Valesca Lima, UCD Geary Institute
The Coronavirus pandemic has posed significant challenges for homeless services and for people experiencing homelessness in Ireland. Clusters of Covid-19 have been identified among homeless groups, but the number of cases and deaths has been low. The relative success of the response to the pandemic, with low levels of infection and fatalities relating to Covid-19 amongst single homeless persons has shown that the rapid provision of emergency accommodation and innovative responses to drug use are not just possible, but effective. These are important lessons for policy discussions in the Irish post-Covid housing and homelessness context.
The Covid-19 pandemic has highlighted the urgency of providing adequate and appropriate accommodation for the most vulnerable groups within the context of strategies being implemented to curb the spread of the virus. When the stay-at-home orders came into effect in March 2021 in Ireland, having a home to stay in became an important aspect in the response to the spread of the virus, together with the recommendations to wear face coverings, to wash hands and to maintain social distancing from others. The lack of access to adequate housing and water/sanitation services placed homeless people at a greater risk.
Previous research has shown that people experiencing homelessness are more vulnerable to infectious diseases owing to them finding it difficult to adhere to public health directives and the high prevalence among them of long-term health conditions (Perri et al., 2020). In Ireland, the homeless community have been the most affected population group during the COVID-19 pandemic with 65% of homeless service providers stating that the homeless community’s health and wellbeing has been highly impacted (IGEES, 2021).
The high risk of transmission in congregate accommodation led to rapid interventions to reduce transmission risks such as testing, the use of single occupancy accommodation and the provision of extra emergency beds in hostels. Even though clusters of infection among people experiencing homelessness were identified, pragmatic responses alongside well-coordinated actions by health services, homeless organisations and local authorities during the pandemic saved lives and ensured that such a vulnerable group was protected (O’Carroll et al., 2020; Finnerty and Buckley, 2021). These results were particularly positive in Dublin during the country’s first wave of Covid-19.
Trends of Covid-19 Infection Among Single Homeless Adults
Given that people experiencing homelessness are at a higher risk of contracting such a virus and are thus considered a vulnerable group, from the outset of the pandemic in Ireland policy responses have been targeted at this group. A safety net was put into place with services being reconfigured to respond to the specific needs of people in situations of homelessness in order to support them. Pandemic protocols and guidance were created by the HSE Social Inclusion Division and sent to local authorities by the Dublin Region Homeless Executive (DRHE). The mitigation strategies are summarised in Table 1 below.
Table 1 – Summary of temporary mitigation measures proposed by the HSE in order to respond to challenges caused by the pandemic amongst the homeless population.
|Individual prevention (hygiene and social distancing).|
|Triage and testing – both outreach and inreach.|
|Restrictions on visitors to homeless accommodation.|
|Special provision for people who use drugs or are on drug maintenance programs.|
|Decrease in density in existing emergency hostels with the provision of dedicated accommodation for self-isolation/quarantine.|
Prevention measures such as social distancing, hygiene, shielding and containment (self-isolation) were seen as key to reducing the spread of the virus but difficult to implement. The immediate identification and testing of symptomatic homeless people was implemented, with 750 symptomatic clients being tested by early June and 120 people being moved from high occupancy units to new reduced-occupancy accommodation (O’Carroll et al., 2020). Visitors to homeless settings were restricted and kept to a minimum. People who used drugs were fast tracked in terms of being enrolled in methadone programs along with the ‘delivery’ of methadone for those isolating or shielding.
Decreasing occupancy levels in homeless accommodation involved the provision of extra emergency accommodation, in which individual rooms were made available. Most emergency hostels reduced their bed numbers in order to provide more space for clients and staff and three facilities were closed altogether in line with public health advice from the HSE (Kelleher and Norris, 2020). The DRHE also reported the sourcing of new beds with a view to increasing capacity, with some facilities being converted into 24-hour accommodation. According to the DRHE, there were just over 3,000 emergency beds in place throughout the Dublin region (mostly in the city) in December 2020 in order to comply with social distancing rules (Housing SPC, 2021).1
According to a homeless service user survey carried out by the HSE Social Inclusion Office, 70% of survey respondents were satisfied with the health service and/or supports received and over 50% of respondents reported positive changes to their overall health and well-being (HSE, 2020b).
Number of Outbreaks in Homeless Facilities
Preventative measures, along with a rapid crisis response by agencies involved with the homeless (the DHRE, HSE Social Inclusion, homeless services providers, local authorities) were introduced to keep and expand homeless services throughout the COVID-19 period. By early June 2020, there was only one death related to Covid-19 among the homeless population and 63 cases, a fraction of what had been initially predicted in Dublin, as shown in Figure 1 (O’Carroll et al., 2020).
Figure 1 – Predicted vs Actual Number of Covid-19 Deaths in the Homeless Sector.
By 29 July 2020, 15 coronavirus cases were associated with four clusters (Oireachtas, 2020). As observed in a report by Finnerty and Buckley (2021), the low levels of infection and mortality amongst people experiencing homelessness during the first wave of the pandemic (March-August 2020) is explained by the early recognition of homeless clients as a highly vulnerable group, and the expansion and acceleration of homeless services. The report also notes that, different to other countries, Ireland did not release a national homeless plan for Covid-19 nor did it create a task-force to address the crisis, working instead with guidelines and recommendations.
Table 2 – Homeless Clusters/Outbreak Figures During the Pandemic, Nationally
|Date range||Number of outbreaks|
|01/03/2020 – 31/08/2020||5|
|01/09/2020 – 30/11/2020||6|
|01/12/2020 – 16/03/2021||28|
Data from the HPSC encompassing the three waves of the pandemic in Ireland shows that there were 39 COVID-19 outbreaks in homeless facilities reported to the HPSC between 1 March 2020 and 16 March 2021, as seen in Table 2. A total of 222 confirmed COVID-19 cases were linked to these outbreaks and four of these have died.2
Single Adults Presentations and Exiting in Dublin
In December 2019, there were 2,586 single adults in emergency accommodation in the Dublin region. By December 2020, this number had increased to 3,037 (DRHE, 2020, 2021). Between January and December 2019, an average of 156 single adults entered emergency accommodation for the first time each month, a total of 1,870 individuals. In 2020, there was a slight decrease, with 1,660 individuals accessing emergency accommodation for the first time. The breakdown is outlined in Table 3 below.
In 2019, 575 single adults exited emergency accommodation into new tenancies, while in 2020 this number increased to 1,006, as shown in the Figure 2 breakdown below. The number of people exiting homelessness into tenancies was higher in 2020 (+431) than in 2019 (pre-pandemic). The increased number of exits seems to be connected to new tenancies in social housing as well as tenancies sourced in the Private Rental Sector via HAP (Housing Assistance Payment). According to DRHE reports, 264 new HAP tenancies were created in 2019 for single homeless people exiting emergency accommodation, while 640 were created in 2020, an increase of nearly 150%, confirming the trend of accommodating people in need of social housing in the private rental sector.
Table 3 – Singles, New Presentations per Month (2019-2020) in Dublin
|Month||Total Singles (2019)||Total Singles (2020)|
Figure 2 – Singles, Homeless Exits in 2019 by Tenancy Type in Dublin
Innovative Responses To Drug Use And Restructuring of Services
The COVID-19 pandemic raised grave concerns for people who are homeless and use drugs. In March 2020, the HSE published a ‘Guidance on Contingency Planning for People who use Drugs and COVID-19’ (HSE, 2020c). In addition to rapid testing and the evaluation of housing needs, this plan guided the support and treatment of substance use, recognising that harm reduction interventions for substance users were necessary (HSE, 2020). Harm reduction strategies for people who use drugs during the COVID-19 pandemic have included: opiate substitution therapy (OST); naloxone; and benzodiazepine (BZD) maintenance. Table 4 below outlines these harm reduction actions.
Table 4 – Harm Reduction Interventions for Those Who Were Using Drugs during the Pandemic
|Opiate Substitution Therapy (OST)||Two key changes: faster access to the OST programme and the dispensing of methadone. – Reduced waiting times and removal of caps on recruitment to OST. Waiting times were reduced from 12-14 weeks to 2–3 days. – Access was further expanded and improved by other treatment clinics agreeing to take on homeless patients who were resident in their catchment areas. – Staff were authorised to collect clients’ OST medications and deliver to clients’ place of isolation.|
|Naloxone||Access pathways to Naloxone, a prescription-only medication used for treatment in opioid overdose cases, were relaxed. – The new guidelines recommend that everyone in receipt of OST should be offered and encouraged to take a supply of naloxone. – It was to be administered by a person trained in its use and the injectable product used instead of the intranasal product. – Access was then extended to those most at risk of overdose in the evolving situation, and packs were distributed to those using a needle and syringe programme by Ana Liffey Drug Project.|
|Benzodiazepine maintenance||– The use of BZD in Ireland is normally restricted to detoxification but due to the pandemic, the national contingency guidelines recommended that isolating clients of treatment services could be offered up to 30 mg daily in divided doses using 2mg tablets to prevent withdrawals for the period of isolation. – Staff were allowed to deliver medications to clients in their accommodation.|
People experiencing homelessness who were substance users were offered support to both reduce the risk of contracting the virus among this cohort and to reduce the risk of harm to individuals. The IGEES (2021) noted that addiction treatment services during the pandemic have focused on continuity of care for those already in treatment and faster induction to treatment for those who are opioid dependent. For example, in Ireland, the focus of national guidelines for the treatment of BZD use is detoxification, not maintenance (HRB, 2020b) but there has been an increase in Benzodiazepine prescriptions to allow the easier stabilisation of drug use during isolation (IGEES, 2021).
In summary, the restructuring of services to meet client needs in light of COVID-19 have included:
1. Administrative changes, faster processing of clients into treatment, electronic transfer of prescriptions between doctors and pharmacies, and reductions in waiting times to start treatment;
2. Changes in regulation, with temporary amendments to the Medicinal Products Regulations (2020) and Misuse of Drug Regulations (2020)3, as amended, ensuring that patients can continue to access their ongoing treatment and ‘regular’ medicines during the ongoing emergency and to assist in easing the additional burdens on prescribers and pharmacists arising from the pandemic as well as the extension of the validity of prescriptions from six to nine months.
Homeless and drug treatment services in Ireland have adapted innovatively to the challenges with both positive and negative results. On the one hand, the rapid adaptation of existing services, the redeployment of staff, the creation of new protocols and guidelines, the faster processing of clients into drug treatment, and new collaborations among homeless service providers were important changes in policy practices. On the other hand, reduced availability when it comes to buying drugs and the reduced ability to collect drugs (e.g. because of lockdown restrictions), resulted in the reporting of increased overdoses and drug related deaths (IGEES, 2021).
The pandemic has had a significant impact on the delivery of services for homeless people. The restructuring of services was successful in limiting the direct effects of COVID-19 transmission and infection. While a combination of these elements was a key determinant of policy success, the future impact and continuation of these services after the pandemic is unclear. Health practitioners, homelessness organisations and homeless service providers have recommended that the changes be retained in the post-Covid era.
DRHE, Dublin Region Homeless Executive (2021). Report to the Joint Committee on Housing, Local Government and Heritage. 29th January 2021. Available at: https://data.oireachtas.ie/ie/oireachtas/committee (Accessed on 16 Mar 2021).
Baggett, T.P., Racine, M.W., Lewis, E., De Las Nueces, D., O’Connell, J.J., Bock, B., Gaeta, J.M., 2020. Addressing COVID-19 Among People Experiencing Homelessness: Description, Adaptation, and Early Findings of a Multiagency Response in Boston. Public Health Rep 135, 435–441.
DRHE, Dublin Region Homeless Executive, 2021. Dublin City Council reports Housing Special Policy Committee (Housing SPC, 11th March, Item No. 4ii). DRHE, Dublin, Ireland.
Finnerty, J., Buckley, M., 2021. Systems Accelerant? The Responses of Simon Communities To ‘First Wave’ Covid-19. Simon Communities of Ireland, University College Cork.
Health Research Board, 2020. Report on Irish response to Covid-19. Drugnet Ireland Autumn, 9–10.
HSE, Health Service Executive, 2020a. COVID-19 Guidance for Homeless Settings and other vulnerable group settings. Dublin, Ireland.
HSE Health Service Executive, 2020b. National COVID-19 Homeless Service User Experience Survey (Report of findings). HSE Social Inclusion Office, Dublin, Ireland.
HSE, Health Service Executive, 2020c. Guidance on Contingency Planning for People who use Drugs and COVID-19. Dublin, Ireland.
HPSC, Health Protection Surveillance Centre (2021). Computerised Infectious Diseases Reporting (CIDR) system at the Health Protection Surveillance Centre (HPSC) 22/03/2021. Dublin, Ireland.
IGEES, Irish Government Economic and Evaluation Service, 2021. Impact of COVID-19 on Drug and Alcohol Services and People who use Drugs in Ireland: A report of survey findings. Department of Health, Dublin, Ireland.
Kelleher, J., Norris, M., 2020. Day Services for People Who are Homeless in Dublin: A review commissioned by the Dublin Region Homeless Executive (DRHE). University College Dublin, Ireland.
Lewer, D., Braithwaite, I., Bullock, M., Eyre, M.T., White, P.J., Aldridge, R.W., Story, A., Hayward, A.C., 2020. COVID-19 among people experiencing homelessness in England: a modelling study. The Lancet Respiratory Medicine 8, 1181–1191.
O’Carroll, A., Duffin, T., Collins, J., 2020. Saving lives in the time of COVID-19. Case study of harm reduction, homelessness and drug use in Dublin, Ireland. (Report). London School of Economics and Political Science, London.
Oireachtas, H. of the, 2020. Public Health, Well-being and National Drugs Strategy: Statements – Dáil Éireann (33rd Dáil) – Thursday, 10 Sep 2020 – Houses of the Oireachtas.
Perri, M., Dosani, N., Hwang, S.W., 2020. COVID-19 and people experiencing homelessness: challenges and mitigation strategies. CMAJ 192, E716–E719.
1 It is unclear from the report whether this number refers to single people experiencing homelessness or homeless singles and families. It is likely to be the latter.
2 Data obtained from the HPSC on 22 March 2021 via direct request. Note that the number of confirmed COVID-19 cases linked to outbreaks in homeless facilities includes both service users and staff and that data regarding the homeless is still being updated and some historical cases have not been reconciled with the HPSC data up to the date of the consultation.
3 S.I. No. 98/2020 – Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations 2020 and S.I. No. 99/2020 – Misuse of Drugs (Amendment) Regulations 2020.