key: cord-1043972-qcvrnlkp
authors: Leifheit, Kathryn M; Chaisson, Lelia H; Medina, Jesus A; Wahbi, Rafik N; Shover, Chelsea L
title: Elevated mortality among people experiencing homelessness with COVID-19
date: 2021-06-04
journal: Open Forum Infect Dis
DOI: 10.1093/ofid/ofab301
sha: 92aa069bea99e2c323a56d0c9b52757d5993f021
doc_id: 1043972
cord_uid: qcvrnlkp

We reviewed publicly available data from major U.S. health jurisdictions to compare SARS-CoV-2 case fatality rates in people experiencing homelessness to the general population. Case fatality among people experiencing homelessness was 1.3 times (95% CI 1.1, 1.5) that of the general population, suggesting that PEH should be prioritized for vaccination.

People experiencing homelessness (PEH) are highly vulnerable to COVID-19 due to numerous factors including increased risk of SARS-CoV-2 exposure and infection. Lacking permanent shelter, PEH are less able to mitigate exposures through social distancing, often living doubledup with friends and family, in crowded shelter facilities, or in densely populated encampments.

Preventing infection may be challenging for PEH, as access to high-quality masks may be limited and inconsistent access to running water impedes hand hygiene. Throughout the pandemic, health authorities have reported high seroprevalence among PEH 1 and large outbreaks at homeless shelters and encampments. [2] [3] [4] Relatedly, research has linked evictions to community-level COVID-19 risk. 5 Once infected, PEH may be at elevated risk of COVID-19 morbidity and mortality.

Homelessness takes a dramatic toll on health, with life expectancies among the chronically homeless estimated to be as low as 42-52 years. 6 Weathering homelessness means that PEH develop age-related health problems decades earlier than their housed counterparts. 7, 8 Many of these conditions may increase risk for severe COVID-19 illness and death. For example, the prevalence of chronic obstructive pulmonary disease among PEH is 2-3 times that of the general population. 8, 9 Based on this underlying risk, a modeling study projected that 4% of the U.S. homeless population would require hospitalization due to COVID-19 and that nearly 1% would die. 10 Despite substantial vulnerability to COVID-19 among PEH, few data exist to gauge the impact of homelessness on COVID-19 outcomes. We reviewed publicly-available data in U.S. health jurisdictions to compare case fatality rates among PEH to population-wide case fatality rates.

A c c e p t e d M a n u s c r i p t 5

We queried publicly-available online data from government websites of public health agencies with jurisdiction over the 25 most populous U.S. counties, the 25 most populous U.S. cities (n=12 additional), and the most populous city in each state (n=39 additional) to identify PEHspecific COVID-19 case and mortality data. We included data from March 1, 2020-February 28,

If PEH-specific data were available, we extracted the most recent cumulative case and death counts for PEH, as well as jurisdiction-wide case and death counts. Where possible, we also extracted data by age.

For each jurisdiction, we calculated PEH case fatality rates (CFRs, defined as deaths per 100 cases) and jurisdiction-wide CFRs, and compared these via relative risk (a ratio of PEH CFR over jurisdiction-wide CFR). We summarized CFRs and relative risk estimates across all jurisdictions as a population-weighted average. For jurisdictions with age-stratified data, we calculated age-specific CFRs and relative risk.

All analyses were based on publicly available, aggregate data collected by jurisdictions through routine public health surveillance. For this reason, our study is not considered human subjects research and was exempted from IRB review as well as requirements to obtain written consent.

A c c e p t e d M a n u s c r i p t 6

Of the 76 jurisdictions reviewed, 7 (9.2%) included data on PEH. In these jurisdictions the CFR for PEH ranged from 0.3% to 4.8%, compared to jurisdiction-wide CFRs that ranged from 0.6% to 2.5% (Figure 1a , relative risks ranging from 0.3 to 2.2). Across jurisdictions, the overall CFR was 2.1% (95% CI 1.8, 2.3) among PEH and 1.6% (CI 1.6, 1.6) for the general population 

We identified few jurisdictions reporting on COVID-19 among PEH; however, among jurisdictions that did report these data, PEH with COVID-19 had a 30% higher risk of death than the overall population. This increased risk was especially pronounced in younger age groups.

Our findings underscore the need to prioritize PEH for COVID-19 prevention interventions, including vaccination.

A c c e p t e d M a n u s c r i p t 7 Despite expanded COVID-19 vaccine eligibility throughout the U.S., PEH are at risk of being left behind in settings implementing appointment-based vaccination at hospitals, pharmacies, and mass vaccination centers. Leveraging homeless outreach and healthcare personnel to offer vaccines to PEH in encampments and shelters will prevent COVID-19 morbidity and mortality while promoting health equity. In addition to promoting vaccination, interventions such as isolation and quarantine rooms, along with more permanent housing options for PEH, should be central to discussions of pandemic mitigation moving forward.

We found substantial heterogeneity in case fatality and CFR ratios across jurisdictions, likely reflecting local differences in COVID-19 dynamics, surveillance and testing practices, homeless services, PEH living conditions (e.g. crowding, indoor vs. outdoor), and reporting. Careful evaluation of local COVID-19 prevention and control programs is important to identify effective strategies to reduce the burden of COVID-19 in PEH. Interestingly, we found that PEH cases >65 years had a lower risk of COVID-19 mortality than cases in Los Angeles' overall >65 population. The most likely explanation for this finding is survivor bias: on average, PEH who survive to age 65 without shelter may be less frail than older adults in the general population.

Given low life expectancy among PEH, 6 we also hypothesize differing age distributions, with fewer PEH aged ≥80. Importantly, however, older PEH remained at substantially elevated mortality risk compared with younger PEH.

There are several limitations to our study. Because so few jurisdictions published PEH-specific data and all but one of these jurisdictions were on the West Coast, the generalizability of our estimates may be limited. Since available PEH data were rarely disaggregated, we were not able to account for underlying differences such as age structure in our comparisons of PEH A c c e p t e d M a n u s c r i p t 8 versus jurisdiction-wide cases. Additionally, PEH status is prone to misclassification and differential classification across jurisdictions. Specifically, we expect that PEH not accessing homeless services would be misclassified as not PEH. Furthermore, screening programs by homeless services and health departments may increase detection of mild COVID-19 cases and asymptomatic SARS-CoV-2 infections among PEH compared with the general population.

Finally, deaths from substance use represent a substantial competing risk in our study.

Specifically, fentanyl-involved deaths have increased leading up to and during the COVID-19 pandemic, disproportionately rising among PEH. 11,12 Importantly, these limitations would likely lead to underestimation of the degree to which homelessness increases COVID-19 case fatality, strengthening our conclusion that PEH are a highly vulnerable population in need of effective interventions to prevent COVID-19.

Only seven of 76 jurisdictions reviewed published data on COVID-19 among PEH, likely because housing status is not routinely collected as part of public health surveillance. The paucity of COVID-19 data specific to PEH represents a limitation not just for our study, but for public health surveillance as a whole. Disaggregated data allow for development of targeted public health interventions that prioritize high-risk populations for case finding and vaccination.

Moreover, these data allow for monitoring of health inequities, documenting the degree to which PEH are disproportionately burdened by COVID-19. Moving forward, it is essential that data on homelessness be made available to understand the degree to which structural failures such as insufficient housing have compromised U.S. pandemic preparedness. Routinely collecting housing status as part of disease surveillance may pose logistical challenges in some jurisdictions; however, we see this as an important step for the control of COVID-19 and other infectious diseases in this high risk and underserved population.

A c c e p t e d M a n u s c r i p t 9

As COVID-19 vaccines bring new signs of hope, we urge public agencies to prioritize PEH for vaccination and other public health interventions. Past outbreaks and seroprevalence studies have shown that exposure and infection risk are extremely high among PEH. Our analyses suggest that COVID-19 may also be particularly deadly for this population, independent of age.

By bringing prioritizing PEH for interventions, public health agencies can prevent deaths, promote health equity, and reduce community transmission of COVID-19 in many of the country's hardest hit cities. 13 M a n u s c r i p t

Notes: Case fatality rates (CFRs) for each jurisdiction and age category appear on the primary (left) y-axis, with estimates for PEH appearing in light blue bars and jurisdiction-wide estimates appearing in dark blue. Relative risk (ratio of PEH vs. jurisdiction-wide CFR) appear on the secondary (right) y-axis

Seroprevalence and risk factors of exposure to COVID-19 in homeless people

Coronavirus is spreading under the radar in US homeless shelters

Prevalence of SARS-CoV-2 Infection in Residents of a Large Homeless Shelter in Boston

Coronavirus Disease 2019 Outbreak in a San Francisco Homeless Shelter

Expiring eviction moratoriums and COVID-19 incidence and mortality

Premature Mortality in Homeless Populations: A review of the literature

Hospitalized younger: A comparison of a national sample of homeless and housed inpatient veterans. J Health Care Poor Underserved

Geriatric syndromes in older homeless adults

Obstructive lung disease among the urban homeless

Estimated Emergency and Observational/Quarantine Capacity Need for the US Homeless Population Related to COVID-19 Exposure by County; Projected Hospitalizations, Intensive Care Units and Mortality

A c c e p t e d M a n u s c r i p t 11 A c c e p t e d M a n u s c r i p t