key: cord-307273-pplky6g4
authors: Schrooyen, Loïc; Delforge, Marc; Lebout, Faustine; Vanbaelen, Thibaut; Lecompte, Amaryl; Dauby, Nicolas
title: Homeless people hospitalized with COVID-19 in Brussels
date: 2020-08-07
journal: Clin Microbiol Infect
DOI: 10.1016/j.cmi.2020.08.002
sha: 
doc_id: 307273
cord_uid: pplky6g4

nan

To the editor, Compared to the general population, homeless people have higher mortality, both related to communicable and non-communicable diseases, partly explained by higher exposure to risk factors including alcoholism, illicit drug abuse and smoking(1,2). Transmissible infectious diseases contribute significantly to the morbidity and mortality of homeless(1). Notably, airborne diseases such as tuberculosis, influenza and pneumococcal pneumonia have been reported with increased incidence and severity in homeless population (2) . Shelters overcrowding and limited access to hygienic supplies could enhance the transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in this vulnerable population.

We assessed the prevalence, incidence and outcome of homeless patients hospitalized in our institution with COVID-19 between 3 rd March and 26 th May 2020. Sociodemographic features and risk factors were compared with those of non-homeless patients admitted during the same period. Only symptomatic hospitalized patients with SARS-CoV-2 positive RT-PCR or rapid antigen test with evidence of pneumonia on computed tomography were included. Nosocomial cases and pregnant women were excluded. Demographic data including age, gender, smoke, alcohol abuse, methadone therapy for opioid substitution, Human Immunodeficiency Virus, Hepatitis B Virus and Hepatitis C Virus serological status and chronic comorbidities as arterial hypertension, diabetes, obesity, neurological, cardiovascular and pulmonary diseases were collected. Homeless patients were retrospectively identified based on systematic social inquiry performed upon admission. In order to assess disease severity and outcome, each case (homeless) was matched to three controls based on sex and age categories. Nonparametric Wilcoxon's and Fisher's exact tests were used for continuous and binomial variables analyses, respectively. Between 3 rd March and 26 th May 2020, 14 homeless people were identified among 238 patients hospitalized for a COVID-19 pneumonia resulting in a homelessness prevalence of 5.88%. All but 3 resided in homeless shelters. Incidences of COVID-19 among homeless and non-homeless patients were calculated using homeless census report and our hospital catchment population. According to the last homeless census report, there were 2151 homeless people in Brussels in November 2018 (3) . Most of them were found to attend homeless shelters located in the downtown area surrounding our hospital. The Centre Hospitalier Universitaire (CHU) Saint-Pierre is a public tertiary hospital, working closely with public social services of the capital and is a referral center for resourcelimited patients in Brussels City. The estimated catchment population of our institution was 122.808 people in 2018 (data provided by the Federal Public Health Service, Food Chain and Safety Environment). For the reporting period, incidences were 650 and 194/100.000 hospitalized homeless and non-homeless patients for COVID-19, respectively.

The median age was 56.36 (Standard Deviation ±16.76) and 61.78 (Standard Deviation ±16.87) years old for homeless and non-homeless patients, respectively. We observed a male predominance in both populations (71.43% and 58.04%). Compared to nonhomeless patients, the homeless were more likely to smoke (OR 4.14, IC95 1.73-9.85), suffer from alcoholism (9.82, IC95 3.07-30.64), be treated with methadone for opioid substitution (OR 37.17, IC95 3.90-538.2) and have neurological diseases (OR 5.88, IC95 1.84-18.64). There was no difference between the 2 groups in terms of C-reactive protein and lactate dehydrogenase levels and lymphocytes count at admission, delay of symptoms before admission, Intensive Care Unit (ICU) admission, invasive ventilation, dialysis, treatment uptake with Hydroxychloroquine, length of stay (LOS) in ICU, total LOS in hospital and death. (table 1) In the present study, we found an incidence of hospitalization for COVID-19 three times higher in homeless as compared to the general population. A recent report in the USA identified a high prevalence (36%) of SARS-CoV-2 RT-PCR positivity in a homeless shelter (4) . Most subjects (88%) with positive RT-PCR in the latter study were asymptomatic, highlighting the risk of spread among residents of homeless shelters. We found a high but similar proportion of comorbidities (arterial hypertension, diabetes and cardiovascular diseases) in both populations hospitalized with COVID-19. Smoking, opioid substitution and alcohol abuse were highly prevalent among homeless patients as previously reported(1). The high prevalence of comorbidities and the increased exposure to risk factors in the homeless population could increase their risk of more severe disease and mortality following SARS-CoV-2 infection. Although more severe manifestations could explain higher hospitalization rates, the disease severity of the homeless included in this study tended to be reduced as compared to non-homeless with decreased rate of ICU admission and mechanical ventilation requirement and shorter hospital and ICU LOS. Moreover, a trend of shorter duration of symptoms upon admission in homeless patients was not evoking any delay in the access to care. The main limitation of our study is the small sample size of homeless group and the monocentric design. Larger studies are required to properly assess the outcome of COVID-19 in homeless patients.

In conclusion, we found a high incidence of hospitalization for COVID-19 among homeless patients in Brussels. They had high but similar proportion of comorbidities as compared to non-homeless. Outcome was not worse, although the interpretation is limited by the small sample size of homeless patients. Our results illustrate the urgent need for implementing strategies in order to stop the spread of COVID-19 in homeless population. Strategies based on wide scale preventing, screening and managing COVID- 

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