Border detention facilities, prisons and refugee camps have something in common with communal homeless shelters, University of Washington School of Medicine researchers say.
They’re home to “closed, crowded conditions where people have to live in small spaces and share a lot of common facilities,” said Dr. Helen Y. Chu, associate professor at the UW School of Medicine. Researchers from her lab have spent the last four months routinely testing residents of King County homeless shelters for COVID-19.
An analysis of those four months of testing was published Tuesday in the Annals of Internal Medicine. Researchers found that of the 1,434 homeless shelter residents tested for COVID-19 across 14 shelters, 29 turned up positive. Twenty-one had no symptoms when they were tested, and 24 of them had slept in a communal shelter in the prior week, as opposed to a private or family room.
The findings, particularly those showing the degree of asymptomatic spread, highlight how important it is to create safer conditions for people in crowded settings and to test vulnerable people regularly outside of the clinic, researchers say.
Chu and the researchers, as part of the Seattle Flu Study, already had a presence in some shelters before the pandemic broke out. When it did, the researchers got to work offering regular COVID-19 testing in shelters as well as “surge testing” of as many shelter residents as they could when a positive case was discovered.
The viral load for asymptomatic cases wasn’t any different from that of symptomatic cases, Chu said, showing that asymptomatic people had enough of the virus to spread it to others.
“In the homeless population, where a lot of people are chronically ill, it’s also very challenging to figure out when somebody has a new symptoms,” Chu said. “So if you have lung disease and you’re always coughing, what is a new cough?”
What the researchers learned can be applied to detention facilities, prisons and more, according to Chu.
Infectious disease experts worried early in the pandemic that people living homeless might be particularly vulnerable to the spread of COVID-19 in shelter settings. Many feared that people in homeless shelters, like those in nursing homes, might also be more severely affected if they contracted the disease, given the aging shelter population and high prevalence of chronic illness.
But in King County, the researchers found far fewer cases than they had feared.
“I think those are reflective of the fact that Seattle in general had controlled the pandemic very early and that community transmission was just low,” Chu said. “And I think probably this strategy of rapid identification and testing of the entire shelter probably also helped control.”
Daniel Malone, executive director of the Downtown Emergency Service Center, which collaborated with the researchers, said that if his organization hadn’t moved people out of crowded communal shelters into Exhibition Hall at Seattle Center and individual rooms at Renton’s Red Lion Hotel, he would have expected a much bigger outbreak.
“If memory serves, literally the day we were moving we found out about a case in that shelter, and then we did some broad-scale testing and haven’t yet had a bigger outbreak,” Malone said. “I do not think that would have been the case if we had remained in that congregate setting.”
The question for political leaders, homeless service providers and researchers going forward is whether the system will ever return to what it once looked like, with much of the shelter space consisting of mats crowded together on floors.
“Is there still the will to keep homeless people housed in a less crowded way?” Chu asked.
“We have empty office buildings but then people crowded in these shelters,” Chu said. “There must be a way to sort of to come to a better solution than the one we have now.”
The other takeaway from researchers’ work was the importance of testing people where they are, and not necessarily in a clinical setting.
“A lot of studies now have shown that homeless people are not necessarily going to receive the same level of care as non-homeless people” in emergency rooms or clinical settings, Chu said. “That also sort of ties to sort of the racial inequity that we see where homeless people are disproportionately people of color.”
Many of the people tested at the shelters didn’t want to go to a clinic for a test or care, Chu said. But making the testing accessible at the shelter helped capture the spread of the illness.
The researchers will continue to test in homeless shelters through 2021.