The authors have declared that no competing interests exist.
To describe the work environment and COVID-19 mitigation measures for homeless shelter workers and assess occupational risk factors for COVID-19.
Between June 9-August 10, 2020, we conducted a self-administered survey among homeless shelter workers in Washington, Massachusetts, Utah, Maryland, and Georgia. We calculated frequencies for work environment, personal protective equipment use, and SARS-CoV-2 testing history. We used generalized linear models to produce unadjusted prevalence ratios (PR) to assess risk factors for SARS-CoV-2 infection.
Of the 106 respondents, 43.4% reported frequent close contact with clients; 75% were worried about work-related SARS-CoV-2 infections; 15% reported testing positive. Close contact with clients was associated with testing positive for SARS-CoV-2 (PR 3.97, 95%CI 1.06, 14.93).
Homeless shelter workers may be at risk of being exposed to individuals with COVID-19 during the course of their work. Frequent close contact with clients was associated with SARS-CoV-2 infection. Protecting these critical essential workers by implementing mitigation measures and prioritizing for COVID-19 vaccination is imperative during the pandemic.
Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), has spread rapidly among people experiencing homelessness in some homeless shelters throughout the United States [
Homeless shelters provide an essential service and, like many congregate settings, have remained open during the COVID-19 pandemic. Homeless shelters have previously experienced outbreaks of tuberculosis, hepatitis A, and invasive bacterial disease [
Other crowded occupational environments, including long-term care facilities, correctional facilities, military facilities and cruise ships, have been associated with high risk of exposures and transmission of COVID-19 among workers [
Local public health and healthcare collaborators (e.g., local health departments, nongovernmental organizations, local government agencies) in Seattle, Washington; Boston, Massachusetts; Salt Lake City, Utah; Baltimore, Maryland; and across Georgia identified homeless shelters in their jurisdictions where at least one staff member had tested positive for SARS-CoV-2. We informed the shelter administrators of the survey objectives and requested participation of their staff. All staff who work at a shelter facility were eligible to participate. Public health partners or shelter administrators sent a recruitment email with a link to the online survey to all workers. The online survey was open between June 9 and August 10, 2020. Participation was voluntary and anonymous. At least two follow-up emails were sent to encourage participation.
The Centers for Disease Control and Prevention (CDC) and Public Health—Seattle & King County (PHSKC) developed the standardized online survey (
We conducted the analyses using Stata/SE 16.0 and R version 4.0.2. Body Mass Index (BMI) was calculated by multiplying weight in pounds by a conversion factor of 703 and dividing by height in inches squared. Job titles and job descriptions were used to categorize job positions as primarily administrative (e.g., supervisors, office administration, information technology, accounting) or client engagement (e.g., case manager, food server, floor monitor, housing advocate, social worker). Individual shelters that were managed by the same organization were grouped into shelter networks for analyses. Because some workers were tested more than once, a worker was classified as positive for SARS-CoV-2 if he/she self-reported a positive non-blood test result for at least one testing event. Workers who reported “Don’t know” for a test result were categorized as a non-positive. We calculated frequencies, medians, and ranges to describe demographic and work characteristics of participants. To explore associations between SARS-CoV-2 positivity and participant characteristics, we used generalized linear models with a binary outcome (COVID-19 positivity according to at least one non-blood test) and a log link, clustered by shelter network (to allow for intragroup correlation), to produce unadjusted prevalence ratios (PR) and 95% confidence intervals (CI). Frequency of close contact, defined as less than 6 feet for more than 15 minutes at a time, was dichotomized into low (never, rarely, a few times a month) and high (a few times a week to a few times a day). We produced PRs comparing workers who reported testing positive at least once to workers who reported testing negative for every test by demographics (e.g., age, sex, ethnicity), work environment (e.g., hours worked, frequency of close contact, COVID-19 mitigation strategies implemented by facility), and attitudes (e.g., thought about quitting).
This activity underwent human subjects ethics review by CDC and was conducted consistent with applicable federal law and CDC policy (45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq). Completing the survey was voluntary.
Among 17 shelter networks that represented 27 individual shelters, 106 homeless shelter workers (range per shelter network, 1–33) completed the online survey. The median age of participants was 42 years (range 21–67); 65 (61%) were female and 55 (52%) were non-Hispanic White (
Demographics | Number (% |
Job practices, mitigation measure and attitudes | Number (%) |
---|---|---|---|
GA | 16 (15.1) | Most/all of the time | 91 (85.8) |
Boston, MA | 33 (31.1) | Sometimes | 11 (10.4) |
Baltimore, MD | 2 (1.9) | Rarely/never | 1 (0.9) |
Salt Lake City, UT | 25 (23.6) | ||
Seattle, WA | 30 (28.3) | A few times a day | 34 (32.1) |
A few times a week | 12 (11.3) | ||
21–30 years old | 23 (21.7) | A few times a month | 10 (9.4) |
31–40 years old | 28 (26.4) | Rarely | 2 (1.9) |
41–50 years old | 24 (22.6) | Never | 46 (43.4) |
>50 years old | 31 (29.2) | ||
A few times a day | 12 (11.3) | ||
Male | 35 (33.0) | A few times a week | 10 (9.4) |
Female | 65 (61.3) | A few times a month | 4 (3.8) |
Rarely | 13 (12.3) | ||
Male | 38 (35.8) | Never | 65 (61.3) |
Female | 64 (60.4) | ||
Non-Binary | 2 (1.9) | A few times a day | 61 (57.5) |
A few times a week | 12 (11.3) | ||
Non-Hispanic White | 55 (51.8) | A few times a month | 11 (10.4) |
Non-Hispanic Black | 26 (24.5) | Rarely | 15 (14.2) |
Non-Hispanic Other | 6 (5.7) | Never | 7 (6.6) |
Hispanic | 15 (14.2) | ||
Yes | 60 (56.6) | ||
Yes | 39 (36.8) | |
34/60 (56.7) |
No | 56 (52.8) | No | 43 (41.8) |
Current smoker/vaper | 23 (21.7) | Increased handwashing | 88 (83.0) |
Past smoker | 22 (20.8) | Safe distancing (≥6 ft) | 82 (77.4) |
Masks for staff/clients | 97 (91.5) | ||
Yes | 67 (63.2) | Provision of PPE for staff | 80 (75.5) |
No | 38 (35.9) | No measures implemented | 1 (0.9) |
Yes | 30 (28.3) | Yes | 67 (63.2) |
No | 71 (67.0) | No | 14 (13.2) |
Don’t Know | 12 (11.3) | ||
Yes | 15 (14.2) | ||
No | 86 (81.1) | Yes | 80 (75.4) |
|
19/80 (23.8) | ||
Yes | 96 (90.6) | No | 21 (19.8) |
No | 6 (5.7) | ||
Yes | 87 (82.1) | ||
Administrative | 43 (40.6) | No | 9 (8.5) |
Client engagement | 63 (59.4) | ||
Yes | 83 (78.3) | ||
Yes | 30 (28.3) | No | 19 (17.9) |
No | 73 (68.9) | ||
Yes | 66 (62.3) | ||
Yes | 18 (17.0) | No | 38 (35.9) |
No | 86 (81.1) | ||
0–6 months | 20 (18.9) | ||
7–12 months | 21 (19.8) | ||
13–36 months | 25 (23.5) | ||
37–60 months | 14 (13.2) | ||
>60 months | 23 (21.7) |
+May not sum to 100% in some categories due to missing data.
*For example, nursing, medicine, or emergency medical technician.
**Close contact = within 6 feet for ≥15 minutes.
***Direct physical contact = touching.
^Chronic lung disease, High blood pressure, chronic kidney or liver disease, diabetes mellitus, rheumatoid arthritis, heart disease.
#Disposable or reusable mask.
Sixty-three participants (59%) reported some sort of client engagement as part of their regular work duties, including case management, providing medical and mental health care, client intake, client outreach, client screening, serving food to clients, providing education and employment advice, monitoring clients while at the shelter, and janitorial activities (
All 17 shelter networks had implemented at least one COVID-19 prevention measure. At the participant level, the most common mitigation measures were use of masks by staff or clients (97/106, 92%) and increased handwashing (88/106, 83%) (
Characteristic | Number (Percent) |
---|---|
Worker used mask |
47 (81.0%) |
Worker used mask |
9 (15.5%) |
Worker used mask |
2 (3.5%) |
Clients used mask |
25 (43.1%) |
Clients used mask |
20 (34.5%) |
Clients used mask |
13 (22.4%) |
Used gloves most/all of the time when in direct physical contact |
22 (56.4%) |
Used gloves sometimes when in direct physical contact |
7 (17.9%) |
Used gloves rarely/never when in direct physical contact |
9 (23.1%) |
Used gloves when touching clients’ belongings/shared items | 48 (85.7%) |
Used mask |
62 (76.5%) |
Used mask most/all of the time when interacting with known COVID-19 | 29 (76.4%) |
Used mask sometimes when interacting with known COVID-19 | 3 (7.9%) |
Used mask rarely/never when interacting with known COVID-19 | 3 (7.9%) |
Used gloves when interacting with known COVID-19 | 24 (63.2%) |
Used gown when interacting with known COVID-19 | 2 (5.3%) |
Used respirator (N95) when interacting with known COVID-19 | 8 (21.1%) |
Used goggles when interacting with known COVID-19 | 1 (2.6%) |
Did not use masks or any PPE when interacting with known COVID-19 | 2 (7.1%) |
^Denominator = 58 (workers who had close or direct physical contact with clients).
#Disposable or reusable mask.
*Close contact = within 6 feet for ≥15 minutes.
**Direct physical contact = touching.
Of the 106 participants, 77 reported being tested for SARS-CoV-2 with 62% of participants (48/77) reported undergoing testing for SARS-CoV-2 more than once. For the 77 participants who reported being tested at least once, the median number of testing events per participant was 2 (range: 1–10). Of the 187 testing events reported by the 77 participants, 9 were blood tests (assumed to be serological testing), 170 were non-blood tests (assumed to be molecular testing), and 8 did not select a test type (
Non-blood test | 170/187 (90.9) |
Blood test | 9/187 (4.8) |
118/187 (63.1) | |
Workplace | 114/187 (61.0) |
|
|
Medical provider | 45/187 (24.1) |
|
|
Other | 25/187 (13.4) |
|
|
<3 days | 108/187 (57.8) |
3–7 days | 62/187 (33.2) |
+7 days | 9/187 (4.8) |
58/187 (31.0) | |
16/21 (76.2) | |
Worked while having symptoms | 1/16 (6.30) |
Sought medical care for symptoms | 10/16 (62.5) |
Supervisor | 3/15 (20.0) |
Called testing provider | 1/15 (6.70) |
Health department staff | 6/15 (40.0) |
Primary care physician | 1/15 (6.70) |
Other | 2/15 (13.3) |
Stay home and isolate | 12/15 (80.0) |
Continue to work | 0/15 (0.0) |
No instruction provided | 2/15 (13.3) |
Home or in Community | 0/15 (0.0) |
Work | 12/15 (80.0) |
Don’t know where | 2/15 (13.3) |
^ N = 187 tests from 77 participants.
^^ n = 21 tests from 15 participants.
*Some categories may not sum to 100% due to missing data.
**Non-blood tests were assumed to be molecular testing while blood tests were assumed to be serological tests.
When analyzing the 77 participants who reported at least one testing event, we identified demographic characteristics that were associated with testing positive for SARS-CoV-2, including having a BMI ≥30 (PR 1.86, 95% CI 1.31, 2.63; p = 0.001) or identifying as Non-Hispanic Black race (PR 2.00, 95% CI 1.23, 3.26; p = 0.01)(
Characteristic | PR (95% CI) | p-value |
---|---|---|
Age (>40 years old) | 1.54 (0.85, 2.78) | 0.15 |
Sex (Female) | 1.63 (0.32, 8.28) | 0.55 |
Hispanic ethnicity | 2.67 (0.60, 11.9) | 0.20 |
Current smoker | 0.75 (0.44, 1.29) | 0.30 |
Has an underlying condition | 0.44 (0.10, 1.88) | 0.27 |
Received influenza vaccine this year | 0.78 (0.30, 2.02) | 0.61 |
Household size (>3 people) | 0.34 (0.11, 1.05) | 0.06 |
Job involves client engagement | 0.65 (0.21, 2.00) | 0.46 |
Length of employment (>12 months) | 1.61 (0.95, 2.73) | 0.08 |
Formal health education | 1.02 (0.38, 2.78) | 0.96 |
Frequent |
1.64 (0.94, 2.86) | 0.08 |
Frequent |
2.44 (0.98, 6.07) | 0.06 |
Cleaning activities as part of job | 1.13 (0.27, 4.68) | 0.87 |
Received training on COVID-19 cleaning | 1.55 (0.78, 3.11) | 0.22 |
Any mask use for close contacts with clients | 1.40 (0.54, 3.61) | 0.49 |
Always/mostly use gloves when in direct physical contact with clients | 0.82 (0.08, 8.47) | 0.87 |
Use of mask when in close contact with coworkers | 1.46 (0.56, 3.82) | 0.44 |
Always used masks when interacting with COVID-19 case | 1.44 (0.95, 2.22) | 0.09 |
^n = 15 positive homeless shelter workers.
+α< 0.05.
**Close contact = within 6 feet for ≥15 minutes.
#Direct physical contact = touching.
This study sought to characterize homeless shelter worker job practices, occupational exposures to SARS-CoV-2, and COVID-19 mitigation measures in the workplace. In this sample of homeless shelter workers, participants reported close contact and direct physical contact with clients. Nearly 40% of workers reported having close contact with a person with known COVID-19 and all reported that they believed the contact occurred at work; 24% of those workers did not use masks all of the time during these interactions (
Recommendations for homeless service providers to help protect the staff and clients include hand hygiene and cleaning supplies, PPE (including masks), administrative controls (e.g., flexible work schedules), facility layout/ventilation considerations, and maintaining social distance [
In this study, workers reported being worried about becoming infected at work and had thought about quitting. Nearly 40% of workers had been at their shelter less than one year. Homeless shelter workers tend to be a transient work population with a high burnout rate [
Homeless shelter workers have many different job roles, including case managers, janitors, administrative/managerial staff, cooks, security guards and floor monitors. In our sample, close contact with clients was not limited to workers whose job duties included known client engagement; more than 50% of workers with administrative job duties also reported close or direct physical contact with clients. Thirty-six percent of homeless shelter workers said that they had close contact with a known COVID-19 case at work. Of the 15 who tested positive by non-blood testing, 80% believed that they were infected at work. Homeless shelter workers, regardless of primary job duties, may be at increased risk for COVID-19, due to frequent close contact in congregate settings [
Several demographic factors have been shown to increase risk of SARS CoV-2 infection in the general population, including older age, race, ethnicity, and obesity [
During the survey period, many homeless shelters in major cities were conducting serial testing for SARS-CoV-2 of clients and staff [
This study is subject to several limitations. The questionnaire was online and self-administered where there may have been selection bias (e.g., access to internet, access to survey during working hours) and recall bias when reporting exposures, symptoms, and timing of testing. There were small number of respondents who reported positive tests which limited our ability to conduct more robust analyses to evaluate potential occupational risk factors associated with testing positive (
This is the first study that describes the work environment of homeless shelter workers in the context of COVID-19. We found that surveyed homeless shelter workers reported frequent close contact with clients; this was associated with having a positive test for SARS-CoV-2, while wearing masks and maintaining social distance at work were protective. Shelter management should continue to follow public health recommendations [
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Meagan Kay, Matthew Hanson, Margaret D. Luckoff, Jody Rauch, Libby Page, Public Health-Seattle & King County; Angela McCauley, Baltimore City Mayor’s Office of Homeless Services; Julie L. Self, Centers for Disease Control and Prevention; Jessie Gaeta, Boston Health Care for the Homeless Program; Gerry Thomas, Boston Public Health Commission; Kate Tettamant, Georgia Department of Community Affairs; Tair Kiphibane, Salt Lake County Health Department.
PONE-D-21-22300
Occupational exposures and mitigation strategies among homeless shelter workers at risk of COVID-19
PLOS ONE
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Reviewer #1: In the introduction section – a comment should be made on the incidence of covid-19 infection in the general population versus that of homeless shelter workers.
Workers who reported “Don’t know” for a test result were categorized as a non-positive. This is very problematic. How can this be assumed? Are all workers informed of their test results? More justification should be given for why the study authors classified the data as such, if not this would make the data analysis very unreliable.
It is good that the limitation of convenience sampling is acknowledged. Are there reasons for the response rate of 63% (17 out of 27 shelters)? Are there specific characteristics of the 10 shelters that did not respond? Perhaps some information should be given on this.
Overall this is an interesting study, however there are big gaps in the study methodology which render the generalisability of the study’s findings questionable. It is good that the authors have acknowledged the limitations, however these limitations are pretty significant (In our sample, 15% of respondents reported testing positive compared to 4.3% of a universal testing database.). As such this study is of limited value.
There are some grammatical errors:
Line 275:
In our sample, close contact with clients was not limited to workers whose job duties with known client engagement;
Line 302:
There were small number of positives which limited our ability to conduct more robust analyses
Reviewer #2: This is a very well written manuscript that describes in detail the results of a multi-center homeless shelter workers survey. The survey is detailed and the data is robust related to respondents demographics, homeless shelter worker directed mitigation strategies and risk for covid infection. The tables are easy to read and understand.
The survey has touched on the mitigation strategies initiated in the center directed to shelter workers however does not go into details related to client related mitigation strategies and client education related to covid. If this information is available would be valuable.
I would recommend to expand a little more and emphasize in the discussion the section related to race/ethnicity and BMI and increased covid risk.
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Reviewer #1:
a. In the introduction section – a comment should be made on the incidence of covid-19 infection in the general population versus that of homeless shelter workers,
RESPONSE: Thank you for this comment. The COVID-19 case data that is available for homeless shelter workers from
There is a recent publication, however, which is a meta-analysis of prevalences of COVID-19 among homeless populations, both in outbreak settings and non-outbreak settings. We have replaced the dashboard citation with this meta-analysis that is more robust than the NHCHC voluntary dashboard. (Mohsenpour A, Bozorgmehr K, Rohleder S, Stratil J, Costa D. SARS-Cov-2 prevalence, transmission, health-related outcomes and control strategies in homeless shelters: Systematic review and meta-analysis. EClinicalMedicine. 2021:101032.) We have revised the introduction (lines 61-68) in the marked up revised version of the manuscript.
b. Workers who reported “Don’t know” for a test result were categorized as a non-positive. This is very problematic. How can this be assumed? Are all workers informed of their test results? More justification should be given for why the study authors classified the data as such, if not this would make the data analysis very unreliable.
RESPONSE: We had conducted a sensitivity analysis that excluded the 10 respondents who reported “don’t know” for their testing result (N=67). The variables that were most important for work factors (i.e., close contact with residents and IPC measures) did not change between the two groups. In addition, race and obesity also did not change. The variables that did change (highlighted in yellow) only changed in significance level; magnitude and direction of the PRs did not change. We think this is a power issue with small sample sizes. The sensitivity analysis is described in lines 231-235 in the revised, marked up version of the manuscript.
In our experience with universal testing of homeless shelter workers, all workers were informed of their positive test results. Not all workers who tested negative, however, were informed of their negative results. Thus, we included the “don’t knows” as negatives in the modeling (N=77). Excluding the “don’t knows” would not change the conclusions or work-related recommendations of the study.
c. It is good that the limitation of convenience sampling is acknowledged. Are there reasons for the response rate of 63% (17 out of 27 shelters)? Are there specific characteristics of the 10 shelters that did not respond? Perhaps some information should be given on this.
RESPONSE: There seems to be some confusion over individual shelter (n=27) and shelter network (n=17). Some shelter networks had more than one individual shelter. There were 27 individual shelters within 17 shelter networks. All 27 individual shelters in the 17 shelter networks participated. For analysis, the 27 individual shelters that were managed by the same organization were grouped into their 17 shelter networks since management of staff and mitigation strategies would have been the same across the entire shelter network. We have tried to clarify this in the text in lines 121-122, 127-128, and 141 in the revised, marked up version of the manuscript.
d. Overall this is an interesting study, however there are big gaps in the study methodology which render the generalisability of the study’s findings questionable. It is good that the authors have acknowledged the limitations, however these limitations are pretty significant (In our sample, 15% of respondents reported testing positive compared to 4.3% of a universal testing database.). As such this study is of limited value.
RESPONSE: The 4.3% for the universal testing database is not directly comparable to the 15% prevalence among respondents. Study sites had to have had a positive case within their shelter to be included in the study versus anyone who can submit data to the universal testing database dashboard. Thus, it is not unexpected that the prevalence would be higher in this study population than the overall homeless shelter worker population since the respondents would have been at increased risk of exposure. In fact, when compared to the recently published meta-analysis (new citation Mohsenpour et al., 2021), the prevalence from our population (15%) was closer to the pooled prevalence among shelter workers during outbreaks (14.8%). The confusing sentence (line 324-325) regarding the universal testing database is deleted from the text.
e. There are some grammatical errors:
Line 275: In our sample, close contact with clients was not limited to workers whose job duties with known client engagement: Error fixed
f. Line 302: There were small number of positives which limited our ability to conduct more robust analyses: Error fixed
Reviewer #2: This is a very well written manuscript that describes in detail the results of a multi-center homeless shelter workers survey. The survey is detailed and the data is robust related to respondents demographics, homeless shelter worker directed mitigation strategies and risk for covid infection. The tables are easy to read and understand.
a. The survey has touched on the mitigation strategies initiated in the center directed to shelter workers however does not go into details related to client related mitigation strategies and client education related to covid. If this information is available would be valuable.
RESPONSE: The survey did not include questions on client related mitigation strategies or client education. There were questions on safe distancing and face coverings for staff/clients, which were included in Table 1. No additional information on mitigations strategies for clients is available for this survey.
b. I would recommend to expand a little more and emphasize in the discussion the section related to race/ethnicity and BMI and increased covid risk.
RESPONSE: Thank you for this important comment. Non-Caucasian race/ethnicity and BMI are known risk factors for COVID-19 infection and poor outcomes. Although the focus of the study is on modifiable work-related factors that could impact infection, we also agree that homeless shelter workers may have important demographic factors that could impact COVID-19 infections. The study population was 24.5% Non-Hispanic black and 36.8% with BMI > 30. A new paragraph to highlight these demographic factors has been added to lines 295-303 in the revised, marked up version of the manuscript.
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Occupational exposures and mitigation strategies among homeless shelter workers at risk of COVID-19
PONE-D-21-22300R1
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PONE-D-21-22300R1
Occupational exposures and mitigation strategies among homeless shelter workers at risk of COVID-19
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