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Sites and Settings Associated with

People Experiencing Homelessness (PEH)

B73 COVID-19 - Procedural Guidance for DPH Staff


Sites and Settings Associated with People Experiencing Homelessness

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REPORTING PROCEDURES

Outbreak Definitions:

Under Title 17, Section 2500, California Code of Regulations all suspected outbreaks are reportable. COVID-19 outbreak definitions are determined based on risk of transmission in particular sites, and are as follows:

Congregate residential sites associated with PEH such as shelters, encampments, or recuperative care centers:

At least 3 confirmed cases of COVID-19 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 with at least 3 Persons Under Investigation (PUI) in residents or staff within a 14-day period.

Of note: this definition includes the combination of 1 confirmed case with 2 PUIs or 2 confirmed cases with 1 PUI .

Outdoor congregate areas other than encampments (e.g., Safe Parking sites):

At least 3 confirmed cases of COVID-19 in residents or staff from 3 different households within a 14-day period.

Semi-congregate or non-congregate residential sites associated with PEH such as Single Room Occupancy housing, Tiny Home Villages, Project Roomkey or Project Homekey housing or shelters for which the layout is discrete apartments:

At least 3 confirmed cases of COVID-19 in residents or staff from 3 different households within a 14-day period.

Non-residential sites providing homeless services such as hygiene centers, food distribution centers, case management or other access centers for services for PEH:

At least 3 confirmed cases of COVID-19 in clients or staff within a 14-day period.

Medical shelters for isolation of persons diagnosed or suspected of COVID-19 or for quarantine of contacts (e.g., Isolation/Quarantine (IQ) sites):

At least 3 confirmed cases of 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 the onset date that initiated the investigation.
  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. Recall that in residential settings, exposures may be difficult to ascertain accurately, and all the residents may be considered exposed in some settings.
  6. Exposed people include residents/clients, 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 or until site meets outbreak closure criteria. Last exposure refers to the last date a person with COVID-19 was at the site while infectious.
  12. If  new cases or symptomatic persons are identified within one incubation period (i.e., 14 days) of the date that the last symptomatic or lab confirmed case was identified, then outbreak investigation will be re-opened, as per outbreak definitions above, 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: PEOPLE EXPERIENCING HOMELESSNESS (PEH) 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 complicated 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-19.

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-19 suspicion.

Follow Airborne 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 personal protective equipment (PPE), including gloves. If soap and water are not available, use alcohol-based hand sanitizer that contains at least 60% alcohol.
    3. Wear a fitted respirator (e.g., N95, KN95, and KF94), 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

In addition to the general definitions for close contacts, in high risk congregate settings, accurate exposure histories and contacts may be difficult to determine, and all residents may be considered exposed.

For all interactions with contacts:

    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 a fitted respirator (e.g., N95, KN95, and KF94), and gloves.
    3. Do not rub eyes or nose or touch face until proper hand hygiene has been performed.

 

Isolation of Cases

Cases

Isolation Instructions for cases can be found here.

Contacts

Quarantine of close contacts is no longer required. Masking and testing instructions can be found here.

Staff

Work Considerations

  • Staff who are close contacts may continue to work with a negative diagnostic test upon identification (but not earlier than 24 hours after exposure), and if negative, test at days 3 and 5.
  • All of these staff must wear a highly protective mask (e.g., a well-fitting medical mask or respirator) around others until they test negative on Day 5.
  • If staff develop symptoms after returning to work, they must be excluded from the workplace and must test as soon as possible. If staff test positive, they must follow the isolation requirements for cases. 

 

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. Testing strategy may depend on CDC COVID-19 Community Levels.
  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. Outbreak closure criteria may change when community transmission rates are elevated.
  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. Because exposure and contacts may be difficult to ascertain in high risk congregate settings, mass testing is often warranted and appropriate.
  8. Post-exposure testing is needed in exposed residents and staff of PEH settings regardless of vaccination status.
  9. On a case by case basis, targeted testing may be recommended if testing resources are limited and transmission appears more limited.
  10. Prepare to request expedited testing through the DPH Testing Logistics Team and the Community Testing Team, as appropriate.
  11. 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.
  12. When partner organizations are conducting the outbreak testing, follow up on all test results and include in the line list for outbreak management.
  13. 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 newly symptomatic within 90 days of COVID-19 infection.
  14. 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/residents, staff, and volunteers), and post signage as reminders.
  • Promote masking, practice social distancing throughout the setting, and increase ventilation and air filtration.
  • Emphasize respiratory etiquette (cover cough and sneezes, dispose of tissues properly).
  • Encourage clients/residents, staff, and volunteers to stay up to date with all COVID-19 vaccines (fully vaccinated and received a booster dose or fully vaccinated and not yet booster eligible).

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

  1. May admit new residents while doing initial assessments (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 airborne 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 area around the case. Actual isolation 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.
  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 beds 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. 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.
  9. Symptomatic clients should eat meals separately from clients without symptoms.
  10. Review current status of all PEH to identify all who are symptomatic and relocate to available isolation/quarantine locations per protocol.
  11. 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.
  12. 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 need to stay up to date with all COVID-19 vaccines.
  13. Clients who are unable to access oral COVID-19 therapeutics through their own provider or who do not heave health insurance can be referred to a Test to Treat program or the DPH Public Health Call Center/Tele-Health service, which provides testing, consultation, and prescriptions. 1-833-540-0473 open 7 days a week, 8:00 am-8:30 pm. Ensure adequate and easily accessible supplies for good hygiene, including:
    1. Tissues and trash receptacles
    2. No touch hand sanitizer dispenser near customer entrances if feasible
    3. Hand sanitizer with at least 60% alcohol
    4. Handwashing stations
    5. Soap
    6. Paper towels
  14. Restrict all volunteers and non-essential congregate setting personnel from entering the facility.
  15. Initiate temperature and symptom checks at entry to the shelter with wellness checks daily.
  16. 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.
  17. Staff may discontinue isolation for a client when all 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 5 days have passed since symptoms first appeared; AND a negative COVID-19 antigen test result from a specimen collected on Day 5 or later. Wear a well-fitting medical mask or respirator (e.g., N95, KN95, and KF94) indoor and outdoor for a total of 10 days. If test on Day 5 is positive or if decide not to test, continue isolation for 10 days total. Please note that Day 0 is first day of symptoms and Day 1 is the first full day after symptoms developed.

Continuing new admissions/readmissions to shelters and PEH facilities while under initial assessments

Shelters and PEH sites under initial assessments 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 cohort new admissions and readmissions from outbreak investigation cohort of residents. This would require facilities to have separate areas and separate staff.
  6. Shortage of staff or inability to cohort staff for new admissions/readmissions.
  7. Inadequate supply of PPE for residents and staff.

Additional guidance and resources:

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

  1. Initiate standard and airborne precautions for all suspect PEH with symptoms. Give the suspect PEH with symptoms a well-fitting medical mask or respirator (e.g. N95, KN95, and KF94) 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 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 isolation options are available or if the person refuses, instruct the person to shelter in place in an individual tent. 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. 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.
  7. If encampments under outbreak investigation disperse, determine where exposed residents moved to and if whether they entered any housing, prioritizing follow-up and notification of congregate housing.
  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. 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 a mask that fits and filters well (e.g., double mask, high filtration cloth mask, medical mask) or respirator (e.g., N95s, KN95s, KF94s) 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, those who still need their second vaccine dose, and those who are eligible for a vaccine booster. Camp members who are unable to access oral COVID-19 therapeutics through their own provider or who do not heave health insurance can be referred to a Test to Treat program or the DPH Public Health Call Center/Tele-Health service, which provides testing, consultation, and prescriptions. 1-833-540-0473 open 7 days a week, 8:00 am-8:30 pm.
  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. Belongings that must be thrown away can be handled using universal precautions. Biohazard disposal is not necessary.
  14. 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.
  15. The outbreak investigation may move to closure after 14 days from when the last symptomatic person or the last positive test is identified, whichever is later. Outbreak closure criteria may change when community transmission rates are elevated.

Patient refusal

  1. If a PUI/case refuses to go to a medical shelter, 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 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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