Podcast: Preventing COVID-19 among unhoused people

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Jim Dryden (host): Hello, and welcome to Show Me the Science, conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri, the Show-Me State. As we continue to look at Washington University’s response to the COVID-19 pandemic, we focus in this episode on a group of people society often forgets about: those who don’t have adequate housing.

Nathanial Nolan, MD: I believe that when you look at St. Louis and the greater metropolitan area, there is somewhere around 1,800 individuals who would be defined as being unhoused. Now, that does not mean unsheltered. There is a proportion of people who have some opportunities or resources but, unless there’s very dire situations outside as far as weather, choose to remain unhoused.

Dryden: That’s Nathan Nolan, a fellow in the Division of Infectious Diseases. He’s part of a team that was assembled in cooperation with the city and county health departments to try to help prevent the spread of COVID-19 among people who live on the streets, in tents and in shelters around St. Louis City and County. The effort involves the region’s health departments, other health providers, and faculty and staff at Washington University, both from the School of Medicine and from the School of Social Work. Steve Liang is an infectious diseases and emergency medicine specialist at Washington University. He says as he and other health care professionals work to protect the unhoused population from COVID-19, the doctors are learning more about just how many of those people need better health care.

Stephen Liang, MD: It’s opened our eyes to a problem that’s always been there, a challenge that’s always been there, and that is providing and offering adequate health-care services to our unhoused population both in shelters and in encampments, to be able to provide that resource not only for COVID-19 testing but for just routine health-care needs.

Dryden: There are all sorts of reasons people might find themselves without a place to live, from psychiatric illness and substance abuse to eviction from housing. But however a person ends up on the street, Liang, Nolan, and their colleagues are working to keep them as safe from infection with the SARS-CoV-2 virus as possible. Somewhat surprisingly, Nolan says, some practices of unhoused people may actually help protect them.

Nolan: I think there are certainly many logistical challenges among the unhoused, such as, if there is a stay-at-home order, where do they stay at home at? However, I would say there are some protective factors. One being that many of these individuals stay outside in the open air. Or when they don’t, many of them are living in tents or single, individual-type dwellings so that they’re not typically sharing small, cramped spaces with one another. One of the things that we’ve learned as time has gone on is that air circulation, really just air quality in general, matters a lot in transmission of coronavirus. We presume that one of the reasons we see such low rates of infection among people that are living out of doors is just because they have such good airflow and good air circulation around them.

Dryden: Are the rates low? What are those rates?

Liang: A difficult question to answer, mostly because testing within shelters as well as within that population has always been challenging to achieve, both in terms of extending testing to them and then performing testing in this population.

Dryden: But there are some studies where epidemiologists have looked at infection rates in other cities. But the results vary widely. In shelters in Boston, for example, indoors, where people tend to be close together, 30% of those people were positive for COVID-19, though many didn’t have symptoms. But a study in Washington that used blood tests, looking for antibodies in people who didn’t have any symptoms and who were living in shelters, found only 2% tested positive. Whatever the actual rates are, they are expected to rise across the country as the weather gets colder and it’s no longer possible to be outdoors, as it has been since the pandemic began last spring.

Nolan: And I think that there are a lot of people that are thinking critically about what is the winter going to look like, especially as we need to move people indoors. And so one thing I’ve been telling a lot of people I’ve interacted with or advised is, we’ll probably never get to a position of zero risk, but we have to mitigate risk where we can. And so knowing that, that being out on the street and freezing is probably the worst-case scenario, if we’re to bring these people indoors, how do we do it in the most safe manner for all involved? Historically, in St. Louis and, I suspect, in many communities around the United States, there are places that open up as winter-only shelters. And many of these are church basements, or gymnasiums, or places that are otherwise being unoccupied. And oftentimes, they create a higher risk environment because they essentially are bed mats or cots that are laid out in very close proximity with the goal of just getting people out of the freezing conditions at night.

Dryden: St. Louis doesn’t get as cold as many cities further to the north. But during our coldest period, the average low temperature at night is 30 degrees in December, 24 in January, and 27 during February. But that’s the average. During the last two years, those months frequently have featured many nights in the single digits, with the temperatures reaching 6 below 0 in both January of 2018 and 2019, and falling as low as 8 below in January of 2014. If it gets that cold during the coming winter, people without houses could be faced with a tough choice. Risk exposure to the elements, or risk coronavirus in a shelter — if the shelter they normally go to in the cold is even open this winter.

Nolan: There are many places that are a little bit hesitant to open up as a winter shelter because, again, if you’re a church, and you have an elderly congregation, or you had predominately elderly volunteers, those people may be less comfortable being volunteers in emergency shelters. Dr. Liang can talk a little bit about this, but, knowing that this will be a risk, but how can we mitigate this risk to make it be an appropriate risk-benefit ratio of being able to house people during freezing conditions but make sure that we don’t have large spikes in coronavirus among that population?

Dryden: What are you proposing to do, Dr. Liang?

Liang: First of all, we have to understand a lot of the spaces that many of these temporary shelters are going to be opening up this winter are working with. A lot of things we worry about in these areas would be the air exchange as well as the proximity with distancing, the importance of distancing, and also the inability to mask where– it’s not easy to mask when you’re sleeping, so we can’t, certainly, expect people to wear a mask while they’re sleeping. So in those instances, we want to not only distance folks but also create some temporary barriers between folks to block potential droplets from transmitting from one person to another.

Dryden: Barriers sort of like we saw in the vice-presidential debate? I mean, literally, is that what you’re talking about? Sheets of plexiglass or cardboard or just something to block air flow like that?

Liang: Definitely. We’re looking at more low-tech solutions, so something even as simple as a clear drape, or a shower curtain, or a sheet. Very simple, can block droplets within that six-foot radius around a patient– or around a client, in this case.

Dryden: Now, do homeless shelters typically feed people too, especially some of these temporary shelters? Or is it more or less dangerous if you’re doing both the eating and the sleeping activity in the same place?

Nolan: That’s something that we’ve been evaluating as well. Many of these temporary shelters, or even permanent shelters, do have some sort of eating facility. The two times that people are probably most vulnerable indoors in these large, congregate settings are sleeping and eating because those are the times they typically aren’t wearing masks. We have been working to create some precautions around eating as far as staggering eating times so that we can have smaller groups of people eating at the same time and have them spaced out. Maybe having one server that’s serving helpings of food rather than everyone touching the same spoon. Making sure that we have appropriate sanitation in between eating as far as hand hygiene, but also wiping down tables between eating. And so these are things that we’ve certainly been evaluating, and it’s been part of the equation as we move forward.

Dryden: This year, we’re worried about COVID. Every other year, though, there’s colds and flus and other respiratory problems. Have there been efforts to reduce those sorts of infections in these shelters in the past? And how’d they work, if there were?

Nolan: There are people that have been doing that work, but never in such a way where we thought so critically about social distancing, masking, things like that. I suspect that, moving forward, we’ve heard from a lot of shelters that once we initiate some of these protocols, it may be that they want to keep some of these moving forward to try to reduce the risk of infections that happen within congregate settings.

Dryden: How did you guys get involved in this?

Liang: That’s a great question. And this was a request that was made to our division, the Division of Infectious Diseases, early on during the COVID-19 pandemic back in the spring, as a group of Washington University faculty, both in the School of Medicine and School of Social Work, were looking at vulnerable populations within our region. And among those, the unhoused population and those living in encampments really struck us as being a highly vulnerable population, not only because of shelter but also within shelters, because of the inability to socially distance as well as the lack of access, or inadequate access, to health care.

Dryden: As they did with decisions about whether to open schools for in-person learning, Liang says the health departments in St. Louis City and County are involved in this effort to help prevent the spread of COVID-19 in the unhoused population. And health departments aren’t the only ones.

Liang: So this is part of a large, regional effort of multiple organizations, including the COVID-19 Regional Response Team as well as the St. Louis City Continuum of Care. So we have representatives from both St. Louis City as well as St. Louis County health departments, multiple shelters, just lots of stakeholders at the table who are extremely concerned about this highly vulnerable population.

Dryden: Do we know how many homeless people there are in this region?

Nolan: I believe that when you look at St. Louis and the greater metropolitan area, there is somewhere around 1,800 individuals who would be defined as being unhoused. Now, that does not mean unsheltered, and that does not mean not in temporary housing, but would be defined as being unhoused. There is a proportion of people who have some opportunities or resources but, unless there’s very dire situations outside as far as weather, choose to remain unhoused. For some people, it’s a very transient thing. And one thing that we are worried about is, as the economy continues to contract with job loss, and as we see evictions rise, that we may see a rise in transient homelessness. So these would be, maybe, single-parent families or single-income families that, maybe, now have no stable income. And that population is somewhat of a different population than those who are chronically unhoused based on their own choice or based on lifestyle decisions.

Liang: I will add that during this pandemic, the city has, in many cases, rented hotels and other kind of vacant buildings, lodging facilities that were not full, to help with the spacing out of shelters. So trying to, obviously, offer the opportunity for every unhoused client to have a private room with a dedicated bathroom, particularly those who might be at high risk for COVID-19. So that’s one strategy that’s been employed not only in St. Louis but in many other cities, to use hotels as temporary shelters for unhoused.

Dryden: What about the risks posed by people who are on the streets to people who are trying to help them out? If I’m a person who used to give a bottle of water or a piece of fruit, am I facing any risk? Does that pose a danger to other people if this population has an outbreak?

Nolan: So that’s certainly a question that we’ve been asking. The CDC defines an exposure as close proximity to someone for 15 minutes, without a mask. So the transient exposure, especially in an open air environment, is probably not enough to cause a high risk of transmission even to a vulnerable individual. So if you would normally go out and roll down your window and hand out a bottle of water, you would probably still be very safe doing so.

Liang: Would also add to Dr. Nolan’s comment that the good news is there are very simple public-health strategies that can be employed by anyone in terms of masking, as well as hand washing and so forth, that are very effective barriers to transmission of this infection.

Dryden: You had mentioned that some of these churches and other places where volunteers are working may not be opening this year, or they may have trouble staying open. So that makes me think that maybe the capacity problems in the shelters that are open might get worse. The crowds might get worse. Does that increase risk as winter arrives?

Nolan: There are shelter locations that opened up at the beginning of the pandemic in order to shelter people who otherwise were in encampments or who were interested in seeking shelter, and those have stayed open throughout the pandemic and are planning to stay open throughout the winter. So we do already have some increased capacity, though our congregate settings are currently operating at a decreased capacity for infection-prevention measures. There are also several organizations that are looking to step up and increase the amount of sheltering that they can do either through having more nights that they’re open or through looking at new spaces. And I think that we are looking at having enough capacity in order to house most of the individuals that would be willing to be housed.

Dryden: But I wonder about using shelters and places where members of this population would congregate as places to offer testing.

Liang: I think, if anything, the COVID-19 pandemic has kind of— it’s opened our eyes to a problem that’s always been there, a challenge that’s always been there, and that is providing and offering adequate health-care services to our unhoused population both in shelters and in encampments, to be able to provide that resource not only for COVID-19 testing but for just routine health-care needs, very basic needs. Many of these unhoused clients have never really seen or had a primary-care physician. We’re really hoping that this will be an opportunity, again, to be able to improve our health-care safety net infrastructure within the shelters.

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Dryden: Liang and Nolan say that as the weather gets colder and more people have to move indoors, at least at night, the population of people without adequate housing will experience increased risk for infection. And those who run shelters will need to work very hard to prevent the spread of the virus, both among the unhoused population and among the people who work in the shelters. Show Me the Science is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to keep you informed and maybe teach you some things that will give you hope. Thank you for tuning in. I’m Jim Dryden. Stay safe.