Sentinel surveillance and on-site testing in the homeless service sector


The deepening crisis amongst persons experiencing homelessness is a major concern for RNAO and one we are actively urging all levels of government to immediately address.

We asked Dr. Aaron Orkin, Population Medicine Lead with Inner City Health Associates (ICHA), to share with RNAO his expert advice about sentinel surveillance and on-site testing for persons experiencing homelessness in Toronto, which of course is applicable to any other city and jurisdiction.   

The importance of sentinel surveillance is well captured by comparing shelters and the populations we serve in long-term care facilities. We know that long-term care facilities act like canaries in the coal-mine of a broad epidemic – now, with growing numbers of nursing homes outbreaks and growing numbers of related deaths. We have been seeing that happen across North America and in Ontario over the last two weeks.

Shelters are analogous, but in some ways more calamitous for population health. The population in shelters is vulnerable, but largely less frail, and much more mobile and distributed than long-term care residents. There is no capacity to implement lock-downs, restrictive cohorting, or contain outbreaks in shelters in the same manner as is effective in long-term care. There is also much more limited healthcare infrastructure in shelters than in long-term care because shelters do not operate under the health care administrative umbrella. As a result, outbreak management, testing, and treatment procedures are less robust in shelters.

All this conspires to make shelter outbreaks dangerous for the shelter residents, for their staff and for the population at large. In effect, preventing and managing shelter outbreaks is a key element in preventing and managing the outbreak across the entire urban landscape. This is similar to long-term care because the outbreaks will be early and calamitous, but different because the outbreaks are perhaps harder to identify, harder to control, and result in wider community spread.

The goal of a sentinel surveillance program would be to identify COVID-19 in shelters earlier than we could identify it otherwise. So far, there have been a handful of confirmed cases in the shelter system in Toronto, but this is likely a severe underestimation. A large number of patients and clients in shelters are unable or very unwilling to go to a COVID-19 Assessment Centre, and therefore do not receive testing for COVID-19. There is no infrastructure for on-site testing (swabs, PPE, personnel). 

Dr. Orkin says that with support from the provincial government, a nimble partnership between COVID-19 Assessment Centers, an organization working with the homeless population, and public health could launch a sentinel surveillance program within days. He stresses that together, they would assemble small teams of staff, with the right equipment and supports, and go on-site to shelters. RNAO knows this is possible, we have leadership in Street Health  that would eagerly join a collective effort to massively scale up testing, and offer on-site nasopharyngeal swabs to anyone who was symptomatic, in our shelters. A partnering lab (hospital or public health) would provide prompt results under the structure of a surveillance program. Dr. Orkin adds that we would then be able to implement appropriate interventions in shelter settings, catch COVID-19 earlier in these high-risk settings, and reduce spread community-wide. This program could operate for people who are sleeping outside as well. I can see nursing leaders like Cathy Crowe, Kathy Hardill and many others echoing with a yes, yes, yes!

With ongoing surveillance in the shelter setting, we would also be able to use emerging hotel space more rationally and for the greatest impact.

A robust sentinel surveillance program in shelters will also be critical for the subsequent phases of the epidemic, says Dr. Orkin, referring to the time when we will be trying to determine whether there is ongoing transmission and identify facilities that are COVID-19 free. Ongoing surveillance will be critical for that in the shelters, otherwise COVID-19 transmission will continue in these facilities long after the epidemic has subsided elsewhere in the community, and will be an ongoing source of health problems, worker problems, and stigma.

In RNAO’s view, a sentinel surveillance program such as that proposed by Dr. Orkin, is both essential and urgent. We urge all levels of government to listen and act now by funding ICHA to bring together various stakeholders to come to the table and launch a sentinel surveillance program STAT. Inaction on this front will have devastating impacts on the homeless population and on the community at large.