A qualitative assessment of cleaning and hand hygiene practices at shelters serving people experiencing homelessness during the COVID-19 pandemic, Atlanta, GA - May-June, 2020.

BACKGROUND: Cleaning practices and hand hygiene are important behaviors to prevent and control the spread of infectious disease, especially in congregate settings. This project explored hygiene- and cleaning-related experiences in shelters serving people experiencing homelessness (PEH) during May-June 2020 of the COVID-19 pandemic. METHODS: We conducted qualitative, in-depth interviews by phone with 22 staff from six shelters in Atlanta, Georgia. The interview guide included questions about cleaning routines, cleaning barriers and facilitators, cleaning promotion, hand hygiene promotion, and hand hygiene barriers and facilitators. We analyzed interview transcripts using thematic analysis. RESULTS: Multiple individuals, such as shelter individuals (clients), volunteers, and staff, played a role in shelter cleaning. Staff reported engaging in frequent hand hygiene and cleaning practices. Barriers to cleaning included staffing shortages and access to cleaning supplies. Staff reported barriers (e.g., differing perceptions of cleanliness) for clients who were often involved in cleaning activities. Barriers to hand hygiene included limited time to wash hands, forgetting, and inconvenient handwashing facilities. Specific guidance about when and how to clean, and what supplies to use, were requested. CONCLUSION: During the early months of the COVID-19 pandemic, shelters serving PEH in the Atlanta-metro area needed resources and support to ensure sufficient staffing and supplies for cleaning activities. As part of future pandemic planning and outbreak prevention efforts, shelters serving PEH could benefit from specific guidance and training materials on cleaning and hand hygiene practices.

The intersection of health and housing: Analysis of the research portfolios of the National Institutes of Health, Centers for Disease Control and Prevention, and U.S. Department of Housing and Urban Development.

BACKGROUND: Housing is a major social determinant of health that affects health status and outcomes across the lifespan. OBJECTIVES: An interagency portfolio analysis assessed the level of funding invested in "health and housing research" from fiscal years (FY) 2016-2020 across the National Institutes of Health (NIH), the United States Department of Housing and Urban Development (HUD), and the Centers for Disease Control and Prevention (CDC) to characterize the existing health and housing portfolio and identify potential areas for additional research and collaboration. METHODS/RESULTS: We identified NIH, HUD, and CDC research projects that were relevant to both health and housing and characterized them by housing theme, health topic, population, and study design. We organized the assessment of the individual housing themes by four overarching housing-to-health pathways. From FY 2016-2020, NIH, HUD, and CDC funded 565 health and housing projects combined. The Neighborhood pathway was most common, followed by studies of the Safety and Quality pathway. Studies of the Affordability and Stability pathways were least common. Health topics such as substance use, mental health, and cardiovascular disease were most often studied. Most studies were observational (66%); only a little over one fourth (27%) were intervention studies. DISCUSSION: This review of the research grant portfolios of three major federal funders of health and housing research in the United States describes the diversity and substantial investment in research at the intersection between housing and health. Analysis of the combined portfolio points to gaps in studies on causal pathways linking housing to health outcomes. The findings highlight the need for research to better understand the causal pathways from housing to health and prevention intervention research, including rigorous evaluation of housing interventions and policies to improve health and well-being.

Previous Health Care Experiences' Influence on Health Care Perceptions Among Residents of Six Homeless Shelters in Seattle, Washington, July-October 2021.

Purpose: The study purpose was to learn and describe 1) where homeless shelter residents receive health care, 2) what contributes to positive or negative health care experiences among shelter residents, and 3) shelter resident perceptions toward health care. Methods: Semi-structured interviews (SSIs) utilizing purposive sampling and focus group discussions (FGDs) utilizing convenience sampling were conducted at 6 homeless shelters in Seattle-King County, Washington, during July-October 2021. All residents (age ≥18) were eligible to participate. SSIs were conducted with 25 residents, and 8 FGDs were held. Thematic analysis was conducted using Dedoose. Results: Participants received health care in settings ranging from no regular care to primary care providers. Four elements emerged as contributing positively and negatively to health care experiences: 1) ability to access health care financially, physically, and technologically; 2) clarity of communication from providers and staff about appointment logistics, diagnoses, and treatment options; 3) ease of securing timely follow-up services; and 4) respect versus stigma and discrimination from providers and staff. Participants who felt positively toward health care found low- or no-cost care to be widely available and encouraged others to seek care. However, some participants described health care in the United States as greedy, classist, discriminatory, and untrustworthy. Participants reported delaying care and self-medicating in anticipation of discrimination. Conclusions: Findings demonstrate that while people experiencing homelessness can have positive experiences with health care, many have faced negative interactions with health systems. Improving the patient experience for those experiencing homelessness can increase engagement and improve health outcomes.

Trends and factors associated with change in COVID-19 vaccination intent among residents and staff in six Seattle homeless shelters, March 2020 to August 2021.

Introduction: Achieving high COVID-19 vaccination coverage in homeless shelters is critical in preventing morbidity, mortality, and outbreaks, however, vaccination coverage remains lower among people experiencing homelessness (PEH) than the general population. Methods: We conducted a cross-sectional study to retrospectively describe attitudes and identify factors associated with change in COVID-19 vaccination intent among shelter residents and staff during March 2020 - August 2021. To identify factors associated with change in COVID-19 vaccine intent becoming more positive overall compared to other attitudes, we utilized a Poisson model to calculate Risk Ratios with robust standard errors, adjusting for confounding by shelter site and demographic variables determined a priori. Results: From July 12 - August 2, 2021, 97 residents and 20 staff participated in surveys across six shelters in Seattle King County, Washington. Intent to be vaccinated against COVID-19 increased from 45.3 % (n = 53) when recalling attitudes in March 2020 to 74.4 % (n = 87) as of August 2021, and was similar among residents and staff. Many participants (43.6 %, n = 51) indicated feeling increasingly accepting about receiving a COVID-19 vaccine since March 2020, while 13.7 % (n = 16) changed back and forth, 10.3 % (n = 12) became more hesitant, and 32.5 % (n = 38) had no change in intent. In the model examining the relationship between becoming more positive about receiving a COVID-19 vaccine compared to all other attitudes (n = 116), we found a 57.2 % increase in vaccine acceptability (RR 1.57; 95 % CI: 1.01, 2.45) among those who reported worsening mental health since the start of the pandemic. Conclusions: Findings highlight opportunities to improve communication with residents and staff about COVID-19 vaccination and support a need for continued dialogue and a person-centered approach to understanding the sociocultural complexities and dynamism of vaccine attitudes at shelters.Clinical Trial Registry Number: NCT04141917.

Health-related economic benefits of universal access to piped water in Arctic communities: Estimates for the Yukon-Kuskokwim Delta region of Alaska.

This paper presents estimates of the potential health-related economic benefits of providing universal access to in-home water and sanitation services to households in rural Alaska. In particular, we use data on disease incidence rates, health care costs, and local estimates of the impact of piped water on disease reduction to estimate the potential health-related economic benefits of providing universal access to piped water in the Yukon Kuskokwim (Y.K.) Delta region of Alaska. We include estimates of avoided treatment and diagnosis costs as well as private benefits associated with reduced morbidity and mortality associated with improved access to in-home piped water. To our knowledge, these are the first estimates of the economic benefits of improved access to water and sanitation in rural Alaska and the Arctic. Our analysis suggests increased access to in-home piped water in the region may yield substantial reductions in direct medical expenses incurred by public agencies and families, as well as reductions in time and travel costs associated with improved health outcomes. These benefits, along with the array of health and non-health-related benefits not included in our analysis, may provide new impetus to expanding access to high-quality water and sanitation services in the region.

Assessment of contact tracing for COVID-19 among people experiencing homelessness, Salt Lake County Health Department, March-May 2020.

PURPOSE: Contact tracing is intended to reduce the spread of coronavirus disease 2019 (COVID-19), but it is difficult to conduct among people who live in congregate settings, including people experiencing homelessness (PEH). This analysis compares person-based contact tracing among two populations in Salt Lake County, Utah, from March-May 2020. METHODS: All laboratory-confirmed positive cases among PEH (n = 169) and documented in Utah's surveillance system were included in this analysis. The general population comparison group (n = 163) were systematically selected from all laboratory-confirmed cases identified during the same period. RESULTS: Ninety-three PEH cases (55%) were interviewed compared to 163 (100%) cases among the general population (P < .0001). PEH were more likely to be lost to follow-up at end of isolation (14.2%) versus the general population (0%; P-value < .0001) and provided fewer contacts per case (0.3) than the general population (4.7) (P-value < .0001). Contacts of PEH were more often unreachable (13.0% vs. 7.1%; P-value < .0001). CONCLUSIONS: These findings suggest that contact tracing among PEH should include a location-based approach, along with a person-based approach when resources allow, due to challenges in identifying, locating, and reaching cases among PEH and their contacts through person-based contact tracing efforts alone.

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.

Care-seeking and appropriate treatment for childhood acute respiratory illness: an analysis of Demographic and Health Survey and Multiple Indicators Cluster Survey datasets for high-mortality countries.

BACKGROUND: Acute lower respiratory illness (ALRI) is a major global cause of morbidity and mortality among children under 5. Antibiotic treatment for ALRI is inexpensive and decreases case fatality, but care-seeking patterns and appropriate treatment vary widely across countries. This study sought to examine patterns of appropriate treatment and estimate the burden of cases of untreated ALRI in high mortality countries. METHODS: This study used cross-sectional survey data from the Phase 5/Phase 6 DHS and MIC3/MICS4 for 39 countries. We analyzed care-seeking patterns and antibiotic treatment based on country-level trends, and estimated the burden of untreated cases using country-level predictors in a general linear model. RESULTS: According to this analysis, over 66 million children were not treated with antibiotics for ALRI in 2010. Overall, African countries had a lower proportion of mothers who sought care for a recent episode of ALRI (41% to 86%) relative to Asian countries (75% to 87%). Seeking any care for ALRI was inversely related to seeking public sector care. Treatment with antibiotics ranged from 8% in Nepal to 87% in Jordan, and was significantly associated with urban residence. CONCLUSIONS: Untreated ALRI remains a substantial problem in high mortality countries. In Asia, the large population numbers lead to a high burden of children with untreated ALRI. In Africa, care-seeking behaviors and access to care issues may lead to missed opportunities to treat children with antibiotics.