6/8/21, 12:00 PMInterim Guidance on People Experiencing Unsheltered Homelessness | COVID-19 | CDC
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CDC has updated its guidance for people who are fully vaccinated. See Recommendations for Fully Vaccinated
People.
Interim Guidance on People Experiencing Unsheltered
Homelessness
Interim Guidance
Updated June 7, 2021 Print
This interim guidance is based on what is currently known about coronavirus disease 2019 (COVID-19). The Centers
for Disease Control and Prevention (CDC) will update this interim guidance as needed and as additional information
becomes available.
Summary of Recent Changes
Added considerations for developing a long term strategy related to COVID-19 prevention among people
experiencing unsheltered homelessness
A revision was made on 6/7/2021 to re!ect the following:
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People experiencing unsheltered homelessness (those sleeping outside or in places not meant for human habitation)
may be at risk for infection when there is community spread of COVID-19. This interim guidance is intended to support
response to COVID-19 by local and state health departments, homelessness service systems, housing authorities,
emergency planners, healthcare facilities, and homeless outreach services. Homeless shelters and other facilities should
also refer to the Interim Guidance for Homeless Shelters. Community and faith-based organizations can refer to the
Interim Guidance for Communities of Faith for other information related to their sta" and organizations.
COVID-19 is caused by a new coronavirus. We are learning about how it spreads, how severe it is, and other features of
the disease.
COVID-19
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Lack of housing contributes to poor physical and mental health outcomes, and linkages to permanent housing for people
experiencing homelessness should continue to be a priority. In the context of COVID-19 spread and transmission, the
risks associated with sleeping outdoors or in an encampment setting are di"erent than from staying indoors in a
congregate setting such as an emergency shelter or other congregate living facility. Outdoor settings may allow people to
increase physical distance between themselves and others. However, sleeping outdoors often does not provide
protection from the environment, adequate access to hygiene and sanitation facilities, or connection to services and
healthcare. The balance of risks should be considered for each individual experiencing unsheltered homelessness.
Community coalition-based COVID-19 prevention and
response
Planning and response to COVID-19 transmission among people experiencing homelessness requires a “whole
community” approach, which means involving partners in the response plan development, with clearly outlined roles
and responsibilities. Table 1 outlines some of the activities and key partners to consider for a whole-community
approach.
Table 1: Using a community-wide approach to prepare for COVID-19 among people experiencing homelessness
Connect to community-wide planningConnect to community-wide planning
Connect with key partners to make sure that you can all easily communicate with each other while preparing for and
responding to cases. A community coalition focused on COVID-19 planning and response should include:
Local and state health departments
Outreach teams and street medicine providers
Homeless service providers and Continuum of Care leadership
Emergency management
Law enforcement
Healthcare providers
Housing authorities
Local government leadership
Other support services like case management, emergency food programs, syringe service programs, and
behavioral health support
People with lived experiences of homelessness
People with lived experiences of homelessness can help with planning and response. These individuals can serve as
peer navigators to strengthen outreach and engagement e"orts. Develop an advisory board with representation from
people with current or former experiences of homelessness to ensure community plans are e"ective.
Identify additional sites and resourcesIdentify additional sites and resources
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Communication
Outreach workers and other community partners, such as emergency food provision programs or law enforcement, can
help ensure people sleeping outside have access to updated information about COVID-19 and access to services.
Stay updated on the local level of transmission of COVID-19 through your local and state health departments.
Build on existing partnerships with peer navigators who can help communicate with others.
Maintain up-to-date contact information and areas frequented for each person.
Communicate clearly with people sleeping outside.
Use health messages and materials developed by credible public health sources, such as your local and state
public health departments or the Centers for Disease Control and Prevention (CDC).
Post signs in strategic places (e.g. near handwashing facilities) providing instruction on hand washing and
cough etiquette.
Provide educational materials about COVID-19 for non-English speakers, those with low literacy or intellectual
disabilities, and people who are hearing or vision impaired.
Ensure communication with clients about changes in homeless services policies and/or changes in physical
location of services such as food, water, hygiene facilities, regular healthcare, and behavioral health resources.
Identify and address potential language, cultural, and disability barriers associated with communicating COVID-19
information to workers, volunteers, and those you serve. Learn more about reaching people of diverse languages
and cultures.
Considerations for outreach sta!
Sta" training and policies
Provide training and educational materials related to COVID-19 for sta".
Continuing homeless services during community spread of COVID-19 is critical. Make plans to maintain services for all
people experiencing unsheltered homelessness. Furthermore, clients who are positive for COVID-19 need to have
access to services and a safe place to stay, separated from others who are not infected. To facilitate the continuation
of services, community coalitions should identify resources to support people sleeping outside as well as additional
temporary housing, including sites with individual rooms that are able to provide appropriate services, supplies, and
sta#ng. These sites should include:
Over!ow sites to accommodate shelter decompression and higher shelter demands
Isolation sites for people who are con$rmed to be positive for COVID-19 by laboratory testing
Quarantine sites for people who are awaiting testing, awaiting test results, or who were exposed to COVID-19
Protective housing for people who are at increased risk for severe illness from COVID-19
Depending on resources and sta" availability, housing options that have individual rooms (such as hotels/motels) and
separate bathrooms should be considered for the over!ow, quarantine, and protective housing sites. In addition, plan
for how to connect clients to housing opportunities after they have completed their stay in these temporary sites.
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Minimize the number of sta" members who have face-to-face interactions with clients.
Develop and use contingency plans for increased absenteeism caused by employee illness or by illness in
employees’ family members. These plans might include extending hours, cross-training current employees, or hiring
temporary employees.
Assign outreach sta" who are at increased risk for severe illness from COVID-19 to duties that do not require them
to interact with clients in person.
Outreach sta" should review stress and coping resources for themselves and their clients during this time.
Sta" prevention measures
Encourage outreach sta" to maintain good hand hygiene by washing hands with soap and water for at least 20
seconds or using hand sanitizer (with at least 60% alcohol) on a regular basis, including before and after each client
interaction
Advise sta" to maintain 6 feet of distance while interacting with clients and other sta", where possible.
Require outreach sta" to wear masks when working in public settings or interacting with clients. They should still
maintain a distance of 6 feet from each other and clients, even while wearing masks.
Advise outreach sta" to avoid handling client belongings. If sta" are handling client belongings, they should use
disposable gloves, if available. Make sure to train any sta" using gloves to ensure proper use and ensure they
perform hand hygiene before and after use. If gloves are unavailable, sta" should perform hand
hygiene immediately after handling client belongings.
Outreach sta" who are checking client temperatures should use a system that creates a physical barrier between
the client and the screener as described here.
Where possible, screeners should remain behind a physical barrier, such as a car window, that can protect the
sta" member’s face from respiratory droplets that may be produced if the client sneezes, coughs, or talks.
If social distancing or barrier/partition controls cannot be put in place during screening, PPE (i.e., facemask, eye
protection [goggles or disposable face shield that fully covers the front and sides of the face], and a single pair
of disposable gloves) can be used when within 6 feet of a client.
However, given PPE shortages, training requirements, and because PPE alone is less e"ective than a barrier, try
to use a barrier whenever you can.
For street medicine or other healthcare sta" who are providing medical care to clients with suspected or con$rmed
COVID-19 and close contact (within 6 feet) cannot be avoided, sta" should at a minimum, wear eye protection
(goggles or face shield), an N95 or higher level respirator (or a facemask if respirators are not available or sta" are
not $t tested), disposable gown, and disposable gloves. Masks are not PPE and should not be used when aMasks are not PPE and should not be used when a
respirator or facemask is indicated.respirator or facemask is indicated. Healthcare providers should follow infection control guidelines.
Outreach sta" who do not interact closely (e.g., within 6 feet) with sick clients and do not clean client environments
do not need to wear personal protective equipment (PPE).
Outreach sta" should launder work uniforms or clothes after use using the warmest appropriate water setting for
the items and dry items completely.
Sta" process for outreach
In the process of conducting outreach, sta" should
Greet clients from a distance of 6 feet and explain that you are taking additional precautions to protect yourself
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and the client from COVID-19.
If the client is not wearing a mask, provide them with one.
Screen clients for symptoms by asking them if they feel as if they have a fever, cough, or other symptoms
consistent with COVID-19.
Children have similar symptoms to adults and generally have mild illness
Older adults and persons with medical comorbidities may have delayed presentation of fever and
respiratory symptoms.
If medical attention is necessary, use standard outreach protocols to facilitate access to healthcare.
Continue conversations and provision of information while maintaining 6 feet of distance.
If at any point you do not feel that you are able to protect yourself or your client from the spread of COVID-19,
discontinue the interaction and notify your supervisor. Examples include if the client declines to wear a mask or
if you are unable to maintain a distance of 6 feet.
Considerations for people experiencing unsheltered
homelessness
Help clients prevent becoming sick with COVID-19
Consider the balance of these risks when addressing options for decreasing COVID-19 spread. Those who are
experiencing unsheltered homelessness face several risks to their health and safety.
Continued linkage to homeless services, housing, medical, mental health, syringe services, and substance use
treatment, including provision of medication-assisted therapies (e.g., buprenorphine, methadone maintenance, etc.).
Use telemedicine, when possible.
Some people who are experiencing unsheltered homelessness may be at increased risk of severe illness from
COVID-19 due to older age or certain underlying medical conditions, such as chronic lung disease or serious heart
conditions.
Reach out to these clients regularly to ensure they are linked to care as necessary.
Prioritize providing individual rooms for these clients, where available.
Recommend that all clients wear masks any time they are around other people. Masks should not be placed on
young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise
unable to remove the mask without assistance.
Provide clients with hygiene materials, where available.
Discourage clients from spending time in crowded places or gathering in large groups, for example at locations
where food, water, or hygiene supplies are being distributed.
If it is not possible for clients and sta" to avoid crowded places, encourage spreading out (at least6 feet
between people) to the extent possible and wearing masks.
Help link sick clients to medical care
Regularly assess clients for symptoms.
Clients who have symptoms may or may not have COVID-19. Make sure they have a place they can safely stay
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in coordination with local health authorities.
If available, a nurse or other clinical sta" can help with clinical assessments. These clinical sta" should follow
personal protective measures.
Provide anyone who presents with symptoms with a mask.
Facilitate access to non-urgent medical care as needed.
Use standard outreach procedures to determine whether a client needs immediate medical attention.
Emergency signs include (this list is not all inclusive. Please refer clients for medical care for any other
symptoms that are severe or concerning to you):
Trouble breathing
Persistent pain or pressure in the chest
New confusion or inability to arouse
Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone
Notify the designated medical facility and personnel to transfer that clients might have COVID-19.
If a client has tested positive for COVID-19
Use standard outreach procedures to determine whether a client needs immediate medical attention.
If immediate medical attention is not required, facilitate transportation to an isolation site.
Notify designated medical facility and personnel that the client has tested positive for COVID-19.
If medical care is not necessary, and if no other isolation options are available, advise the individual on how to
isolate themselves while e"orts are underway to provide additional support.
During isolation, ensure continuation of behavioral health support for people with substance use or mental
health disorders.
In some situations, for example due to severe untreated mental illness, an individual may not be able to comply
with isolation recommendations. In these cases, community leaders should consult local health authorities to
determine alternative options.
Ensure the client has a safe location to recuperate (e.g., respite care) after isolation requirements are
completed, and follow-up to ensure medium- and long-term medical needs are met.
Considerations for encampments
If individual housing options are not available, allow people who are living unsheltered or in encampments to
remain where they are.
Clearing encampments can cause people to disperse throughout the community and break connections with
service providers. This increases the potential for infectious disease spread.
Encourage those staying in encampments to set up their tents/sleeping quarters with at least 12 feet x 12 feet of
space per individual.
If an encampment is not able to provide su#cient space for each person, allow people to remain where they
are but help decompress the encampment by linking those at increased risk for severe illness to individual
rooms or safe shelter.
Work together with community coalition members to improve sanitation in encampments.
Ensure nearby restroom facilities have functional water taps, are stocked with hand hygiene materials (soap, drying
materials) and bath tissue, and remain open to people experiencing homelessness 24 hours per day.
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If toilets or handwashing facilities are not available nearby, assist with providing access to portable latrines with
handwashing facilities for encampments of more than 10 people. These facilities should be equipped with hand
sanitizer (containing at least 60% alcohol).
Considerations for a Long-Term Infection Prevention
Strategy for People Experiencing Unsheltered Homelessness
When community COVID-19 transmission levels change, some communities might consider when to modify the COVID-19
prevention measures described above. Below are several factors to consider before modifying community-level COVID-19
prevention approaches for people experiencing unsheltered homelessness, for example, changing outreach team
procedures or approaches to COVID-19 prevention in encampments. These factors should be considered together; no
single factor should be used alone to decide changes in approach.
These factors should be discussed with local public health partners, community homeless service providers, and people
with lived experience of homelessness. Any modi$cations to COVID-19 prevention measures should be conducted in a
phased and !exible approach, with careful monitoring of COVID-19 cases in the community. Connecting people
experiencing homelessness to permanent stable housing should continue to be the primary goal.
Community Transmission LevelsCommunity Transmission Levels
: What is the incidence of COVID-19 in the community?
The incidence of COVID-19 in the community will in!uence the risk of infection for people experiencing unsheltered
homelessness. The CDC COVID Data Tracker has a tool that displays the current level of community transmission at the
county level. Increasing COVID-19 vaccination coverage in the surrounding community is important to help reduce
community transmission, but community vaccination coverage should not be used alone to decide to modify approaches
to prevention among people experiencing unsheltered homelessness.
Vaccination Levels: Vaccination Levels:
What proportion of people experiencing unsheltered homelessness in the community have been
vaccinated against COVID-19?
Vaccination signi$cantly decreases the likelihood of becoming infected with the virus that causes COVID-19. Refer to the
Interim Public Health Recommendations for Fully Vaccinated People for the most up-to-date information on individual-
level modi$cations to prevention measures for people who are fully vaccinated. People experiencing unsheltered
homelessness who are fully vaccinated do not need to wear masks unless they are accessing services in a homeless
service facility. Although we know vaccines help protect individuals, there is not enough information available yet to
determine a level of vaccination coverage needed to modify community-level COVID-19 prevention measures. Note:
Vaccination status should not be a barrier to accessing homeless services. COVID-19 vaccinations should not be
mandatory to receive homeless services unless required by state or local health authorities.
Availability of Housing: Availability of Housing:
What is the housing availability in the community?
Any modi$cations to approaches to encampments or people experiencing unsheltered homelessness should be
conducted with an awareness of housing availability and homeless service capacity. Closing encampments can lead
people to disperse and result in increased crowding at other encampments or in shelters, which can increase the risk of
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spreading infectious disease, including COVID-19. Encampment disbursement should only be conducted as part of a plan
to rehouse people living in encampments, developed in coordination with local homeless service providers and public
health partners.
Even if the community decides to modify some infection prevention measures for people experiencing unsheltered
homelessness, continue to maintain the following key components of a sustainable approach to disease prevention and
response.
1. Monitor community transmission of COVID-19 in the area. For the latest updates on county-level transmission of the
virus that causes COVID-19, use this CDC COVID Data Tracker tool.
2. Create !exible quarantine and isolation locations that are scalable, in case the number of COVID-19 cases in the
community increases.
3. Keep a minimum set of public health prevention and control procedures in place at all times, including
a. Working together with community organizations to improve sanitation in encampments.
b. Ensuring access to handwashing facilities and supplies.
c. Providing place-based, regular health evaluations and linkages to medical care, including access to COVID-19
vaccination, routine vaccinations, and behavioral health services.
More Information
Considerations for food pantries and food distribution sites
Visit cdc.gov/COVID19 for the latest information and resources
Information for health departments
Guidance for homeless service providers
COVID-19 fact sheets for people experiencing homelessness (at the bottom of the page)
Department of Housing and Urban Development (HUD) COVID-19 resources
CDC’s COVID-19 stress and coping information
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Last Updated June 7, 2021
Content source: National Center for Immunization and Respiratory
Diseases (NCIRD), Division of Viral Diseases
