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Coronavirus spreading in homeless shelters; many cases are asymptomatic | COMMENTARY

Nurse Julia Davis took a client's temperature recently before he could enter Health Care for the Homeless in downtown Baltimore. All clients were being screened because of the current coronavirus outbreak.
Nurse Julia Davis took a client's temperature recently before he could enter Health Care for the Homeless in downtown Baltimore. All clients were being screened because of the current coronavirus outbreak.(Jerry Jackson/Baltimore Sun)

While we have plenty to learn about COVID-19, there’s much we already know: people with chronic health conditions are at elevated risk of death, and the virus is highly contagious. Outbreaks in nursing homes and other long-term care facilities have caused public alarm and require proactive measures to contain the spread among highly vulnerable people. Similarly, we should be concerned about residents of homeless shelters who suffer a disproportionately high rate of chronic disease.

Our emerging understanding of asymptomatic spread of the coronavirus in such settings demands immediate response from state and federal leaders as we rapidly approach peak infection in Maryland.

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On any given night, at least 5,200 Marylanders live in emergency and transitional shelters. Last week a small cluster of positive test results in a local substance use disorder treatment program operated by nonprofit The Baltimore Station prompted the Mayor’s Office of Homeless Services, the Baltimore City Health Department and Health Care for the Homeless to take quick action in partnership with The Baltimore Station’s leadership. On Friday, 56 remaining residents were moved to isolation, where they were all tested for coronavirus — a response developed and implemented in less than 24 hours.

The results are concerning. Thirty residents, more than half of those tested, were positive for COVID-19. More troubling, only one was symptomatic at the time of testing. We don’t know if those without symptoms will become sick over the next couple of weeks. We also don’t know how many the virus will reach through silent spread or who may become seriously ill. Nonetheless, these results demonstrate the speed with which the virus can travel in “congregate settings,” where people live or gather closely together, among those who do not display symptoms.

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Similar results have been found at shelters nationally. More than half the residents and staff members of the largest shelter in San Francisco tested positive for the virus last week. In Boston, the Health Care for the Homeless program and state health officials tested everyone in a 400-person shelter; 146 residents tested positive without displaying symptoms. The consistent discovery of asymptomatic spread demands widespread testing in congregate settings — including nursing homes, prisons and homeless shelters — in Maryland and across the country.

Beyond the findings themselves, three factors should guide our efforts to contain the spread in these settings. First is the necessity of swift response by shelter leadership. In this instance, The Baltimore Station adopted a “shelter in place” posture — restricting movement in and out of the facility — on April 7, before the first resident displayed symptoms and was tested and isolated on April 13. As others showed symptoms, they quickly triggered testing and isolation through emergency rooms and health care providers.

Second is the impact of strong cross-sector collaboration of public and private systems. Over the past five weeks, Baltimore City has proactively moved more than 150 people over the age of 62 with chronic conditions to isolation motels. They de-concentrated the largest shelters by moving people to temporary facilities. And they established symptom screening, testing and isolation protocol with area shelters, hospital emergency rooms and Health Care for the Homeless. The city has also mobilized staff necessary to support vulnerable people who are isolating in private rooms and awaiting test results. This emerging response system has helped to identify areas of concern and guide collective action.

But here’s the third and most concerning factor: Try as we might, local public and private agencies, health care providers and shelter operators are treading water with limited staff and diminishing supplies. The number of cases among people experiencing homelessness will increase and overwhelm the local capacity to effectively respond. We see the wave cresting, and we know it will overcome us.

The documented reality of widespread asymptomatic spread of coronavirus in congregate facilities requires increased surveillance, rapid testing and appropriate isolation in homeless shelters throughout Maryland, not in weeks or months, but in hours and days. Unchecked spread in shelters will send medically vulnerable people to hospitals and emergency rooms at the exact same time that we reach peak spread. State “manage in place” teams will help. But localities like Baltimore City need additional state and federal support — financially, but even more importantly in the form of “boots on the ground” staffing and critical supplies, like testing kits and personal protective equipment.

Homelessness was already a public health emergency. COVID-19 illuminates the role of housing in promoting public health. After all, who can “stay at home” and “social distance” without a home or privacy? When this crisis is behind us, we must advance public policy discussions about the fundamental rights to housing and health care. But in the meantime, we must act now. People experiencing homelessness are members of our community, and their risk is our risk.

Kevin Lindamood (klindamood@hchmd.org) is president and CEO of Health Care for the Homeless and Dr. Adrienne Trustman (atrustman@hchmd.org) is chief medical officer.

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