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Comparison of infection control strategies to reduce COVID-19 outbreaks in homeless shelters in the United States: a simulation study
- Author(s): Chapman, Lloyd AC;
- Kushel, Margot;
- Cox, Sarah;
- Scarborough, Ashley;
- Cawley, Caroline;
- Nguyen, Trang;
- Rodriguez-Barraquer, Isabel;
- Greenhouse, Bryan;
- Imbert, Elizabeth;
- Lo, Nathan
- et al.
Published Web Locationhttps://doi.org/10.1101/2020.09.28.20203166
BackgroundCOVID-19 outbreaks have occurred in homeless shelters across the US, highlighting an urgent need to identify the most effective infection control strategy to prevent future outbreaks.
MethodsWe developed a microsimulation model of SARS-CoV-2 transmission in a homeless shelter and calibrated it to data from cross-sectional polymerase-chain-reaction (PCR) surveys conducted during COVID-19 outbreaks in five shelters in three US cities from March 28 to April 10, 2020. We estimated the probability of averting a COVID-19 outbreak when an exposed individual is introduced into a representative homeless shelter of 250 residents and 50 staff over 30 days under different infection control strategies, including daily symptom-based screening, twice-weekly PCR testing and universal mask wearing.
ResultsThe proportion of PCR-positive residents and staff at the shelters with observed outbreaks ranged from 2.6% to 51.6%, which translated to basic reproduction number ( R 0 ) estimates of 2.9–6.2. The probability of averting an outbreak diminished with higher transmissibility ( R 0 ) within the simulated shelter and increasing incidence in the local community. With moderate community incidence (~30 confirmed cases/1,000,000 people/day), the estimated probabilities of averting an outbreak in a low-risk ( R 0 =1.5), moderate-risk ( R 0 =2.9), and high-risk ( R 0 =6.2) shelter were, respectively: 0.35, 0.13 and 0.04 for daily symptom-based screening; 0.53, 0.20, and 0.09 for twice-weekly PCR testing; 0.62, 0.27 and 0.08 for universal masking; and 0.74, 0.42 and 0.19 for these strategies combined.
ConclusionsIn high-risk homeless shelter environments and locations with high community incidence of COVID-19, even intensive infection control strategies (incorporating daily symptom-screening, frequent PCR testing and universal mask wearing) are unlikely to prevent outbreaks, suggesting a need for non-congregate housing arrangements for people experiencing homelessness. In lower-risk environments, combined interventions should be employed to reduce outbreak risk.
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