Much of the Canadian response to COVID-19 and homelessness has been built around the concern related to transmission risk within emergency shelters. This has led to a number of approaches such as de-intensifying shelter spaces, increased cleaning and sanitation, and broad screening for symptoms. While there have been shelter-based cases in Calgary, Montreal, and Toronto for example, to date the cases in Canadian shelters have been much lower than in long-term care or than in American shelters, two comparators of congregate living with vulnerable populations. Looking to an outbreak in an American shelter can provide valuable lessons for how we can continue to keep people safe and minimize shelter-based outbreaks or transmission.
Travis Baggett, Harrison Keyes, Nora Sporn and Jessie Gaeta of Boston Health Care for the Homeless Program (BHCHP) noted a cluster of cases from a large emergency shelter in Boston. They conducted a shelter-wide testing protocol including symptom assessment with 408 residents to understand the true scale of transmission within the shelter and compare this with symptomatic cases.
Findings were striking in terms of the scale of actual spread:
Whereas less than 10% of residents identified symptoms of any kind, 36% of residents were positive for COVID-19.
“The vast majority of newly identified cases had no symptoms and no fever on a single point-in-time assessment” (Baggett, Keyes, Sporn & Gaeta, 2020, pg. 4). The important points are two-fold:
1. COVID-19 can spread incredibly quickly and incredibly broadly within an emergency shelter setting;
2. Front-door symptom screening will miss the vast majority of positive cases.
While the first point is widely understood and has dictated the Canadian response, the second point is less commonly noted and I would presume there is some over-confidence in the efficacy of symptom screening.
Therefore, Baggett and colleagues conclude the necessity of a universal screening protocol within emergency shelters due to the vulnerability and risk involved. However, this creates a challenge where best evidence/best practices fall out of line with real world feasibility:
While universal screening in emergency shelters is best evidence, at no point so far in the pandemic have provinces or territories had the capacity to implement this level of testing.
This article details well why we have capacity limits on testing, both in terms of lab physical/staffing capacity, and in terms of swabs and reagent. Given the limitations on testing, provinces are being forced to make choices on who should be tested based on absolute highest risk and priority has been towards hospitals, healthcare workers, and long-term care residents.
What’s the solution here?
Unfortunately, the solution was to have been better prepared in advance, but clearly that ship has sailed. Similarly, repeatedly stating, “Everyone in shelter should be tested,” is true, but is of no help if it’s not feasible. Unfortunately, at this time we are stuck with focusing on those who are symptomatic, areas of outbreak, and hoping testing capacity keeps increasing as quickly as possible. Small comfort, but a lesson in why public health capacity should always be of upmost importance.
This is part of a blog series by Abe Oudshoorn, which explores recent research on homelessness, and what it means for the provision of services to prevent or end homelessness. See the full series here.