Mortality by Age, Gender, and Race and Ethnicity in People Experiencing Homelessness in Boston, Massachusetts.

Importance: People experiencing homelessness (PEH) face disproportionately high mortality rates compared with the general population, but few studies have examined mortality in this population by age, gender, and race and ethnicity. Objective: To evaluate all-cause and cause-specific mortality in a large cohort of PEH by age, gender, and race and ethnicity. Design, Setting, and Participants: An observational cohort study was conducted from January 1, 2003, to December 31, 2018. All analyses were performed between March 16, 2021, and May 12, 2022. A cohort of adults (age ≥18 years) seen at the Boston Health Care for the Homeless Program (BHCHP), a large federally funded Health Care for the Homeless organization in Boston, Massachusetts, from January 1, 2003, to December 31, 2017, was linked to Massachusetts death occurrence files spanning January 1, 2003, to December 31, 2018. Main Outcomes and Measures: Age-, gender-, and race and ethnicity-stratified all-cause and cause-specific mortality rates were examined and compared with rates in the urban Northeast US population using mortality rate ratios (RRs). Results: Among the 60 092 adults included in the cohort with a median follow-up of 8.6 (IQR, 5.1-12.5) years, 7130 deaths occurred. The mean (SD) age at death was 53.7 (13.1) years; 77.5% of decedents were men, 21.0% Black, 10.0% Hispanic/Latinx, and 61.5% White. The all-cause mortality rate was 1639.7 deaths per 100 000 person-years among men and 830 deaths per 100 000 person-years among women. The all-cause mortality rate was highest among White men aged 65 to 79 years (4245.4 deaths per 100 000 person-years). Drug overdose was a leading cause of death across age, gender, and race and ethnicity groups, while suicide uniquely affected young PEH and HIV infection and homicide uniquely affected Black and Hispanic/Latinx PEH. Conclusions and Relevance: In this large cohort study of PEH, all-cause and cause-specific mortality varied by age, gender, and race and ethnicity. Tailored interventions focusing on those at elevated risk for certain causes of death are essential for reducing mortality disparities across homeless-experienced groups.

Developing a Women's Health track within addiction medicine fellowship: reflections and inspirations.

BACKGROUND: Women who use drugs face sexism and intersectional stigma that influence their drug use experiences and treatment needs. There is a need to build the capacity of addiction medicine specialists who can deliver gender-responsive services and advance research and policy in women-focused addiction care. We describe the development of a Women's Health track within an addiction medicine fellowship program and reflect on successes, challenges, and future directions. MAIN BODY: The Women's Health track was developed in collaboration between program leaders in Addiction Medicine and Obstetrics/Gynecology. Implementing the track led to the development of women-focused rotations and continuity clinics, as well as enrichment of women's health didactic education for all fellows. The fellowship track spurred interdepartmental mentorship and collaboration on research and advocacy projects. CONCLUSION: Addiction medicine fellowships can replicate this curriculum model to advance women-focused education, research, and policy. Future curricula should focus on structural sexism in drug use and addiction treatment throughout a woman's life course.

Awareness, Utilization, and Preferences of Harm Reduction Interventions among Street-Involved Young Adults in Boston.

OBJECTIVES: This study explores knowledge and utilization of, barriers to, and preferences for harm reduction services among street-involved young adults (YA) in Boston, Massachusetts. METHODS: This cross-sectional survey of YA encountered between November and December 2019 by a longstanding outreach program for street-involved YA. We report descriptive statistics on participant-reported substance use, knowledge and utilization of harm reduction strategies, barriers to harm reduction services and treatment, and preferences for harm reduction service delivery. RESULTS: The 52 YA surveyed were on average 21.4 years old; 63.5% were male, and 44.2% were Black. Participants reported high past-week marijuana (80.8%) and alcohol (51.9%) use, and 15.4% endorsed opioid use and using needles to inject drugs in the past six months. Fifteen (28.8%) YA had heard of "harm reduction", and 17.3% reported participating in harm reduction services. The most common barriers to substance use disorder treatment were waitlists and cost. Participants suggested that harm reduction programs offer peer support (59.6%) and provide a variety of services including pre-exposure prophylaxis (42.3%) and sexually transmitted infection testing (61.5%) at flexible times and in different languages, including Spanish (61.5%) and Portuguese (17.3%). CONCLUSIONS: There is need for comprehensive, YA-oriented harm reduction outreach geared toward marginalized YA and developed with YA input to reduce barriers, address gaps in awareness and knowledge of harm reduction, and make programs more relevant and inviting to YA.

Drug Overdose Mortality Among People Experiencing Homelessness, 2003 to 2018.

Importance: Despite high rates of drug overdose death among people experiencing homelessness, patterns in drug overdose mortality, including the types of drugs implicated in overdose deaths, remain understudied in this population. Objective: To describe the patterns in drug overdose mortality among a large cohort of people experiencing homelessness in Boston vs the general adult population of Massachusetts and to evaluate the types of drugs implicated in overdose deaths over a continuous 16-year period of observation. Design, Setting, and Participants: This cohort study analyzed adults aged 18 years or older who received care at Boston Health Care for the Homeless Program (BHCHP) between January 1, 2003, and December 31, 2017. Individuals were followed up from the date of their initial BHCHP encounter during the study period until the date of death or December 31, 2018. Data were analyzed from December 1, 2020, to June 6, 2021. Main Outcomes and Measures: Drug overdose deaths and the types of drugs involved in each overdose death were ascertained by linking the BHCHP cohort to the Massachusetts Department of Public Health death records. Results: In this cohort of 60 092 adults experiencing homelessness (mean [SD] age at entry, 40.4 [13.1] years; 38 084 men [63.4%]), 7130 individuals died by the end of the study period. A total of 1727 individuals (24.2%) died of a drug overdose. Of the drug overdose decedents, 456 were female (26.4%), 194 were Black (11.2%), 202 were Latinx (11.7%), and 1185 were White (68.6%) individuals, and the mean (SD) age at death was 43.7 (10.8) years. The age- and sex-standardized drug overdose mortality rate in the BHCHP cohort was 278.9 (95% CI, 266.1-292.3) deaths per 100 000 person-years, which was 12 times higher than the Massachusetts adult population. Opioids were involved in 91.0% of all drug overdose deaths. Between 2013 and 2018, the synthetic opioid mortality rate increased from 21.6 to 327.0 deaths per 100 000 person-years. Between 2004 and 2018, the opioid-only overdose mortality rate decreased from 117.2 to 102.4 deaths per 100 000 person-years, whereas the opioid-involved polysubstance mortality rate increased from 44.0 to 237.8 deaths per 100 000 person-years. Among opioid-involved polysubstance overdose deaths, cocaine-plus-opioid was the most common substance combination implicated throughout the study period, with Black individuals having the highest proportion of cocaine-plus-opioid involvement in death (0.72 vs 0.62 in Latinx and 0.53 in White individuals; P < .001). Conclusions and Relevance: In this cohort study of people experiencing homelessness, drug overdose accounted for 1 in 4 deaths, with synthetic opioid and polysubstance involvement becoming predominant contributors to mortality in recent years. These findings emphasize the importance of increasing access to evidence-based opioid overdose prevention strategies and opioid use disorder treatment among people experiencing homelessness, while highlighting the need to address both intentional and unintentional polysubstance use in this population.

Experience with a Mobile Addiction Program among People Experiencing Homelessness.

A mobile addiction-focused outreach program designed to improve access to care for people experiencing homelessness was implemented in response to the opioid overdose crisis. This innovative program was readily accepted among participants and can inform the development of similar programs delivering addiction-focused care to people experiencing homelessness elsewhere.

Harm Reduction for Adolescents and Young Adults During the COVID-19 Pandemic: A Case Study of Community Care in Reach.

The coronavirus disease 2019 (COVID-19) pandemic has challenged the ability of harm reduction programs to provide vital services to adolescents, young adults, and people who use drugs, thereby increasing the risk of overdose, infection, withdrawal, and other complications of drug use. To evaluate the effect of the COVID-19 pandemic on harm reduction services for adolescents and young adults in Boston, we conducted a quantitative assessment of the Community Care in Reach (CCIR) youth pilot program to determine gaps in services created by its closure during the peak of the pandemic (March 19-June 21, 2020). We also conducted semistructured interviews with staff members at 6 harm reduction programs in Boston from April 27 through May 4, 2020, to identify gaps in harm reduction services, changes in substance use practices and patterns of engagement with people who use drugs, and how harm reduction programs adapted to pandemic conditions. During the pandemic, harm reduction programs struggled to maintain staffing, supplies, infection control measures, and regular connection with their participants. During the 3-month suspension of CCIR mobile van services, CCIR missed an estimated 363 contacts, 169 units of naloxone distributed, and 402 syringes distributed. Based on our findings, we propose the following recommendations for sustaining harm reduction services during times of crisis: pursuing high-level policy changes to eliminate political barriers to care and fund harm reduction efforts; enabling and empowering harm reduction programs to innovatively and safely distribute vital resources and build community during a crisis; and providing comprehensive support to people to minimize drug-related harms.

Office-Based Addiction Treatment Retention and Mortality Among People Experiencing Homelessness.

Importance: People experiencing homelessness have been disproportionately affected by the opioid overdose crisis. To mitigate morbidity and mortality, several office-based addiction treatment (OBAT) programs designed for this population have been established across the US, but studies have not yet evaluated their outcomes. Objective: To evaluate treatment retention and mortality in an OBAT program designed specifically for individuals experiencing homelessness with opioid use disorder (OUD). Design, Setting, and Participants: A retrospective cohort study was conducted in the Boston Health Care for the Homeless Program (BHCHP). Participants included all adult patients (N = 1467) who had 1 or more OBAT program encounter at BHCHP from January 1 through December 31, 2018. Data analysis was conducted from January 13 to December 14, 2020. Exposures: Sociodemographic, clinical, and addiction treatment-related characteristics were abstracted from the BHCHP electronic health record. Main Outcomes and Measures: The primary outcome was all-cause mortality, identified by linkage to the Massachusetts Department of Public Health vital records. Multivariable Cox proportional hazards regression analyses were performed to evaluate baseline and time-varying variables associated with all-cause mortality. Secondary addiction treatment-related outcomes were abstracted from the electronic health record and included (1) BHCHP OBAT program retention, (2) buprenorphine continuation and adherence verified by toxicology testing, and (3) opioid abstinence verified by toxicology testing. Results: Of 1467 patients in the cohort, 1046 were men (71.3%) and 731 (49.8%) were non-Hispanic White; mean (SD) age was 42.2 (10.6) years. Continuous retention in the OBAT program was 45.2% at 1 month, 21.7% at 6 months, and 11.3% at 12 months. Continuous buprenorphine adherence was 41.5% at 1 month, 17.6% at 6 months, and 10.2% at 12 months, and continuous opioid abstinence was 28.3% at 1 month, 6.1% at 6 months, and 2.9% at 12 months. The all-cause mortality rate was 29.0 deaths per 1000 person-years, with 51.8% dying from drug overdose. Past-month OBAT program attendance was associated with lower mortality risk (adjusted hazard ratio, 0.34; 95% CI, 0.21-0.55). Conclusions and Relevance: Mortality rates were high in this cohort of addiction treatment-seeking homeless and unstably housed individuals with OUD. Although continuous OBAT program retention was low, past-month attendance in care was associated with reduced mortality risk. Future work should examine interventions to promote increased OBAT attendance to mitigate morbidity and mortality in this vulnerable population.

Substance consumption and intoxication patterns in a medically supervised overdose prevention program for people experiencing homelessness.

Background: Opioid overdose is a leading cause of death among homeless individuals. Combining psychoactive substances with opioids increases overdose risk. This study aimed to describe intoxication patterns at a drop-in space offering medical monitoring and harm reduction services to individuals who arrive intoxicated and at risk of overdose. Methods: We examined data from visits to the Supportive Place for Observation and Treatment at Boston Health Care for the Homeless Program between January 1, 2017 and December 31, 2017. We used k-means cluster analysis to characterize intoxication patterns based on clinically assessed sedation levels and vital sign parameters. Multinomial logistic regression analysis assessed demographic and substance consumption predictors of cluster membership. Linear and logistic regression models examined associations between cluster membership and care outcomes. Results: Across 305 care episodes involving 156 unique patients, cluster analysis revealed 3 distinct intoxication patterns. Cluster A (26.6%) had mild sedation and normal vital signs. Cluster B (44.5%) featured greater sedation with bradycardia and/or hypotension. Cluster C (28.9%) was comparable to cluster B but with the addition of hypoxia. Self-reported consumption of non-opioid sedatives prior to arrival was common (63.3% of episodes) and predicted membership in cluster B (aOR 2.75, 95% CI 1.40, 5.40) and cluster C (aOR 3.38, 95% CI 1.48, 7.70). In comparison to cluster A episodes, cluster C episodes were longer (mean 4.8 vs. 2.3 hours, p < 0.001) and more likely to require supplemental oxygen (27.3% vs. 2.5%, p < 0.001). Few episodes required hospital transfer (4.7%) or naloxone (1.0%). No deaths occurred. Conclusions: In a medically supervised overdose monitoring program, reported use of non-opioid sedatives strongly predicted more complex clinical courses and should be factored into overdose prevention efforts. Low-threshold medical monitoring in an ambulatory setting was sufficient for most episodes, suggesting a role for such programs in reducing harm and averting costly emergency services.

Principles of Harm Reduction for Young People Who Use Drugs.

In summarizing the proceedings of a longitudinal meeting of experts on substance use disorders among adolescents and young adults, we review 2 principles of care related to harm reduction for young adults with substance use disorders. The first is that harm reduction services are critical to keeping young adults alive and healthy and can offer opportunities for future engagement in treatment. Such services therefore should be offered at every opportunity, regardless of an individual's interest or ability to minimize use of substances. The second is that all evidence-based harm reduction strategies available to older adults should be available to young adults and that whenever possible, harm reduction programs should be tailored to young adults and be developmentally appropriate.

"That's what we call the cocktail": Non-Opioid medication and supplement misuse among opioid users.

BACKGROUND: Recent evidence suggests that the practice of combining opioid use with non-opioid substances is common, though little is known about this phenomenon and how best to address it. Methods: We recruited adults in Boston, Massachusetts, with recent opioid use. We conducted semi-structured interviews to explore the practice of combining non-opioid substances with opioids and analyzed transcripts to identify themes. Results: Twenty-nine individuals completed interviews. Combining other substances with opioids was a well-known practice: "that's what we call the cocktail." Participants reported the use of clonidine, gabapentin, benzodiazepines, promethazine, amphetamine salts, quetiapine, barbiturates, cough and cold medications, as well as alcohol and candy in combination with opioids. Participants reported purchasing these substances on the street, stealing them, or getting them from a prescriber. Augmenting the opioid high was a common reason for combining substances. Importantly, participants also reported combining substances to treat psychiatric symptoms. Individuals commonly reported learning about combining substances "from people on the street" but also reported learning from the internet and television. Perceived benefits outweighed safety concerns. Participants also felt that using over-the-counter or prescription medications would be safe. Conclusions: Combining a variety of substances with opioids is common and driven by diverse motives. Clinicians caring for opioid-involved patients should consider screening for concurrent use of other substances and discussing the risks of this practice.

Phylogenetic analysis of SARS-CoV-2 in Boston highlights the impact of superspreading events.

Analysis of 772 complete severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genomes from early in the Boston-area epidemic revealed numerous introductions of the virus, a small number of which led to most cases. The data revealed two superspreading events. One, in a skilled nursing facility, led to rapid transmission and significant mortality in this vulnerable population but little broader spread, whereas other introductions into the facility had little effect. The second, at an international business conference, produced sustained community transmission and was exported, resulting in extensive regional, national, and international spread. The two events also differed substantially in the genetic variation they generated, suggesting varying transmission dynamics in superspreading events. Our results show how genomic epidemiology can help to understand the link between individual clusters and wider community spread.

Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for Adults Experiencing Sheltered Homelessness During the COVID-19 Pandemic.

Importance: Approximately 356 000 people stay in homeless shelters nightly in the United States. They have high risk of contracting coronavirus disease 2019 (COVID-19). Objective: To assess the estimated clinical outcomes, costs, and cost-effectiveness associated with strategies for COVID-19 management among adults experiencing sheltered homelessness. Design, Setting, and Participants: This decision analytic model used a simulated cohort of 2258 adults residing in homeless shelters in Boston, Massachusetts. Cohort characteristics and costs were adapted from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were taken from published literature and national databases. Surging, growing, and slowing epidemics (effective reproduction numbers [Re], 2.6, 1.3, and 0.9, respectively) were examined. Costs were from a health care sector perspective, and the time horizon was 4 months, from April to August 2020. Exposures: Daily symptom screening with polymerase chain reaction (PCR) testing of individuals with positive symptom screening results, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternative care sites (ACSs) for mild or moderate COVID-19, and temporary housing were each compared with no intervention. Main Outcomes and Measures: Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case of COVID-19 prevented. Results: The simulated population of 2258 sheltered homeless adults had a mean (SD) age of 42.6 (9.04) years. Compared with no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild or moderate disease was associated with 37% fewer infections (1954 vs 1239) and 46% lower costs ($6.10 million vs $3.27 million) at an Re of 2.6, 75% fewer infections (538 vs 137) and 72% lower costs ($1.46 million vs $0.41 million) at an Re of 1.3, and 51% fewer infections (174 vs 85) and 51% lower costs ($0.54 million vs $0.26 million) at an Re of 0.9. Adding PCR testing every 2 weeks was associated with a further decrease in infections; incremental cost per case prevented was $1000 at an Re of 2.6, $27 000 at an Re of 1.3, and $71 000 at an Re of 0.9. Temporary housing with PCR every 2 weeks was most effective but substantially more expensive than other options. Compared with no intervention, temporary housing with PCR every 2 weeks was associated with 81% fewer infections (376) and 542% higher costs ($39.12 million) at an Re of 2.6, 82% fewer infections (95) and 2568% higher costs ($38.97 million) at an Re of 1.3, and 59% fewer infections (71) and 7114% higher costs ($38.94 million) at an Re of 0.9. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission. Conclusions and Relevance: In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in SARS-CoV-2 infections at modest incremental cost and should be considered during future surges.

Community Care in Reach: Mobilizing Harm Reduction and Addiction Treatment Services for Vulnerable Populations.

Opioid overdoses killed 47,600 people in the United States in 2017. Despite increasing availability of office-based addiction treatment programs, the prevalence of opioid overdose is historically high and disproportionately affects vulnerable populations, including people experiencing homelessness. Despite availability of effective treatment, many at greatest risk of death from overdose experience myriad barriers to care. Launched in 2018, the Community Care in Reach mobile health initiative uses a data-driven approach to bring harm reduction and medication for opioid use disorder directly to those at highest risk of near-term death. Proof-of-concept results suggest that mobile addiction services may serve as a model for expanding access to addiction care for the most vulnerable.

Phylogenetic analysis of SARS-CoV-2 in the Boston area highlights the role of recurrent importation and superspreading events.

SARS-CoV-2 has caused a severe, ongoing outbreak of COVID-19 in Massachusetts with 111,070 confirmed cases and 8,433 deaths as of August 1, 2020. To investigate the introduction, spread, and epidemiology of COVID-19 in the Boston area, we sequenced and analyzed 772 complete SARS-CoV-2 genomes from the region, including nearly all confirmed cases within the first week of the epidemic and hundreds of cases from major outbreaks at a conference, a nursing facility, and among homeless shelter guests and staff. The data reveal over 80 introductions into the Boston area, predominantly from elsewhere in the United States and Europe. We studied two superspreading events covered by the data, events that led to very different outcomes because of the timing and populations involved. One produced rapid spread in a vulnerable population but little onward transmission, while the other was a major contributor to sustained community transmission, including outbreaks in homeless populations, and was exported to several other domestic and international sites. The same two events differed significantly in the number of new mutations seen, raising the possibility that SARS-CoV-2 superspreading might encompass disparate transmission dynamics. Our results highlight the failure of measures to prevent importation into MA early in the outbreak, underscore the role of superspreading in amplifying an outbreak in a major urban area, and lay a foundation for contact tracing informed by genetic data.

Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for People Experiencing Sheltered Homelessness During the COVID-19 Pandemic.

IMPORTANCE: Approximately 356,000 people stay in homeless shelters nightly in the US. They are at high risk for COVID-19. OBJECTIVE: To assess clinical outcomes, costs, and cost-effectiveness of strategies for COVID-19 management among sheltered homeless adults. DESIGN: We developed a dynamic microsimulation model of COVID-19 in sheltered homeless adults in Boston, Massachusetts. We used cohort characteristics and costs from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were from published literature and national databases. We examined surging, growing, and slowing epidemics (effective reproduction numbers [Re] 2.6, 1.3, and 0.9). Costs were from a health care sector perspective; time horizon was 4 months, from April to August 2020. SETTING & PARTICIPANTS: Simulated cohort of 2,258 adults residing in homeless shelters in Boston. INTERVENTIONS: We assessed daily symptom screening with polymerase chain reaction (PCR) testing of screen-positives, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternate care sites [ACSs] for mild/moderate COVID-19, and temporary housing, each compared to no intervention. MAIN OUTCOMES AND MEASURES: Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case prevented of COVID-19. RESULTS: We simulated a population of 2,258 sheltered homeless adults with mean age of 42.6 years. Compared to no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild/moderate disease led to 37% fewer infections and 46% lower costs (Re=2.6), 75% fewer infections and 72% lower costs (Re=1.3), and 51% fewer infections and 51% lower costs (Re=0.9). Adding PCR testing every 2 weeks further decreased infections; incremental cost per case prevented was $1,000 (Re=2.6), $27,000 (Re=1.3), and $71,000 (Re=0.9). Temporary housing with PCR every 2 weeks was most effective but substantially more costly than other options. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission. CONCLUSIONS & RELEVANCE: In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer COVID-19 infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in COVID-19 infections at modest incremental cost and should be considered during future surges.

Addressing COVID-19 Among People Experiencing Homelessness: Description, Adaptation, and Early Findings of a Multiagency Response in Boston.

People experiencing homelessness are at high risk for coronavirus disease 2019 (COVID-19). In March 2020, Boston Health Care for the Homeless Program, in partnership with city and state public health agencies, municipal leaders, and homeless service providers, developed and implemented a citywide COVID-19 care model for this vulnerable population. Components included symptom screening at shelter front doors, expedited testing at pop-up sites, isolation and management venues for symptomatic people under investigation and for people with confirmed disease, quarantine venues for asymptomatic exposed people, and contact investigation and tracing. Real-time disease surveillance efforts in a large shelter outbreak of COVID-19 during the third week of operations illustrated the need for several adaptations to the care model to better respond to the local epidemiology of illness among people experiencing homelessness. Symptom screening was de-emphasized given the high number of asymptomatic or minimally symptomatic infections discovered during mass testing; contact tracing and quarantining were phased out under the assumption of universal exposure among the sheltered population; and isolation and management venues were rapidly expanded to accommodate a surge in people with newly diagnosed COVID-19. During the first 6 weeks of operation, 429 of 1297 (33.1%) tested people were positive for COVID-19; of these, 395 people were experiencing homelessness at the time of testing, representing about 10% of the homeless adult population in Boston. Universal testing, as resources permit, is a focal point of ongoing efforts to mitigate the effect of COVID-19 on this vulnerable group of people.

Assessment of SARS-CoV-2 Infection Prevalence in Homeless Shelters - Four U.S. Cities, March 27-April 15, 2020.

In the United States, approximately 1.4 million persons access emergency shelter or transitional housing each year (1). These settings can pose risks for communicable disease spread. In late March and early April 2020, public health teams responded to clusters (two or more cases in the preceding 2 weeks) of coronavirus disease 2019 (COVID-19) in residents and staff members from five homeless shelters in Boston, Massachusetts (one shelter); San Francisco, California (one); and Seattle, Washington (three). The investigations were performed in coordination with academic partners, health care providers, and homeless service providers. Investigations included reverse transcription-polymerase chain reaction testing at commercial and public health laboratories for SARS-CoV-2, the virus that causes COVID-19, over approximately 1-2 weeks for residents and staff members at the five shelters. During the same period, the team in Seattle, Washington, also tested residents and staff members at 12 shelters where a single case in each had been identified. In Atlanta, Georgia, a team proactively tested residents and staff members at two shelters with no known COVID-19 cases in the preceding 2 weeks. In each city, the objective was to test all shelter residents and staff members at each assessed facility, irrespective of symptoms. Persons who tested positive were transported to hospitals or predesignated community isolation areas.