Individuals experiencing homelessness often face more barriers to obtaining a COVID-19 vaccination than others. As more vaccines become available and supplies increase, new and emerging best practices for vaccinating individuals in homeless shelters may help states more efficiently vaccinate other hard-to-reach or medically vulnerable populations, such as those living in rural areas or congregate settings.
The Centers for Disease Control and Prevention (CDC) classifies individuals experiencing homelessness as a high-risk population. Homeless shelters are congregate settings, which can facilitate the rapid spread of COVID-19 infection, and many individuals who are homeless also suffer from other medical conditions that put them at high risk of COVID-19-related complications. While some states group all individuals residing in congregate settings into one vaccination priority category, others specifically identify individuals in homeless shelters as a priority population. As a result, these individuals’ vaccination eligibility differs between states.
According to a recent analysis by the National Academy for State Health Policy (NASHP), 34 states explicitly include residents of homeless shelters as a priority population. A few states, including Wyoming and Washington, DC, explicitly prioritize “individuals experiencing homelessness.” Washington State lists “people experiencing homelessness that access services or live in congregate settings (e.g., shelters, temporary housing)” in its latest vaccine prioritization plan.
Every state has changed its eligibility criteria and prioritization guidelines as the CDC and the Department of Health and Human Services (HHS) have issued new recommendations based on the constantly changing vaccine rollout picture. Some states have identified these individuals in their plans and moved this population up in priority, while others have instead reprioritized other populations. For example, Wyoming recently moved individuals experiencing homelessness up in their prioritization. Arizona elevated individuals with high-risk medical conditions living in shelters as well all adults in congregate settings. Wisconsin added individuals in homeless shelters and in transitional housing to a priority phase of the state plan after previously not prioritizing this population. As of March 1, 2021, 15 states were vaccinating individuals experiencing homelessness.
In addition to the general vaccine distribution challenges states are facing – such as limited vaccine supplies, tracking data on doses administered, personnel shortages, and vaccine hesitancy – vaccinating individuals experiencing homelessness has its own difficulties:
- Conflicting priorities: On top of concerns about vaccine safety and mistrust of the health care system, many individuals experiencing homelessness are hesitant to receive the vaccine because they see other challenges – such as housing status, food insecurity, and financial instability – as more immediate concerns.
- Transportation barriers: Many individuals experiencing homelessness face transportation barriers that prevent them from traveling to mass vaccination clinics.
- Tracking second doses: For those who receive the Moderna or Pfizer vaccines, the state must figure out how to track where individuals are to ensure they receive their second dose and are fully immunized. It is particularly challenging for states to track second doses for individuals who are only in a shelter temporarily, or primarily live on the street.
- Limited technology: Many people living on the street or in shelters do not have internet access, and therefore cannot sign up for vaccine appointments through state websites.
- Connection to health care providers: Individuals experiencing homelessness are less likely to be connected to health care providers or health care systems, making it more difficult to get an appointment or find out when they are eligible.
- Vaccine Storage: In order to reach individuals living on the street, providers need to be able to transport doses to encampments and other areas where individuals frequently live. However, the vaccines’ refrigerated storage requirements make bringing doses directly to individuals on the street difficult.
States are working diligently to determine strategies and best practices for vaccinating individuals experiencing homelessness. As supply increases and becomes less of a barrier to vaccine administration, it is critical to address access-related barriers that may prevent some individuals from receiving the vaccine and exacerbate existing health disparities.
As with most decisions related to vaccine distribution, eligibility criteria for priority populations has been left to states. Of the limited states already vaccinating individuals experiencing homelessness, many have turned to private organizations to aid in vaccinating individuals experiencing homelessness. In these cases, the state distributes doses to nonprofit organizations that work to address homelessness or provide health care to the homeless, and these organizations take the lead in organizing clinics and administering doses.
Since early February 2021, the Washington, DC Department of Human Services has partnered with Unity Health Care, the District’s largest network of federally qualified heath centers, to hold vaccination clinics at homeless shelters. Unity Health Care is also trying to vaccinate individuals living on the street when possible through case managers and outreach teams. Washington, DC is eliminating certain barriers to vaccination for individuals experiencing homelessness, including waiving the requirement to provide an ID at appointments, giving individuals waterproof wallets in which to keep their vaccination cards, and providing free transportation to clinics located at some homeless shelters.
In Connecticut, the state and local health departments are coordinating vaccination efforts in congregate facilities – including homeless shelters – affiliated with the state, and partnering with private nonprofits to actually administer the doses. Some hospitals and cities in Connecticut are also using mobile vaccination clinics to reach individuals in congregate settings.
In Massachusetts, the nonprofit Boston Health Care for the Homeless Program (BHCHP) is playing a crucial role in vaccinating individuals experiencing homelessness in the Boston area. BHCHP is leveraging the City of Boston’s Homeless Management Information System (HMIS) – which connects to their electronic health records system Epic – in conjunction with the state’s Immunization Information System (IIS) to track first doses administered and to send out second dose text reminders. Shelter can access these reminders and provide outreach to patients to make sure they get their second doses. BHCHP is also using their grant funding and their own funding to incentivize vaccinations among the populations they serve, including providing gift cards, clothing, and snacks and combatting vaccine hesitancy by training individuals experiencing homelessness to provide peer counseling. To date, the nonprofit reports it has been successful at ensuring individuals return for their second doses. BHCHP also announced plans to start vaccinating individuals living on the street. They hope to use a van to store doses while they drive to areas where individuals on the street often live.
As states try to simultaneously provide information about vaccination clinic locations, recruit and train personnel to administer vaccines, monitor individuals after vaccination, and plan mass clinics, nonprofits are a valuable resource for reaching specific populations. Many private organizations, especially those already working to address homelessness and housing insecurity, have existing relationships with individuals experiencing homelessness and are already trusted service providers. They have been providing outreach to these communities throughout the pandemic and are poised to take on some of the work of vaccinating individuals experiencing homelessness.
Because demand for the vaccine still exceeds supply, states are challenged to prioritize their populations. States have to make tough decisions that promote health equity, decrease infection rates, promote vaccine efficiency, and prevent deaths. States that have not yet started vaccinating individuals experiencing homelessness can learn from others that are already vaccinating this population so that they can more effectively reach those living in shelters and on the street.
As states – and their partnering nonprofits – pilot strategies like mobile vaccine clinics and offer incentive payments and peer counseling in order to reach individuals experiencing homelessness and encourage vaccinations, these and similar initiatives can inform efforts to vaccinate other hard-to-reach populations.
Acknowledgements: This blog is supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $250,000 with 100 percent funded by CDC/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US government. CDC General Terms and Conditions for Non-research Awards, Revised: February 2021.