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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


November 22, 2021


TO:
Local Public Health Department Staff, Shelter Operators, Others

SUBJECT:
Infection Control Guidance for Clients in Congregate Shelters, Including Shelters for People Experiencing Homelessness



People experiencing homelessness and other clients in congregate shelters who are not fully vaccinated* may be at especially high risk for COVID-19 infection and complications from it, especially those who come into close contact with others, or who are older or have chronic medical conditions. Homeless shelters, warming shelters and cooling shelters, and other shelters where individuals have close contact with one another indoors (congregate shelters) are especially vulnerable to outbreaks of COVID-19.

Local public health department staff responding to suspected or confirmed cases of COVID-19 in congregate shelters should implement recommended physical distancing and required masking measures, increase ventilation to the extent possible, and vaccinate willing clients and staff to reduce the risk of transmission.

The following recommendations are intended to assist congregate shelter operators to mitigate the risk from COVID-19 infection for clients and visitors. When possible, the use of alternative housing sites or non-congregate settings such as a Project Roomkey site should be prioritized in lieu of congregate shelters. Please see the November 3, 2021 CDC guidance for detailed information: Interim Guidance for Homeless Service Providers to Plan and Respond to Coronavirus Disease 2019 (COVID-19).

To mitigate the risk of COVID-19 for employees, employers are subject to the State Public Health Officer Order for Health Care Workers in High-Risk Settings. Employers subject to the Cal/OSHA COVID-19 Prevention Emergency Temporary Standards (ETS) must comply with those requirements. In some workplaces the Cal/OSHA Aerosol Transmissible Diseases (ATD) Standard (PDF) is also applicable. Facilities should follow the CDPH and Local Health Jurisdiction recommendations where they may exceed the Cal/OSHA standards.

Planning

  • Encourage all staff, volunteers and clients of congregate shelters to be vaccinated. See Interim Guidance for Health Departments: COVID-19 Vaccination Implementation for People Experiencing Homelessness for more information. At this time, children age 5 and older are eligible for COVID-19 vaccination.
  • Recipients of Pfizer and Moderna vaccines are recommended to receive a booster dose at least six months after completion of the initial vaccine series. Recipients of J&J vaccine are recommended to receive a booster dose of J&J, Pfizer or Moderna vaccine at least two months after vaccination.
  • Post signs at entrances and in strategic places providing instruction on hand hygienecough etiquette (PDF), required mask wearing, and physical distancing.
  • Minimize the number of unvaccinated staff members and volunteers who have face-to-face interactions with clients with respiratory symptoms or who are in isolation for COVID-19 infection.
  • Put in place plans on how to maintain physical distancing (remaining 3-6 feet apart) between all clients and staff/volunteers, regardless of vaccination status, while still providing necessary services.
  • Per CDPH Guidance Use of Face Coverings Guidance, universal masking is required of all clients and staff/volunteers, regardless of vaccination status. The shelter should ensure that a supply of masks is available to distribute to anyone who arrives without one. Surgical masks or respirators are strongly recommended for this setting.
  • Shelters should ensure that unvaccinated workers comply with the additional masking requirements in the State Public Health Officer Order for Health Care Workers in High-Risk Settings.
  • Staff and volunteers who do not interact closely (within 6 feet) with sick or isolated clients and do not clean client environments do not need to wear personal protective equipment (PPE) aside from complying with masking requirements.
  • All shelters should have plans for isolation and quarantine areas. In general, there should be a plan for non-congregate housing off-site (e.g., isolation in a designated hotel).

Prioritization of non-congregate housing for clients

Non-congregate housing resources, such as Project Roomkey, are recommended and should be prioritized for:

  • Those who test positive for COVID-19 (regardless of vaccination status), for isolation.
  • Those who are not vaccinated and are exposed to COVID-19, for quarantine.
  • Those who are at high-risk for severe COVID-19 infection or medical complications should they become infected, such as people over 65 or those who have underlying health conditions that increase the risk of severe COVID-19 infection.
  • Families with children.

COVID-19 vaccination verification

  • Consistent with the State Public Health Officer Order, shelter operators must assess the COVID-19 vaccination status of all staff/volunteers. It is permissible to ask staff and volunteers to provide information about their vaccination status. The Order also requires that unvaccinated staff and volunteers in high-risk congregate settings undergo diagnostic screening testing at least weekly.
  • When feasible, shelter operators should assess the COVID-19 vaccination status of all clients and assist them with initiating or completing COVID-19 vaccination and boosters, if recommended. Shelters should not decline entry to clients based on vaccination status.
  • Shelter operators may enroll in the California Immunization Registry (CAIR) to confirm client COVID-19 vaccination status. To apply for access, go to: CAIR Enrollment Website.
  • Per the CDPH Guidance for Vaccine Records Guidelines & Standards, the following information can be used as proof of vaccination:
    • vaccination card (which includes name of person vaccinated, type of vaccine provided, and date last dose administered); OR
    • a photo of a vaccination card as a separate document; OR
    • a photo of the attendee's vaccine card stored on a phone or electronic device; OR
    • documentation of vaccination from a healthcare provider; OR
    • digital record that includes a QR code that when scanned by a SMART Health Card reader displays to the reader client name, date of birth, vaccine dates and vaccine type (the QR code must also confirm the vaccine record as an official record of the state of California); OR
    • documentation in CAIR.

Clients who are children who are too young to be vaccinated

  • Children less than age 5 are not currently eligible for COVID-19 vaccination.
  • Children who are not fully vaccinated* should be treated as any other unvaccinated client except that they may be sheltered with other household members during their isolation or quarantine periods (see Prioritization of Non-Congregate Housing for Clients).

Sleeping areas

  • When community transmission is substantial or high, mats/cots/beds (for those not experiencing respiratory symptoms), should be arranged so that clients lie head-to-toe relative to each other, and ensure that client faces are at least 6 feet apart from each other. This distance may be reduced to no less than 3 feet when community transmission is moderate or low.
  • For clients with symptoms consistent with COVID-19, testing should be conducted as soon as possible, and such clients should be isolated until test results are known. If such clients cannot be placed in individual rooms, ensure physical distancing and that mats/beds are at least 6 feet apart.
  • Move all staff desks so they are at least 6 feet from sleeping areas. This distance may be reduced to no less than 3 feet when community transmission is moderate or low.
  • No physical distancing is required between members of the same household, regardless of COVID-19 vaccination status.
  • If COVID-19 vaccination status is verified, physical distancing is encouraged but not required for those who are verified as being fully vaccinated*.
  • All staff and clients must wear masks in congregate settings including shelters regardless of COVID-19 vaccination status.
  • Use of top bunks is allowed for members of the same household as the person in the lower bunk or those who are verified as being fully vaccinated.*

Common areas

  • Encourage dining and other group activities to take place outdoors as much as possible; this is especially true for dining since masks must be removed for eating or drinking.
  • Rearrange seating in shared indoor dining areas so that there is at least 6 feet between individuals (e.g., remove every other chair and use only one side of the table) when community transmission is substantial or high.
  • Members of the same household can sit together indoors without distancing but should remain 6 feet from other individuals when community transmission is substantial or high.
  • Eliminate non-essential group indoor activities; if such activities are conducted, ask clients and staff to remain at least 6 feet apart from one another when community transmission is substantial or high.
  • Deliver food or stagger mealtimes to reduce crowding in shared dining areas.
  • Stagger the schedule for use of common areas such as kitchens, living spaces, and recreation areas.
  • Create a staggered bathing schedule to reduce the number of people using the facilities at the same time.
  • Educate clients and staff on basic infection control measures for respiratory infections, including hand hygiene, respiratory hygiene, and cough etiquette.
  • Follow the Centers for Disease Control and Prevention (CDC) cleaning and disinfection guidelines for community facilities, and cleaning facilities if someone is sick.
  • Place signs throughout the facility with reminders about hand hygiene, required masking, cough etiquette, and reporting any symptoms to staff.

Ventilation

Face coverings          

  • Visitors and staff/volunteers must follow current CDPH Guidance for the Use of Face Coverings regarding masking while in the shelter, which requires all persons in the shelter to wear a face covering regardless of vaccination status.
  • The shelter should ensure that a supply of masks is available to distribute to anyone who arrives without one and should supply surgical masks or respirators to clients or visitors if feasible. Unvaccinated staff must be provided with an FDA-cleared surgical mask, which they must wear in indoor settings when working with another person, consistent with the State Public Health Officer Order for Health Care Workers in High-Risk Settings.

Cleaning protocols

Handling waste:

  • Wear gloves.
  • Handle trash bags by their empty upper sections and do not hold against body.

Doing laundry:

  • Do not shake dirty laundry; this minimizes the possibility of dispersing virus, if present, through the air.
  • Wash items as appropriate in accordance with the manufacturer's instructions.
  • Launder items using the warmest appropriate water setting for the items and dry items completely.
  • Dirty laundry that has been in contact with an infectious person can be washed with the laundry of other people.
  • Clean and disinfect hampers or other carts for transporting laundry according to guidance above for hard or soft surfaces.

Guidance on COVID-19 client screening and testing in congregate shelters

Diagnostic screening testing is required for all unvaccinated staff and volunteers at least once per week under the State Public Health Officer Order for Health Care Workers in High-Risk Settings.

Screening clients for COVID-19 signs and symptoms

Clients:

  • Anyone reporting one or more symptoms of COVID-19 (that cannot be explained by a pre-existing condition) or has a measured temperature of 100.4°F/38°C or higher should be isolated and tested.
  • Designate a limited number of staff members to conduct screening.
  • If social distancing or barrier/partition controls cannot be put in place during screening, PPE should be used when within 6 feet of a client.
  • PPE should include a respirator, eye protection (goggles or disposable face shield that fully covers the front and sides of the face), and a single pair of disposable gloves. Gowns are not routinely required for staff performing screening. Additional CDC information about PPE is available.
  • In addition to regular screening, encourage clients who develop symptoms to report those symptoms to designated staff member(s) as soon as possible.
  • Clients may be screened with a questionnaire (PDF) regarding COVID-19 symptoms.

Screening testing for clients

  • Screening testing of asymptomatic clients who are not fully vaccinated* is a component of a layered approach to prevent SARS-CoV-2 transmission in congregate settings, particularly when community transmission rates are high.
  • Screening testing may be performed at admission and/or regularly, e.g., weekly, on all or a sample of clients. Local health departments may have guidance on screening testing in shelters.
  • The State of California offers resources to set up and operate testing sites. Shelters may apply for testing resources at the State of California website.

Isolation of clients with acute respiratory illness or confirmed COVID-19

  • CDPH recommends that those who test positive or who are exposed to COVID-19 and are not fully vaccinated* should be placed in non-congregate setting such as a Project Roomkey site. See CDC Guidance for Shared or Congregate Housing for additional information.
  • If a client is identified with symptoms of COVID-19, they should be moved to a private area of the facility for isolation and tested as soon as possible.
  • Consult with the local public health department about whether clients with mild illness due to suspected or confirmed COVID-19 infection should remain isolated in the shelter or be directed to alternative housing sites or a non-congregate setting until their COVID-19 status is known.
  • If the client has severe symptoms, arrange for the client to receive immediate medical assessment and care as appropriate.
  • If the sick client cannot be placed in a non-congregate setting and remains in the shelter, he or she should be isolated to the greatest extent possible from other clients and staff.
  • Sick clients should wear a surgical mask, if available, or other mask with multiple layers.
  • If available, place each sick client in an individual room.
  • If individual rooms for sick clients are not available, consider housing sick clients in a large, well-ventilated room with a door that can be closed to other clients.
  • Clients with confirmed COVID-19 can be cohorted together in the same room during their isolation period.
  • Clients who are ill and who have not been diagnosed with COVID-19 should not be cohorted with clients with known COVID-19 infections.
  • In areas where clients with respiratory illness are staying, keep beds at least 6 feet apart, use temporary barriers between beds (such as curtains), and request that all clients sleep head-to-toe.
  • If possible, designate a separate bathroom for sick clients.
  • After clients use shared items, they should be cleaned thoroughly before use by another client.
  • Notify the local public health department of new cases of respiratory illness or fever among clients and any clusters of respiratory illness or fever in clients or staff.

Identification, quarantine, testing and cohorting of exposed clients

Identification:

  • Exposed clients are those who were within six feet of an infectious person with confirmed COVID-19 for at least 15 minutes in a 24-hour period.

Testing:

  • Exposed clients who develop COVID-19 symptoms should be isolated and tested as soon as possible.
  • It is recommended that all asymptomatic exposed clients, regardless of vaccination status, receive testing unless they have recovered from SARS-CoV-2 infection in the prior 90 days.
  • Exposed asymptomatic clients who are fully vaccinated* should be tested 5-7 days after exposure.
  • Exposed asymptomatic clients who are not fully vaccinated* should be tested at baseline and every 7 days until no new infections are identified among this population for 14 days.

Quarantine:

  • Exposed asymptomatic clients who have recovered from SARS-CoV-2 infection in the prior 90 days do not need to quarantine.
  • Exposed, asymptomatic clients who are fully vaccinated* do not need to be quarantined, but should be tested 5-7 days after exposure per CDC recommendations.
  • Exposed, asymptomatic clients who are not fully vaccinated* should be placed in a non-congregate setting, if available, during their quarantine period; such clients may be quarantined as a group separate from other clients.

Cohorting:

  • All clients who test positive (regardless of symptoms) should be placed in a non-congregate setting, or if that is not available in an isolation area. This area can include others who have the same confirmed infection (cohorting of infected persons).
  • If infected clients cannot be housed separately, they may be isolated as a cohort in a designated on or off-site area that is separated from other clients.

Additional Resources


*Per CDC, people are considered fully vaccinated:

  • 2 weeks after their second dose in a 2-dose series, such as the Pfizer-BioNTech or Moderna vaccines, or
  • 2 weeks after a single-dose vaccine, such as Johnson & Johnson's Janssen vaccine.

This guidance applies to COVID-19 vaccines currently approved or authorized for emergency use by the U.S. Food and Drug Administration (Pfizer-BioNTech, Moderna, and Johnson & Johnson [J&J]/Janssen COVID-19 vaccines) and can be applied to COVID-19 vaccines that have been listed for emergency use by the World Health Organization (such as AstraZeneca/Oxford). Additionally, this guidance can be applied to clinical trial participants from U.S. sites who received all recommended doses of a COVID-19 vaccine that is neither approved nor authorized for use by FDA but is listed for emergency use by WHO, or who have received the full series of an "active" (not placebo) COVID-19 vaccine candidate for which vaccine efficacy has been independently confirmed (e.g., by a data and safety monitoring board). Currently, participants in the U.S.-based AstraZeneca and Novavax COVID-19 vaccine trials meet these criteria. These U.S. participants in COVID-19 vaccine trials can be considered fully vaccinated 2 weeks after they complete the vaccine series, if it has been confirmed that they received "active" vaccine, and not placebo.