Estimating COVID-19 vaccine uptake and its drivers among migrants, homeless and precariously housed people in France

COVID-19 vaccination at a hospital in Paris: Spatial analyses and inverse equity hypothesis

Background

Vaccination against SARS-CoV-2 has been deployed in France since January 2021. Without specific action for different population subgroups, the inverse equity hypothesis postulates that people in the most deprived neighbourhoods will be the last to benefit. The article aims to study whether the inverse care law has been verified in the context of vaccination against SARS-CoV-2 from a vaccination centre of a hospital in the Paris region.

Methods

We performed a spatial analysis using primary data from the vaccination centre of the Avicenne Hospital in Bobigny from January 8th to September 30th, 2021. Primary data variables include the vaccinated person's date, age, and postal address. Secondary data calculates access times between residential neighbourhoods and the vaccination centre and social deprivation index. We performed flow analysis, k-means aggregation, and mapping.

Results

32,712 people were vaccinated at the study centre. Vaccination flow to the hospital shows that people living in the most disadvantaged areas were the last to be vaccinated. The number of people immunized according to the level of social deprivation then scales out with slightly more access to the vaccination centre for the most advantaged. The furthest have travelled more than 100 km, and more than 1h45 of transport time to get to this vaccination centre.

Conclusion

The study confirms the inverse equity hypothesis and shows that vaccination preparedness strategies must consider equity issues. Public health interventions should be implemented according to proportionate universalism and use community health, health mediation, and outreach activities for more equity.

A conceptual framework to model social determinants of COVID-19 vaccination uptake among underserved homeless populations

Background

 Homeless people have a higher risk of COVID-19 infection, linked to several social, economic and environmental determinants, frequent comorbidities, obstacles to exercising their constitutional social and health rights, poor medical cover, and insufficient use of the healthcare system. Data on COVID-19 vaccine uptake and its main determinants are lacking for this underserved population.

Objectives

 To construct and test a conceptual framework to model structural social determinants of COVID-19 vaccine uptake among underserved homeless populations, and to test this model to identify the determinants of COVID-19 vaccine uptake on the homeless population living in two metropolitan areas in France.

Methods

 We implemented a multicenter cross-sectional survey from 15/11/2021 to 22/12/2021 in homeless adults in the city of Marseille and in the greater Paris area. Persons sheltered in migrant worker hostels or in emergency social shelters, members of the COVID HOMELESS cohort study in Marseille, and Travelers living in traditional housing were all eligible. A standardized face-to-face questionnaire was administered to the participants where they lived in various languages by trained interviewers. We used structural equation modeling to analyze the structural social determinants of COVID-19 vaccine uptake, the latter defined as receiving at least one dose.

Results

 The participation rate was 64 %, accounting for 3811 participants. There were three main factors associated with greater vaccine uptake: i) opportunity, which included having a personal general practitioner (β = 0.05, p < 0.05), healthcare cover (β = 0.05, p < 0.05), and somebody to accompany the participant for medical appointments (β = -0.04, p < 0.05); ii) motivation, which included attitudes towards vaccination (β = 0.55, p < 0.05), press- and poster-based information (β = 0.03, p < 0.05), and vaccination history (β = 0.03, p < 0.05); iii) type of housing (β = 0.13, p < 0.05) and housing stability (β = 0.04, p < 0.05).

Conclusion

 Our results highlight that housing exclusion is a structural social determinant of COVID-19 vaccine uptake in homeless people in France. They also underline the role which opportunity and motivation play in improving uptake in this underserved homeless population.

Assessment of the impact of the vaccine pass policy on COVID-19 vaccine hesitancy and uptake among Chinese adults in Hong Kong

BACKGROUND

Recognising the importance of attaining high vaccine coverage to mitigate the COVID-19 impact, a Vaccine Pass scheme was implemented during and after the first large Omicron wave with high mortality in older ages in Hong Kong in early 2022 requiring three doses by June 2022. We did not identify any studies evaluating the policy impact of vaccination mandates with vaccine uptake over whole policy period of time in a Chinese population. We aim to evaluate the impact of the Vaccine Pass policy on COVID-19 vaccine uptake in adults in a Chinese population in Hong Kong.

METHODS

We analysed patterns in vaccine uptake and hesitancy using local data from population vaccine registry and 32 cross-sectional telephone surveys conducted from October 2021 to December 2022. The association of Vaccine Pass phases with vaccine uptake was examined using logistic regression analyses, taking into account covariates including self-risk perception, perceived self-efficacy in preventing COVID-19 and trust in government in pandemic control as well as physical distancing measures and demographics.

RESULTS

The uptake of primary series and third doses was positively significantly associated with the successive stages of Vaccine Pass implementation (adjusted odds ratios ranged from 2.41 to 7.81). Other statistically significant drivers of uptake included age group, chronic condition, higher perceived personal susceptibility to COVID-19, higher trust in government, and higher educational attainment.

CONCLUSION

Vaccine uptake in older adults was observed to have increased by a greater extent after the policy annoucement and implementation, under the contextual changes during and after a large Omicron wave with high mortality in Hong Kong in early 2022. Since the policy withdrawal the uptake of further booster doses has been very low in all ages. We suggest that improving voluntary booster uptake in older adults should be prioritized.

Impact of COVID-19 on individuals experiencing homelessness: Lessons learned and recommendations for practitioners

The COVID-19 pandemic, which brought about unprecedented changes globally, shed light on the significant disparities faced by persons experiencing homelessness (PEH). These individuals faced an elevated risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to factors such as lack of safe housing, limited access to hygiene and sanitation, and communal living situations. The unique challenges, vulnerabilities, and effects of COVID-19 on PEH is discussed, as well as lessons learned from these experiences, recommendations for practitioners, and the ongoing implications for addressing homelessness.

COVID-19 vaccination uptake and receptivity among veterans enrolled in homelessness-tailored primary health care clinics: provider trust vs. misinformation

BACKGROUND

Compared to the general population, individuals experiencing homelessness are at greater risk of excess morbidity and mortality from COVID-19 but have been vaccinated at lower rates. The U.S. Department of Veterans Affairs (VA)'s Homeless Patient Aligned Care Team (HPACT) program integrates health care and social services for Veterans experiencing homelessness to improve access to and utilization of care.

METHODS

This study explores the vaccination uptake behavior and attitudes through a qualitative comparative case study of two HPACT clinics, one in California (CA) and one in North Dakota (ND). Semi-structured telephone interviews were conducted with Veterans enrolled in the two VA HPACT clinics from August to December 2021 with 20 Veterans (10 at each clinic).

RESULTS

Four themes emerged from the interviews: (1) Vaccination uptake and timing- While half of the Veterans interviewed were vaccinated, ND Veterans were more likely to be vaccinated and got vaccinated earlier than CA Veterans; (2) Housing- Unsheltered or precariously housed Veterans were less likely to be vaccinated; (3) Health Care- Veterans reporting positive experiences with VA health care and those who trusted health providers were more likely to vaccinate than those with negative or nuanced satisfaction with health care; (4) Refusers' Conspiracy Theories and Objectivity Claims- Veterans refusing the vaccine frequently mentioned belief in conspiracy theories while simultaneously asserting their search for objective information from unbiased sources.

CONCLUSIONS

These findings amplify the importance of improving access to population-tailored care for individuals experiencing homelessness by reducing patient loads, expanding housing program enrollment, and increasing the provider workforce to ensure personalized care. Health care providers, and housing providers, social workers, and peers, who offer information without discrediting or criticizing Veterans' beliefs, are also key to effectively delivering vaccine messaging to this population.

A systematic review and meta-analysis of the global prevalence and determinants of COVID-19 vaccine acceptance and uptake in people living with HIV

People living with HIV (PLHIV) are at higher risk of poor outcomes of SARS-CoV-2 infection. Here we report the pooled prevalence of COVID-19 vaccine acceptance/uptake and determinants among this vulnerable population of PLHIV based on a systematic review and meta-analysis of studies published by 25 August 2023. Among the 54 included studies (N = 167,485 participants), 53 (N = 166,455) provided data on vaccine acceptance rate, while 27 (N = 150,926) provided uptake data. The global prevalences of COVID-19 vaccine acceptance and uptake were 67.0% and 56.6%, respectively. Acceptance and uptake rates were 86.6% and 90.1% for the European Region, 74.9% and 71.6% for the Region of the Americas, 62.3% and 78.9% for the South-East Asian Region, 64.6% and 19.3% for the Eastern Mediterranean Region, 58.0% and 35.5% for the African Region, and 57.4% and 44.0% for the Western Pacific Region. The acceptance rate increased from 65.9% in 2020 to 71.0% in 2022, and the uptake rate increased from 55.9% in 2021 to 58.1% in 2022. Men, PLHIV aged ≥40 years and those who had recently received the influenza vaccine were more likely to accept and receive the COVID-19 vaccine. Factors associated with lower uptake included Black race, other races (Latinx/Hispanic/mixed race), low education level and being unemployed. Vaccine-related factors associated with higher acceptance included belief in vaccine effectiveness, vaccine trust, perceived high susceptibility to SARS-CoV-2 infection and fear of potential COVID-19 effect in PLHIV. Sustained efforts and targeted interventions are needed to reduce regional disparities in COVID-19 vaccine uptake among PLHIV.

Vaccine acceptance, determinants, and attitudes toward vaccine among people experiencing homelessness: a systematic review and meta-analysis

BACKGROUND

COVID-19 has caused millions of deaths globally, with vulnerable populations such as people experiencing homelessness (PEH) at higher risk. This systematic review and meta-analysis aims to identify the prevalence and key factors contributing to vaccine acceptance experienced by PEH.

METHODS

The protocol of this study was registered in PROSPERO (CRD42023391659). We included studies that reported relevant information about vaccine acceptance or vaccine hesitant/refusal among PEH. Eight databases were systematically searched in January 2023. Meta-analysis was conducted for the prevalence of vaccine acceptance, vaccine uptake, and factors associated with vaccine acceptance. Attitudes toward vaccines were combined into bar charts.

RESULT

A total of 29 papers were included in this systematic review and 19 papers were included for meta-analysis. The pooled prevalence of COVID-19 vaccine acceptance among PEH was 66% (95%CI: 58%-73%). Our meta-regression showed vaccine acceptance was significantly increased over time. Moreover, subgroup meta-analysis showed that PEH were more likely to accept the COVID-19 vaccine after June 2021 (78%, 95%CI: 65%-86%) compared with earlier period (56%, 95%CI: 54%-59%). Subgroup meta-analysis also revealed that women and participants without underlying medical condition (chronic diseases) were significantly less likely to accept the COVID-19 vaccine, compared to men and those with medical conditions, respectively.

CONCLUSION

The study emphasizes the need for targeted public health interventions aimed at increasing vaccine acceptance among PEH, especially at the early stage of the pandemic, among females, those without underlying medical conditions, being Black (in Canada and the USA), and young people. These interventions should address the common concerns of vaccine safety, adverse effects, effectiveness, and distrust in health care systems. In addition to offering vaccinations in different areas convenient to them, education programs could be established to increase vaccine acceptance among PEH.

Sociodemographic disparities affect COVID-19 vaccine uptake in non-elderly adults with increased risk of severe COVID-19

BACKGROUND

There is limited information about sociodemographic disparities in COVID-19 vaccine uptake among non-elderly adults with an increased risk of severe COVID-19. We investigated the COVID-19 vaccine uptake in individuals aged 18-64 years with an increased risk of severe COVID-19 (non-elderly risk group) in Stockholm County, Sweden.

METHOD

We used population-based health and sociodemographic registries with high coverage to perform a cohort study of COVID-19 vaccine uptake of one to four doses up until 21 November 2022. The vaccine uptake in the non-elderly risk group was compared with non-risk groups aged 18-64 years (non-elderly non-risk group) and individuals aged ≥65 years (elderly).

RESULTS

The uptake of ≥3 vaccine doses was 55%, 64% and 87% in the non-elderly non-risk group (n = 1,005,182), non-elderly risk group (n = 308,904) and elderly (n = 422,604), respectively. Among non-elderly risk group conditions, Down syndrome showed the strongest positive association with receiving three doses (adjusted risk ratio [aRR] 1.62, 95% confidence interval [CI] 1.54-1.71), whereas chronic liver disease showed the strongest negative association (aRR 0.90, 95% CI 0.88-0.92). Higher vaccine uptake among the non-elderly risk group was associated with increasing age, being born in Sweden, higher education, higher income and living in a household where other adults had been vaccinated. Similar trends were observed for the first, second, third and fourth doses.

CONCLUSION

These results call for measures to tackle sociodemographic disparities in vaccination programmes during and beyond the COVID-19 pandemic.

Morbidity and mortality in a prospective cohort of people who were homeless during the COVID-19 pandemic

Introduction

Certain living conditions, such as homelessness, increase health risks in epidemic situations. We conducted a prospective observational cohort study to investigate the impact of the COVID-19 pandemic on morbidity and mortality in adult people who were homeless.

Methods

The study population comprised around 40% of the entire population experiencing homelessness in Marseille. They were enrolled at 48 different locations during the first pandemic wave (June to August 2020) and were followed up 3 and 6 months later. Rapid serological screening for SARS-CoV-2 was performed by community outreach teams at each follow-up, who also conducted interviews. Death registers and hospital administrative databases were consulted.

Results

A total of 1,332 participants [mean age 40.1 years [SD 14.2], women 339 (29.9%)] were enrolled in the cohort. Of these, 192 (14.4%) participants were found positive for COVID-19 and were propensity score matched (1:3) and compared with 553 non-COVID-19 cases. Living in emergency shelters was associated with COVID-19 infection. While 56.3% of the COVID-19-infected cohort reported no symptoms, 25.0% were hospitalized due to the severity of the disease. Presence of three or more pre-existing comorbidities was associated with all-cause hospitalization. Among COVID-19 cases, only older age was associated with COVID-19 hospitalization. Three deaths occurred in the cohort, two of which were among the COVID-19 cases.

Conclusion

The study provides new evidence that the population experiencing homelessness faces higher risks of infection and hospitalization due to COVID-19 than the general population. Despite the efforts of public authorities, the health inequities experienced by people who are homeless remained major. More intensive and appropriate integrated care and earlier re-housing are needed.