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A sudden spike in cases at two downtown shelters and a dispute over another provider’s requests for additional testing shed light on struggles the city, county and shelter operators face as they try to protect vulnerable residents from coronavirus in risky congregate settings.
As the county ramped up vaccinations earlier this year, hundreds of homeless San Diegans moved out of the San Diego Convention Center and into smaller shelters with new safety precautions.
Five months later, nearly 100 homeless San Diegans staying in two Father Joe’s Villages shelters downtown tested positive for coronavirus, triggering a rush to isolate them. County hotel rooms for people who have COVID-19 or who have been exposed to it weren’t immediately available for all who needed them last week.
The county is now hurrying to institute weekly testing at all city shelters after falling into a monthly testing schedule at shelters that relied on its assistance. The past monthly testing schedule didn’t match Aug. 17 guidance from the U.S. Interagency Council on Homelessness urging widespread testing in shelters regardless of symptoms amid the rise of the delta variant or the Centers for Disease Control and Prevention’s recommendation of shelter-wide testing at least once a week in areas like San Diego with high transmission of COVID-19.
The county defends its decision to do monthly testing, despite those federal recommendations, by arguing it had previously found low positivity rates at city shelters. But one shelter provider, Alpha Project, says it previously requested more frequent county testing weeks after the Convention Center operation ended and as the delta variant hit San Diego, but did not get it.
The county maintains it wasn’t aware of the requests, which the nonprofit says it had communicated to the city’s Housing Commission. The Housing Commission, meanwhile, says it was only aware of one specific request that it worked with the county to address.
The dispute over what Alpha Project requested, and the sudden spike in cases at Father Joe’s, sheds light on the city, county and shelter operators’ struggles to protect vulnerable residents in congregate settings considered particularly at risk of outbreaks more than a year into a public health emergency.
The county’s testing plans changed when, from Aug. 20 through last Friday alone, Father Joe’s learned 90 of its shelter residents had tested positive for COVID-19. The nonprofit and the county organized three rounds of tests after eight clients with symptoms tested positive.
The outbreaks set off a scramble. Last Friday, Father Joe’s put up an open-air outdoor isolation tent in a gated area outside its Paul Mirabile Center shelter in East Village, which recorded 62 cases in August, and to clear a second-floor space at its downtown Golden Hall shelter, which saw 36 cases. It coordinated with the city on the isolation spaces and needed supplies and services. The county also offered monoclonal antibody treatment to help some shelter residents fight off COVID-19.
Father Joe’s reports it took as long as four days for shelter residents who received positive test results to move from the makeshift isolation areas into county hotel rooms, though some moved there within a few hours.
“We had to try to temporarily isolate people longer than we ever had to do before,” said Dr. Jeffrey Norris, Father Joe’s chief medical officer.
He said the county’s hotel rooms had typically been available the same day. In the past, Father Joe’s has temporarily isolated shelter residents in conference rooms — or even bathrooms — with cots under the watchful eye of nonprofit staffers while they waited for rooms.
Then came the surge of cases.
Marlon “Mo” Saville, 44, said he was one of the Father Joe’s residents who got a positive test result two weeks ago. Saville said he had heard increasing coughing in the men’s shelter and worried about COVID-19 before he was tested. Then he started getting mild symptoms.
Saville said he and about a dozen others had waited 12 hours — much of it in an outdoor gated area on the shelter campus – to be taken to county hotel rooms. At one point, Saville said a Father Joe’s staffer showed him and others who were waiting in a bathroom where they could potentially isolate. Saville was relieved when they didn’t stay there.
Saville, who said he is immunocompromised, said he has gotten emotional when he considers how things could have gone. He spent almost two weeks at Crowne Plaza, the county’s foremost isolation hotel.
“I realized I could have died,” Saville said.
As test results came back, the city and Father Joe’s decided to stop welcoming newcomers at the two shelters.
The county is now starting weekly testing at city-funded shelters. Before the Father Joe’s outbreaks, the county recently tested residents at most city shelter residents once a month. (Downtown shelter provider PATH says it has, until this week, relied on its partner, Family Health Centers of San Diego, for testing.)
Bob McElroy, Karen Pucci and Jesse Miller of Alpha Project said the nonprofit requested more frequent testing from the county via the Housing Commission, which oversees city shelter contracts, at its East Village and Barrio Logan shelters in part out of fear the delta variant could spread in its shelters. They had also expected more regular testing when they moved out of the Convention Center.
“We ask, and whether we receive it or not is a different story,” said Pucci, Alpha Project’s senior director of special projects.
Pucci said Alpha Project’s past requests went unfulfilled — other than when county testing revealed two cases at one of its shelters in late July. The county returned a week later for another round of tests on Aug. 5.
The county is now set to return to the nonprofit’s shelters on Friday as it begins weekly testing – a month later.
County spokeswoman Sarah Sweeney wrote in an email that the county fulfilled all requests for additional testing that it knew of and has coordinated closely with the city and the Housing Commission on testing and other needs at city shelters.
“The county is not aware of any instance where Alpha Project requested testing and it was not provided,” Sweeney said.
Housing Commission spokesman Scott Marshall wrote in an email that the city agency has served as a liaison between the county and shelter operators to coordinate testing and that the county has decided how often testing occurs based on positivity rates.
He acknowledged shelter operators sometimes inquire about testing schedules but said the agency was only aware of a single request by Alpha Project for more testing, specifically after the July incident Alpha Project referenced where two people at one of their shelters tested positive. In response, Marshall wrote, the commission worked with the county to schedule more testing a week later.
Barbara Poppe, who once led the U.S. Interagency Council and more recently provided input on a San Diego State review of the county’s COVID hotel program, said increased testing will be a crucial tool to protect people staying in city shelters. Regular testing allows shelters to better combat outbreaks.
“You only know you have an outbreak if you have testing,” Poppe said.
Other experts say the rash of cases in San Diego homeless shelters was virtually inevitable amid the rise of the delta variant even with safety protocols the city says it instituted when it reactivated city shelters.
Outbreaks have popped up at homeless shelters across the country this summer, including an outbreak of more than 100 people staying at Sonoma County’s largest shelter and more than three dozen cases at a Gainesville, Fla. shelter.
And even before the delta variant struck, the Convention Center was hit with more than 200 cases last December after city officials for months touted the low number of cases and safety procedures there.
Complicating matters, local providers and homeless advocates report lower-than-average vaccination rates among homeless San Diegans due to skepticism many have about the government and health systems.
“It’s an absolutely impossible situation, and if we keep people in congregate settings that are crowded, it is very, very difficult,” said Dr. Margot Kushel, director of the UC San Francisco’s Center for Vulnerable Populations. “This disease has always been very infectious, but the delta variant is so much more infectious.”
For now, the city and other shelter providers funded by the city say they haven’t seen spikes in cases at other shelters.
In the aftermath of the Father Joe’s outbreaks, Marshall said city shelters are continuing to follow mitigation procedures based on guidance from the county, CDC and lessons learned during the Convention Center operation. He shared a reference guide provided to shelter operators he said is regularly updated that describes enhanced sanitation, daily public health screenings, mask requirements and steps shelters must take when a person tests positive or shows COVID-like symptoms.
The city isn’t planning to reduce bed counts at city-funded homeless shelters where occupancies have already been dialed back during the pandemic or to try to move more shelter residents to hotel rooms unless they contract COVID-19.
Yet McElroy said the surge of cases at the two Father Joe’s rattled him.
At the Convention Center, the Alpha Project CEO said, protocols and resources for residents with COVID-like symptoms or who had tested positive were more seamless. McElroy said shelter providers and residents benefited from on-site medical care, isolation and assessment areas and seemingly easier access to county hotel rooms.
“We’ve got lots of people in a relatively confined area doing the best we can, and we need the backup resources that we had before,” McElroy said.
Among the new challenges has been accessing county hotel rooms for people who show symptoms or have tested positive.
This summer, Pucci said bridge shelter workers sometimes called ambulance provider American Medical Response to take shelter residents stuck in a small isolation tent to the hospital rather than have them continue to wait for an untold period of time for a hotel room.
“My clients are people too and I would never want a client to stay in an isolation tent for hours and hours, hot, waiting to go to lodging,” Pucci said. “It’s not fair to them. It’s not compassionate.”
Though PATH has not had any COVID cases recently, spokesman Tyler Renner said it hadn’t encountered the issues with hotel placements that Alpha Project described.
For more than a year, advocates have argued that the city and county should proactively move more homeless San Diegans out of shelters and off the streets to protect them from COVID.
Federal authorities and medical experts who work with homeless patients have also cautioned that non-congregate spaces are the safest options, particularly for homeless people who are medically vulnerable.
Dr. Kelly Doran of New York University’s School of Medicine emphasized that risk on Twitter last week after seeing news of the Father Joe’s outbreak.
“Any locality not moving people experiencing homelessness out of congregate shelters into safer non-congregate locations in the midst of this delta COVID surge is willfully putting human beings at risk,” wrote Doran, an emergency physician and a researcher who has focused on the homeless population.
Doran later told VOSD she doesn’t believe cities like San Diego are actively trying to do harm but that many have been too optimistic as they try to balance competing priorities including moving homeless people off the streets.
“We know the science,” Doran said. “We know congregate settings are risky.”
Some homeless San Diegans have moved into hotel rooms, though most haven’t moved there from shelters unless they test positive or are exposed to someone with COVID-19.
Through May, the county reported it had temporarily sheltered more than 4,300 homeless San Diegans considered at high risk of complications if they contract COVID-19 and nearly 5,800 people who did not have a safe place to isolate after testing positive or being exposed. Some but not all of the latter group have been homeless. The county plans to seek federal emergency fund reimbursements to support the hotel effort.
“As it has throughout the pandemic, the county is working with community service providers to make sure people experiencing homelessness who test positive for COVID-19 have a place to safely isolate and recover. To that end, we are housing people in our public health hotels and are providing a variety of services to any of those isolating in shelters,” Sweeney, the county spokeswoman, wrote.
As of May 31, the county had 151 hotel rooms for people who needed a safe place to isolate and 640 rooms for homeless San Diegans considered high risk. The county did not provide updated numbers on its hotel rooms or how many were filled this week, despite requests from VOSD.
The city’s Housing Commission earlier this year issued a call to service providers to see if they could support a city non-congregate shelter program. After that process, city officials decided providers couldn’t supply needed case management support.
Dave Rolland, a spokesman for Mayor Todd Gloria, noted in a statement that the mayor’s budget this year included $300,000 to support expanded workforce education for the homeless service sector in hopes the city can have more options in the future.
“Until that capacity grows, and a city-run program becomes feasible, people experiencing homelessness within the city of San Diego who need to isolate are referred to the county’s non-congregate shelter program,” Rolland wrote.