow-up with the site will be at least weekly, but may need to be more frequent initially, and as determined by the CFS physician.
  3. Inform the site that they will be included on a public outbreak notification list posted on the LAC Public Health website until the facility demonstrates that there are no new cases at the facility for at least 2 weeks and outbreak is resolved.
  4. Post a notification letter at the entrance of the shelter and community areas.
  5. Send notification letter to the facility with the name and contact information of the assigned Public Health Nurse.
  6. After positive test confirmation in unsheltered settings, presume you have widespread distribution of SARS CoV2.
  7. Initial mass testing may be implemented if there’s enough test capacity, and the layout of the facility, the movement of staff and residents, supports this need. On a case by case basis, targeted testing may be recommended if testing resources are limited and transmission appears more limited.
  8. Prepare to request expedited testing through the DPH Testing Logistics Team and the Community Testing Team, as appropriate.
  9. Testing at the facility may be conducted by partner organizations, however DPH remains the lead for testing in an outbreak setting and should attempt to arrange for testing to occur within 48 hours of outbreak opening. If no partner organization is scheduled to do testing within that timeframe, a request for a DPH Community Testing Team should be submitted unless the field teams will do the testing themselves.
  10. When partner organizations are conducting the outbreak testing, follow up on all test results and include in the line list for outbreak management.
  11. When serial testing in an outbreak investigation, retesting of persons who are already known to be positive in the past 89 days is discouraged. Testing should be conducted for those who previously were not tested, or tested negative, or it's been 90 days or more since their most recent episode of COVID-19 and they have had another exposure.
  12. Notify ACDC PEH team within 24 hours of identification of any of the following:
      1. Proportion of cumulative cases identified at the site is >10%.
      2. Deaths have been identified. Death reporting form must be filled out and submitted to ACDC (See Forms)

Additional guidance and resources:

SPECIFIC OUTBREAK INFECTION CONTROL RECOMMENDATIONS

  • Emphasize importance of early detection of cases and removing them from contact with others.
  • Reinforce good hand hygiene among all (clients, staff, and volunteers), and post signage as reminders.
  • Emphasize respiratory etiquette (cover cough and sneezes, dispose of tissues properly).
  • Promote and practice social distancing throughout the setting.

Protocol for Sheltered Settings (e.g. shelters, churches, indoor facilities)

  1. Quarantine site until assessments are completed (site visit, assessment of outbreak magnitude including test results, environmental health evaluation if needed, etc.) Residents should only be allowed to attend urgent medical appointments.
  2. Notify staff and residents of COVID-19 outbreak while maintaining patient privacy and request all to abide by infection control measures across the facility/site.
  3. Initiate standard, contact, and droplet precautions for all PUIs and cases with and without symptoms. Ensure masking is enforced and that site has sufficient mask supplies.
  4. Define an isolation/quarantine area around the PUI/case. Actual quarantine area will depend on each site layout but define the area by the local work. Movement of residents within the facility should be thoughtful and aim to minimize transmission.
    1. Consider moving additional PUIs into the isolation/quarantine area if suspicion for COVID-19 is high.
  5. A Department of Public Health call center has been established to assist healthcare providers, homeless service providers, street outreach teams, and law enforcement to find isolation or quarantine bed for their PEH. Call (833)-596-1009 from 8am to 8pm for bed availability.
  6. Rapidly move symptomatic PEH into an isolation area within current setting if possible (ideally in an area with an accessible bathroom or to a designated isolation & quarantine setting (i.e. medical shelter site/IQ site).
  7. Place clear signage outside all isolation areas for staff and clients to properly identify these areas to reduce intermingling of symptomatic and non-symptomatic individuals.
  8. Notify, and quarantine where indicated by current guidelines, all PEH (contacts) who have been identified to have come in close contact (within 6 feet for a total of 15 minutes or more within a 24-hour period) with the symptomatic client for 14 days. Staff should consider monitoring these clients at least once a shift and more frequently if high-risk clients (age over 50, chronic medical problem, pregnant).
  9. Designate a separate area for non-symptomatic PEH contacts who are also high-risk (age over 50, chronic medical problem, pregnant), when possible (separate from low-risk non-symptomatic and symptomatic clients). Consider placing high-risk clients in less densely crowded areas and in rooms with fewer than 10 beds.
  10. Symptomatic clients should eat meals separate from clients without symptoms.
  11. Review current status of all PEH to identify all who are symptomatic and relocate to available isolation/quarantine locations per protocol.
  12. Increase environmental cleaning throughout the congregate setting to 3 times a day with emphasis on high touch surfaces, particularly in the unit where the case was located. Ensure that you are using an EPA registered disinfectant appropriate for SARS-CoV-2.
  13. Determine covid vaccination status of residents and staff. Provide vaccine education and offer referrals for COVID-19 vaccination to any unvaccinated residents or staff. Please make referrals for residents and staff who still need their second vaccine doses, or if they need a third dose as recommended by CDC.
  14. Ensure adequate and easily accessible supplies for good hygiene, including:
    • Tissues and trash receptacles
    • No touch hand sanitizer dispenser near customer entrances if feasible
    • Hand sanitizer with at least 60% alcohol
    • Handwashing stations
    • Soap
    • Paper towels
  15. Restrict all volunteers and non-essential congregate setting personnel from entering the facility.
  16. Initiate temperature and symptom checks at entry to the shelter with wellness checks daily.
  17. Identify all staff who have been in contact with cases/PUIs and initiate home quarantine protocol.
  18. Discontinue all group events:
    • Serve meals "to go" if possible, or stagger dining times to decrease the size of the groups and maintain 6 feet of distance between diners. Disinfect between each group of diners.
    • If smaller group activities are medically necessary, keep the same group together to decrease the risk for virus spread.
    • Signage should be posted in the facility to reinforce frequent hand washing, cover your cough and maintaining social distancing.
  19. Staff may discontinue isolation for a client when both of the following conditions are met: At least 24 hours have passed since resolution of fever without the use of fever-reducing medications and improvement in symptoms (e.g., cough, shortness of breath); AND at least 10 days have passed since symptoms first appeared.
  20. Facility/site quarantine may be lifted after 14 days from the last symptomatic person or the last positive test is identified, whichever is latest; at which point, the outbreak investigation can move to closure.
  21. Extended monitoring for an additional 14 days may be considered after quarantine is lifted for sites with multiple previous outbreaks or high transmission rates. During this period, the site could remain under observation and continue with testing as indicated by MD.

Continuing New Admissions/Readmissions to Shelters and Project Roomkey Hotels/Motels Under Quarantine

Shelters and Project Roomkey sites under quarantine may continue to accept new residents or readmissions depending on a number of factors. Consider closing the facility to admissions if any of the following are concerns:

  1. Inadequate infection prevention and control at the facility as determined during initial site visits at all facilities.
  2. Concerning rates of hospitalizations, deaths, and/or other adverse outcomes.
  3. High proportion of unvaccinated residents or staff.
  4. Evidence of concerning viral transmission based on response testing of residents. In addition to initial testing at all sites, follow up testing on designated intervals would allow the identification of cases as quickly as possible.
  5. Inability to effectively quarantine new admissions and readmissions. This would require facilities to have separate areas and separate staff, cohorting for those under the existing quarantine and for those entering the facility.
  6. Inadequate supply of PPE for residents and staff.
  7. Shortage of staff or inability to cohort staff for new admissions/readmissions.

Additional guidance and resources:

Protocol for Unsheltered Settings (i.e., encampments, cars, drop-in centers, outdoor congregate settings)

  1. Initiate standard, contact, and droplet precautions for all suspect PEH with symptoms. Give the suspect PEH with symptoms a surgical mask and instruct the person to put it on.
  2. If you identify any person with severe symptoms, call 911. Before transfer, notify the transfer team and medical facility that you are referring patient with suspicion of COVID-19. Severe symptoms include:
    1. Extreme difficulty breathing
    2. Bluish lips or face
    3. Persistent pain or pressure in the chest
    4. New confusion, or inability to arouse
    5. Other serious symptom(s)
  3. Unnecessary transportation for any reason should be avoided by the team. Careful assessment of risk of remaining outside must be weighed with risk of relocating to shelter/congregate setting.
  4. On a case by case basis, clinically stable people with suspected or confirmed COVID-19 may be transferred to an isolation or quarantine bed. A Department of Public Health call center has been established to assist healthcare providers, homeless service providers, street outreach teams, and law enforcement to find an isolation or quarantine bed for their PEH. Call (833)-596-1009 from 8am to 8pm for bed availability.
  5. If no indoor quarantine options are available or if the person refuses, instruct the person to shelter in place with an individual tent and quarantine close contacts. Ensure that the street medicine/outreach team visit frequently (daily if possible) to monitor patients for deterioration of condition. Identify a capable encampment resident to report the ill person’s condition back to street medicine/outreach team, especially if phone calls/texting is an option.
  6. Encourage people staying in encampments to go to a quarantine site. If they refuse or if no indoor quarantine options are available, advise on set up of their tents/sleeping quarters with at least 6 feet spacing between tents, ideally 10 feet.
  7. Unless individual housing units are available, do not clear encampments. Clearing encampments can cause people to disperse throughout the community and break connections with service providers as well as increase the potential for infectious disease spread.
  8. Request up-to-date contact information for each person in the unsheltered setting.
  9. Provide straightforward communications to the encampment in the appropriate language. Post signs in strategic locations to provide information on hand hygiene, respiratory hygiene, and cough etiquette. Additional information should include:
    1. The most recent information about COVID-19 spread in their area
    2. Advice to avoid crowded areas if COVID-19 is circulating in their community
    3. Social distancing recommendations
    4. How to recognize the symptoms of COVID-19 and what to do if they are sick
    5. What to do if their friends, family, or community members are sick
    6. How to isolate themselves if they have symptoms
    7. How long to quarantine if there’s an outbreak at the site
    8. Updated information on where to find food, water, hygiene facilities, regular healthcare, and behavioral health resources if there have been local closures or changes
  10. Camp members should be given surgical masks and hygiene resources and told to practice as much isolation from other persons and groups as possible. Camp members also should be instructed how to care for the ill person, such as setting food outside his or her tent without coming into contact with the person.
  11. Provide education and offer referrals for COVID-19 vaccination to any unvaccinated camp members.
  12. Ensure nearby restroom facilities have functional water taps, are stocked with hand hygiene materials (soap, drying materials) and bath tissue, and remain open to PEH 24 hours per day. If toilets or handwashing facilities are not available nearby, provide access to portable latrines with handwashing facilities for encampments of more than 10 people.
  13. If a patient agrees to go to a medical shelter and leaves his or her belongings behind, educate other residents to avoid touching or moving the belongings for several hours to a day, to allow for decontamination.
  14. Belongings that must be thrown away can be handled using universal precautions. Biohazard disposal is not necessary.
  15. Used or contaminated PPE should be put in a plastic waste bag, double knotted shut, and disposed of later in a clinic or other designated location not in the encampment. Biohazard disposal is not necessary.
  16. The outbreak investigation may move to closure after 14 days from the last symptomatic person or the last positive test is identified, whichever is latest.  Extended monitoring for an additional 14 days may be considered at sites with multiple previous outbreaks or high transmission rates. During this period, the site could remain under observation and continue with testing as indicated by MD.

Patient Refusal

  1. If a PUI/case refuses to go to a medical shelter then every effort should be made to assist the encampment to find an onsite “isolation” option.
  2. One option may be an additional tent or a secluded area where friends can still feed and care for the patient.
  3. Camp members should be given masks and adequate hygiene supplies.
  4. Regular camp monitoring routines should be set up for such areas with medical staff who wear adequate protective equipment.

Additional guidance and resources:


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  • Public Health has made reasonable efforts to provide accurate translation. However, no computerized translation is perfect and is not intended to replace traditional translation methods. If questions arise concerning the accuracy of the information, please refer to the English edition of the website, which is the official version.

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