In an occasional series, public health researcher Alison Barrett reports on key public health news, research and developments in the COVID-19 pandemic.
Impacts of COVID-19 on people experiencing homelessness
Public health interventions that have been implemented in an effort to slow the spread of novel coronavirus infections world-wide are nearly impossible to follow in the environments where people experiencing homelessness live.
They might live in crowded conditions where social distancing and self-isolating is a challenge and without access to the basic items required to maintain appropriate hygiene. Or they might sleep rough.
As authors from the United States point out, in the case of cities closing down, public spaces might close and outdoor movements become restricted, meaning homeless people have less access to places they might normally sleep.
People experiencing homelessness often have pre-existing medical conditions and limited access to healthcare, which results in them being more vulnerable to infections and thus, far more likely to feel the impact of COVID-19 than others in general populations.
At the time of writing, there has been no nation-wide strategy in Australia to support people experiencing homelessness during the COVID-19 pandemic (as noted in The Lancet recently).
Nonetheless, individual states and cities have been working hard to get rough sleepers into accommodation.
An online forum, hosted by the Australian Alliance to End Homelessness on 7 April, provided organisations from each state and territory an opportunity to discuss how they are supporting people experiencing homelessness during the pandemic.
Paul Flatau, Director of the Centre for Social Impact, University of Western Australia, said that about 750 rough sleepers across Australia have been housed in temporary accommodation in the last few weeks.
In Adelaide, 256 people have been accommodated in motels as part of a collaborative effort between Neami National, SA Housing Authority, Baptist Care and the Hutt St Centre, according to Kim Holmes from Neami National.
Those involved with the collaboration were working closely with motel staff to ensure people were supported during this transition.
They also maintained daily contact with every person re-homed in the motels, providing education and a coordinated health response (such as flu vaccinations and mental health support).
And in Perth, John Berger from the WA Alliance to End Homelessness, discussed the recent implementation of the ‘Hotels with Heart’ project, where hotels temporarily house people experiencing homelessness during the COVID-19 outbreak.
He said this is an adaptation of an approach recently set up in the UK, in an attempt to prevent hospital admissions from this group.
Other strategies discussed by the organisations include an increase in outreach services, with provision of food, masks, and hand sanitiser; and education about COVID-19 to people who otherwise may not have become aware of the pandemic or how serious it is.
They all raised the importance of collaboration between different agencies and the provision of effective personal protective equipment for outreach staff.
While the immediate priority was to find emergency accommodation for people experiencing homelessness, they stressed the need for plans to be put in place for longer-term accommodation for when the pandemic ends.
The views discussed at the forum have been echoed in recent publications.
In a letter to the editor of the Medical Journal of Australia, the authors identified additional challenges for people experiencing homelessness and those caring for them:
- telehealth, an initiative recently expanded by the Australian Government to limit the spread of COVID-19, is not practical for homeless people who don’t have access to a phone;
- as raised at the forum, outreach services are vital but remain a challenge if sufficient personal protective equipment is not available for outreach staff; and
- if outreach services are cancelled, there will be major consequences if infections are missed.
A commentary published in The Lancet brought attention to the impact that COVID-19 would have on homeless children. Not only are children in temporary accommodation at higher risk of exposure to and infection of COVID-19, they are also likely to experience long-term impacts on their growth, development and health.
In conclusion, as Leilani Farha, UN Special Rapporteur for adequate housing, states: “Housing has become the front-line defence against the coronavirus.”
For those without adequate housing, it is vital governments work closely together with all sectors to reduce overcrowded housing, provide alternative housing for those without a place to remain safe, and protect those most vulnerable.
Watch the forum discussions
Presymptomatic transmission
Presymptomatic transmission of SARS-CoV-2 – Singapore, January 23-March 16, 2020 – Published by US Centers for Disease Control and Prevention, 1 April 2020
An investigation of seven clusters of COVID-19 cases in Singapore adds further support to preliminary evidence from China that presymptomatic transmission of SARS-CoV-2 occurs.
This is important information for public health officials to consider when contact tracing and again highlights the value of social or physical distancing measures to slow the spread of COVID-19.
Presymptomatic transmission occurs when someone infected with the novel coronavirus who does not have symptoms infects another person. It is determined by the dates of exposure and onset of symptoms and a lack of evidence that the second person was exposed to anyone else with SARS-CoV-2.
Contact tracing, thus, becomes difficult without “including a period before symptom onset to account for the possibility of presymptomatic transmission,” the authors advise.
The Singapore investigation found presymptomatic transmission of SARS-CoV-2 occurred in 6.4% of cases that were locally acquired. In comparison, one study in China found that 12.6% of cases were due to presymptomatic transmission.
In four clusters where they were able to determine the date of exposure, presymptomatic transmission happened one to three days before the onset of symptoms in the source patient.
Further research is required but the authors suggest presymptomatic transmission could occur from respiratory droplets, contamination of an object, such as a doorknob, or contact with an infected person’s hands, highlighting the importance of rigorous hygiene practices.
While their investigation was thorough, the authors highlight some limitations in their study: it is possible the clusters were infected by an unknown source rather than presymptomatic transmission; contact tracing is subject to recall bias, and might affect the dates of symptom onset reported by patients, making it difficult to determine the presymptomatic period. As well, because testing and surveillance focus on symptomatic patients, it is possible that asymptomatic cases are under-detected.
In summary, this investigation, in combination with evidence from China, suggests that presymptomatic transmission of novel coronavirus occurs, and emphasises the need for social distancing, rigorous handwashing practices and contact tracing procedures to consider a time period before the onset of symptoms occur.
Messaging matters
Perceptions and behavioural responses of the general public during the COVID-19 pandemic: a cross-sectional survey of UK adults: Preprint
In the United Kingdom, as in many other countries world-wide, non-pharmaceutical interventions (NPI) were introduced to slow the spread of COVID-19. On 16 March 2020, the UK government advised the public that all non-essential contact with others and non-essential travel must stop.
Key findings from an online survey conducted within 48 hours of the announcement of these measures are that most participants (85.8%) reported changing hand washing practices and most (87.6%) were also willing to self-isolate should this be asked by a health professional.
Whilst these are good results, the study also found the participants perceived the preventative measures to be more effective than their actual adoption of them.
For example, approximately 85 percent of participants perceived the effectiveness of avoiding social events in preventing infection of COVID-19, but only 55 percent of participants had put this strategy in place.
The study also found significant differences between the ability and willingness of different demographic and socio-economic groups to self-isolate and social distancing behaviour.
People 70 years or over were nearly twice as likely as 18 to 34-year-olds to adopt social distancing practices. Single adults were less likely to practise social distancing than those who were married or living with partners.
Those from lower income and/or disadvantaged backgrounds had less capability to work from home or self-isolate if needed, indicating the epidemic’s impact will probably be felt unequally unless governments support those most disadvantaged.
While the study is in preprint and not yet been peer-reviewed, it does provide important information for public health and government officials to consider when implementing and communicating about preventive measures.
It is important to tailor messages appropriately to specific groups and ensure more vulnerable populations are supported in ways that enable them to adopt preventive measures.
The authors conclude that:
…the population’s response to public health advice is currently the key factor in tackling the COVID-19 epidemic and whether the curve is flattened sufficiently to allow health services to cope.
Factors affecting uptake and compliance with preventive measures are critical.
Those from socioeconomically more deprived backgrounds, in particular, may need further financial assurance and assistance from the government to be able to implement some of these measures, such as self-isolation.”
Learning from China
Fangcang shelter hospitals: a novel concept for responding to public health emergencies: The Lancet, 2 April 2020
Fangcang shelter hospitals were established in public venues in China during the worst of the COVID-19 outbreak as temporary health care facilities with the ability to isolate people infected with SARS-CoV-2.
The development of Fangcang shelter hospitals was a novel public health response to the influx of confirmed cases and people requiring medical care.
By the beginning of February 2020, the city of Wuhan no longer had beds available in hospitals that were selected for treating patients with COVID-19. To mitigate this and reduce the pressure on the overburdened health system, they converted 16 stadiums and exhibition centres into Fangcang shelter hospitals.
The Fangcang shelter hospitals aimed to reduce the risk of spreading the infection to community and family members by providing a location for infected people to isolate away from home. They also played an important role in triage, medical treatment and care. During the outbreak in Wuhan, they isolated and cared for thousands of patients.
Once the COVID-19 epidemic and need for the temporary hospitals lessened in Wuhan, they were closed down, but provide an excellent example for other countries now experiencing a similar burden to their healthcare systems.
In recent days, it has been reported that the ExCel Convention Centre in East London will be turned into a temporary hospital to treat patients with novel coronavirus, and health ministers in Victoria and New South Wales are investigating similar options should we see hospitals overburdened in Australia.
The authors of this report outline some characteristics and key functions of the Fangcang shelter hospitals. By using infrastructure that already exists, they can be constructed quickly; by using large public venues, they have the capacity house many hospital beds; and they are low cost to build and run.
Their functions are to isolate infected patients from home and community; triage mild to moderate cases, reducing pressure on traditional hospitals; provision of basic medical care; frequent monitoring of symptoms; and “essential living and social engagement” in the form of shelter, food, hygiene, and social activities.
To work effectively, Fangcang shelter hospitals need adequate human resources, communication to make sure communities were aware of them, suitable governance, prevention of infection in the shelter hospitals and privacy for patients.
As the authors conclude, “by embracing Fangcang shelter hospitals, many countries and communities worldwide could boost their response to the current COVID-19 pandemic as well as future epidemics and disasters”.
From the World Health Organization
Director-General’s remarks at COVID-19 media briefings on 3 April
With preventive measures in place restricting work and social activities in many countries, Dr Tedros Adhanom Ghebreyesus said a profound economic effect will be felt, and that “debt relief is essential to enable them to take care of their people and avoid economic collapse”.
“Financing the health response is therefore an essential investment not just in saving lives, but in the longer-term social and economic recovery,” Dr Tedros said
He suggests three areas for countries to focus on in their financial response:
- Fund core public health measures including testing, contact tracing, data collection, communication
- Support health systems by paying health workers’ salaries and ensuring health facilities have adequate funding to purchase necessary supplies
- Remove financial barriers to care: “If people delay or forego care because they can’t afford it, they not only harm themselves, they make the pandemic harder to control and put society at risk.”
Dr Tedros then discussed the impact that the COVID-19 pandemic was having on other diseases such as polio.
Health workers who were previously working to vaccinate children are now required to work in response to COVID-19, many tracing contacts and communicating public health information to communities. He acknowledged that while this is important for reducing the spread of COVID-19, it was likely that cases of polio would increase.
Increases in domestic violence have also been reported since the beginning of the outbreak. Dr Tedros calls on countries to address this issue and ensure that services supporting victims of domestic violence continue to operate at this time.
In his media briefing on 6 April, Dr Tedros announced an event, One World: Together at home, a collaboration between WHO and Global Citizen where artists, including Chris Martin and John Legend, will perform to support global response efforts to the COVID-19 pandemic.
The event will take place on online platforms on Saturday, 18 April, 5pm PT (USA) – in Australia, that is 10am AEST Sunday, 19 April.
Curated by Lady Gaga, Dr Tedros says the event is a way to show “that we’re all in this together, and we can only succeed together”.
Dr Tedros then discussed the recommendation by some countries that the general population should wear masks to prevent infections of novel coronavirus.
The WHO’s recommendations for the wearing of masks are that priority must be made for health workers to have access to them. The WHO is concerned that if the general population are also using them, the shortage of masks for those who really need them will be exacerbated.
The WHO recommends that people who are sick in the general population should wear them, as should those caring for a person who is sick. Otherwise, if masks are to be worn, they should be appropriately following strict guidelines.
Dr Tedros acknowledged there was limited research in the area and encouraged countries using masks in the general population to study their effectiveness.
He reiterated:
…mask or no mask, there are proven things all of us can do to protect ourselves and others – keep your distance, clean your hands, cough or sneeze into your elbow, and avoid touching your face.”
On 6 April, Dr Tedros acknowledged a Twitter conversation with @WePublicHealth where social work academic and practitioner Margareta Windisch is discussing #PandemicSolidarity this week. 
• Alison Barrett is a Masters by Research candidate and research assistant at University of South Australia, with interests in public health, rural health and health inequities. Follow on Twitter: @AlisonSBarrett
See her previous compilations:
- COVID-19 wrap: smoking, kids, communities and cruise ships
- COVID-19 wrap: ranking global health, impact of quarantine, rural and remote health concerns, outbreak investigations, and reasons for humility
Follow this Twitter list for informed news sources, global and Australian.
Follow this Twitter list for news from Aboriginal and Torres Strait Islander health organisations and experts.
