Responding to pandemics and other disease outbreaks in homeless populations: A review of the literature and content analysis

Colocation of COVID-19 Vaccination Services at Syringe Service Programs for People Who Inject Drugs and People Experiencing Houselessness in Oregon

OBJECTIVES

Integrating vaccination services with other essential health services could increase vaccination rates among socially marginalized populations. We examined the associations between colocation of vaccines at syringe service programs and COVID-19 vaccination status among people who inject drugs and people experiencing houselessness.

METHODS

This study included 1891 participants aged ≥18 years at 9 sites in Oregon from July 2021 through March 2022. Participants self-reported whether they had ever received ≥1 dose of a COVID-19 vaccine. We calculated site-level COVID-19 vaccine availability and overall vaccination rates. We compared site-level vaccination rates and analyzed the association between vaccine availability and vaccination status.

RESULTS

We found no significant difference in vaccination rates between sites that did and did not offer COVID-19 vaccines (t7 = -0.33; P = .75). We also found no significant association between vaccine availability and vaccination status. However, the odds of having received a COVID-19 vaccine were 2.79 times higher for each additional site visit during which COVID-19 vaccines were available (odds ratio [OR] = 2.79; 95% CI, 2.18-3.58; P < .001). The association between vaccine availability and vaccine status was not moderated by participant age (OR = 1.03; 95% CI, 0.99-1.07; P = .13) or housing instability (OR = 0.59; 95% CI, 0.13-2.60; P = .48).

CONCLUSIONS

Colocating COVID-19 vaccines at syringe service programs was only positively associated with vaccination status if vaccines were offered frequently on-site. Future work should examine whether the frequency of offering vaccination services increases willingness to engage in vaccination and examine trust and convenience as potential mechanisms.

Real-time evaluation of a multi-agency TB-screening event for persons experiencing homelessness in a town with a low incidence of TB in England

Real-time evaluation (RTE) supports populations (e.g., persons experiencing homelessness (PEH) to engage in evaluation of health interventions who may otherwise be overlooked. The aim of this RTE was to explore the understanding of TB amongst PEH, identify barriers/facilitators to attending screening for PEH alongside suggestions for improving TB-screening events targeting PEH, who have high and complex health needs. This RTE composed of free-text structured one-to-one interviews performed immediately after screening at a single tuberculosis (TB) screening event. Handwritten forms were transcribed for thematic analysis, with codes ascribed to answers that were developed into core themes. All RTE participants (n=15) learned about the screening event on the day it was held. Key concerns amongst screening attendees included: stigma around drug use, not understanding the purpose of TB screening, lack of trusted individuals/services present, too many partner organizations involved, and language barriers. Facilitators to screening included a positive welcome to the event, a satisfactory explanation of screening tests, and sharing of results. A need for improved event promotion alongside communication of the purpose of TB screening amongst PEH was also identified. A lack of trust identified by some participants suggests the range of services present should be reconsidered for future screening events.

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.

Interventions to mitigate the risks of COVID-19 for people experiencing homelessness and their effectiveness: a systematic review

Objectives

People experiencing homelessness also experience poorer clinical outcomes of COVID-19. Various interventions were implemented for people experiencing homelessness in 2020-2022 in different countries in response to varied national guidance to limit the impact of COVID-19. It is important to understand what was done and the effectiveness of such interventions. This systematic review aims to describe interventions to mitigate the risks of COVID-19 in people experiencing homelessness and their effectiveness.

Methods

A protocol was developed and registered in PROSPERO. Nine databases were searched for studies on interventions to mitigate the impact of COVID-19 on people experiencing homelessness. Included studies were summarised with narrative synthesis.

Results

From 8,233 references retrieved from the database searches and handsearching, 15 were included. There was a variety of interventions, including early identification of potential COVID-19 infections, provision of isolation space, healthcare support, and urgent provision of housing regardless of COVID-19 infection.

Conclusion

The strategies identified were generally found to be effective, feasible, and transferable. This review must be interpreted with caution due to the low volume of eligible studies and the low quality of the evidence available.

The Impact of Being Homeless on the Clinical Outcomes of COVID-19: Systematic Review

Objective: The homeless population experiences inequality in health compared with the general population, which may have widened during the COVID-19 pandemic. However, the impact of being homeless on the outcomes of COVID-19 is uncertain. This systematic review aimed to analyse the impact of experiencing homelessness on the clinical outcomes of COVID-19, including the effects on health inequalities. Methods: A review protocol was developed and registered in PROSPERO (PROSPERO registration 2022 CRD42022304941). Nine databases were searched in November 2022 to identify studies on homeless populations which contained primary research on the following outcomes of COVID-19: incidence, hospitalisation, mortality, long COVID, mental wellbeing, and evidence of inequalities. Included studies were summarised with narrative synthesis. Results: The searches yielded 8,233 initial hits; after screening, 41 studies were included. Overall, evidence showed that those in crowded living settings had a higher risk of COVID-19 infection compared to rough sleepers and the general population. The homeless population had higher rates of hospitalisation and mortality than the general population, lower vaccination rates, and suffered negative mental health impacts. Conclusion: This systematic review shows the homeless population is more susceptible to COVID-19 outcomes. Further research is needed to determine the actual impact of the pandemic on this population, and of interventions to mitigate overall risk, given the low certainty of findings from some of the low-quality evidence available. In addition, further research is required to ascertain the impact of long COVID on those experiencing homelessness, since the present review yielded no studies on this topic.

Diagnostic Accuracy of a Rapid SARS-CoV-2 Antigen Test Among People Experiencing Homelessness: A Prospective Cohort and Implementation Study

INTRODUCTION

Detection strategies in vulnerable populations such as people experiencing homelessness (PEH) need to be explored to promptly recognize severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks. This study investigated the diagnostic accuracy of a rapid SARS-CoV-2 Ag test in PEH during two pandemic waves compared with gold standard real-time multiplex reverse transcription polymerase chain reaction (rtRT-PCR).

METHODS

All PEH ≥ 18 years requesting residence at the available shelters in Verona, Italy, across two cold-weather emergency periods (November 2020-May 2021 and December 2021-April 2022) were prospectively screened for SARS-CoV-2 infection by means of a naso-pharyingeal swab. A lateral flow immunochromatographic assay (Biocredit^® COVID-19 Ag) was used as antigen-detecting rapid diagnostic test (Ag-RDT). The rtRT-PCR was performed with Allplex™ SARS-CoV-2 assay kit (Seegene). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated as measures for diagnostic accuracy.

RESULTS

Overall, 503 participants were enrolled during the two intervention periods for a total of 732 paired swabs collected: 541 swabs in the first period and 191 in the second. No significant differences in demographic and infection-related characteristics were observed in tested subjects in the study periods, except for the rate of previous infection (0.8% versus 8%; p < 0.001) and vaccination (6% versus 73%; p < 0.001). The prevalence of SARS-CoV-2 in the cohort was 8% (58/732 swabs positive with rtRT-PCR). Seventeen swabs were collected from symptomatic patients (7%). Among them, the concordance between rtRT-PCR and Ag-RDT was 100%, 7 (41.2%) positive and 10 negative pairs. The overall sensitivity of Ag-RDT was 63.8% (95% CI 60.3-67.3) and specificity was 99.8% (95% CI 99.6-100). PPV and NPV were 97.5% and 96.8%, respectively. Sensitivity and specificity did not change substantially across the two periods (65.1% and 99.8% in 2020-2021 vs. 60% and 100% in 2021-2022).

CONCLUSIONS

A periodic Ag-RDT-based screening approach for PEH at point of care could guide preventive measures, including prompt isolation, without referral to hospital-based laboratories for molecular test confirmation in case of positive detection even in individuals asymptomatic for COVID-19. This could help reduce the risk of outbreaks in shelter facilities.

Providing Housing First services for an underserved population during the early wave of the COVID-19 pandemic: A qualitative study

OBJECTIVE

We assessed the critical role of Housing First (HF) programs and frontline workers in responding to challenges faced during the first wave of the COVID-19 pandemic.

METHOD

Semi-structured interviews were conducted with nine HF frontline workers from three HF programs between May 2020 and July 2020, in Toronto, Canada. Information was collected on challenges and adjustments needed to provide services to HF clients (people experiencing homelessness and mental disorders). We applied the Analytical Framework method and thematic analysis to our data.

RESULTS

Inability to provide in-person support and socializing activities, barriers to appropriate mental health assessments, and limited virtual communication due to clients' lack of access to digital devices were among the most salient challenges that HF frontline workers reported during the COVID-19 pandemic. Implementing virtual support services, provision of urgent in-office or in-field support, distributing food aid, connecting clients with online healthcare services, increasing harm reduction education and referral, and meeting urgent housing needs were some of the strategies implemented by HF frontline workers to support the complex needs of their clients during the pandemic. HF frontline workers experienced workload burden, job insecurity and mental health problems (e.g. distress, worry, anxiety) as a consequence of their services during the first wave of the COVID-19 pandemic.

CONCLUSION

Despite the several work-, programming- and structural-related challenges experienced by HF frontline workers when responding to the needs of their clients during the first wave of the COVID-19 pandemic, they played a critical role in meeting the communication, food, housing and health needs of their clients during the pandemic, even when it negatively affected their well-being. A more coordinated, integrated, innovative, sustainable, effective and well-funded support response is required to meet the intersecting and complex social, housing, health and financial needs of underserved and socio-economically excluded groups during and beyond health emergencies.

Differential impacts of COVID-19 and associated responses on the health, social well-being and food security of users of supportive social and health programs during the COVID-19 pandemic: A qualitative study

The effects of the coronavirus disease-2019 (COVID-19) pandemic on the lives of underserved populations are underexplored. This study aimed to identify the impacts of the COVID-19 pandemic and associated public health responses on the health and social well-being, and food security of users of Housing First (HF) services in Toronto (Canada) during the first wave of the COVID-19 pandemic. This qualitative descriptive study was conducted from July to October 2020 in a subsample of 20 adults with a history of homelessness and serious mental disorders who were receiving HF services in Toronto. A semi-structured interview guide was used to collect narrative data regarding health and social well-being, food security and access to health, social and preventive services. A thematic analysis framework guided analyses and interpretation of the data. The COVID-19 pandemic and response measures had a variable impact on the health, social well-being and food security of participants. Around 40% of participants were minimally impacted by the COVID-19 pandemic. Conversely, among the remaining participants (impacted group), some experienced onset of new mental health problems (anxiety, stress, paranoia) or exacerbation of pre-existing mental disorders (depression, post-traumatic stress disorder and obsessive-compulsive disorder). They also struggled with isolation and loneliness and had limited leisure activities and access to food goods. The pandemic also contributed to disparities in accessing and receiving healthcare services and treatment continuity for non-COVID-19 health issues for the negatively impacted participants. Overall, most participants were able to adhere to COVID-19 public health measures and get reliable information on COVID-19 preventive measures facilitated by having access to the phone, internet and media devices and services. In conclusion, the COVID-19 pandemic and associated response measures impacted the health, social well-being, leisure and food security of people with experiences of homelessness and mental disorders who use supportive social and housing services in diverse ways.

Communicating Effectively With People Experiencing Homelessness to Prevent Infectious Diseases

Background

People experiencing homelessness (PEH) are disproportionately affected by many infectious diseases, including coronavirus disease 2019 (COVID-19). However, communication efforts during public health emergencies like the COVID-19 pandemic often do not consider the unique needs of PEH. We examined how PEH seek and receive health information and how traditional health communication methods resonate with them.

Methods

We conducted in-person focus groups with PEH in 4 jurisdictions (Cincinnati, Ohio; Denver, Colorado; Sacramento, California; and the Bronx, New York) during July 2021.

Results

Findings from 15 focus groups with PEH (n = 53) revealed the need for trusted messengers and consistent messaging across local organizations, as PEH seek to verify information they receive from multiple sources. PEH overwhelmingly preferred to receive health information through face-to-face conversations, especially with healthcare providers with whom they had an established relationship, but they also cited news media, the internet, and social media as their main sources for obtaining health information. PEH reported that effective communication products pair a recommended action with instructions and resources about how to take that action within their community.

Conclusions

These findings support healthcare providers collaborating with public health agencies to ensure that infectious disease prevention messages for PEH are provided by trusted messengers, multimodal, paired with resources, and consistent.

The effects of COVID-19 on the mental health and job stress of frontline homelessness services workers in Texas (U.S.)

As the COVID-19 pandemic persists in the U.S. and elsewhere, there is a growing need to understand the impacts of the pandemic on essential and frontline workers. Given the dearth of research on the experiences of homelessness services workers during the COVID-19 pandemic, this study aimed to understand the impact of COVID-related stressors in the workplace on the wellbeing of the homelessness services workers in the state of Texas (U.S.). Using a cross-sectional survey design, the analysis focusses on examining the relationship between COVID stressors with mental health symptoms and job stress indictors. Data were collected from a sample of 132 frontline homelessness services workers across the state during April, May and June of 2021. Primary outcomes of interest were measured with the Depression, Anxiety and Stress Scale (DASS-42) and the Professional Quality of Life Scale (ProQOL). Multiple linear regression models were specified to explore associations between the outcomes of interest and predictor variables (i.e. demographics, work experiences and COVID-19 stressors). Results showed that perceiving a decline in job satisfaction because of the COVID-19 pandemic was associated with higher stress (β = ++0.18), 95% CI [.13, 6.68], higher burnout (β = 0.32), 95% CI [2.54, 7.30] and lower compassion satisfaction (β = 0.42), 95% CI [-8.14, -3.69]. Additionally, being worried about contracting COVID-19 at work was associated with an increase in burnout (β = 0.19), 95% CI [.40, 4.79]. Also notable is that older age and Black/African American race were associated with lower stress, lower burnout and higher compassion satisfaction. Implications for supporting the homelessness sector through high-quality supervision, useful training, adequate benefits and routine check-ins are discussed.

How COVID-19 has impacted access to healthcare and social resources among individuals experiencing homelessness in Canada: a scoping review

OBJECTIVES

In Canada, individuals experiencing homelessness (IEH) rely on public health and social services for healthcare, food and basic necessities. The COVID-19 pandemic has disproportionately affected marginalised populations, in part by impacting their access to such services. We performed a scoping review to identify from the published literature how access to services has changed for Canadian IEH during the pandemic.

DATA SOURCES

OVID Medline, Web of Science, Sociological Abstracts, CINAHL and OVID EmCare databases, and websites for the Salvation Army, Homeless Hub, Canadian Alliance to End Homelessness, Canadian Network for the Health and Housing of People Experiencing Homelessness and BC Centre for Disease Control.

STUDY DESIGN

We used the scoping review methodology developed by the Joanna Briggs Institute framework and defined access to healthcare and social services using the 10-component Levesque framework. Academic databases and grey literature searches were used, with the final searches for each taking place 24 May and 1 June 2021, respectively. Data were compiled into an Excel spreadsheet. Title and abstract screening and full-text review were completed by two independent reviewers (RG and MM). Data extraction was completed by MM and cross checked by RG.

RESULTS

In total, 17 academic and grey literature articles were included. Positive and negative changes in service access were reported in the literature. During the COVID-19 pandemic, access to social and healthcare resources was generally reduced for Canadian IEH. A new component of access, digital connectivity, was identified. Unexpectedly, coordination and collaboration of services improved, as did the number of outreach services.

CONCLUSIONS

Positive changes to service access such as improved coordination of services should be scaled up. Further work should be done to improve access to digital technologies for IEH.

The Clinical and Genomic Epidemiology of Rhinovirus in Homeless Shelters-King County, Washington

BACKGROUND

Rhinovirus (RV) is a common cause of respiratory illness in all people, including those experiencing homelessness. RV epidemiology in homeless shelters is unknown.

METHODS

We analyzed data from a cross-sectional homeless shelter study in King County, Washington, October 2019-May 2021. Shelter residents or guardians aged ≥3 months reporting acute respiratory illness completed questionnaires and submitted nasal swabs. After 1 April 2020, enrollment expanded to residents and staff regardless of symptoms. Samples were tested by multiplex RT-PCR for respiratory viruses. A subset of RV-positive samples was sequenced.

RESULTS

There were 1066 RV-positive samples with RV present every month of the study period. RV was the most common virus before and during the coronavirus disease 2019 (COVID-19) pandemic (43% and 77% of virus-positive samples, respectively). Participants from family shelters had the highest prevalence of RV. Among 131 sequenced samples, 33 RV serotypes were identified with each serotype detected for ≤4 months.

CONCLUSIONS

RV infections persisted through community mitigation measures and were most prevalent in shelters housing families. Sequencing showed a diversity of circulating RV serotypes, each detected over short periods of time. Community-based surveillance in congregate settings is important to characterize respiratory viral infections during and after the COVID-19 pandemic.

CLINICAL TRIALS REGISTRATION

NCT04141917.

A Scoping Review of the Health Impact of the COVID-19 Pandemic on Persons Experiencing Homelessness in North America and Europe

Persons experiencing homelessness (PEH) are at heightened risk for infection, morbidity, and mortality from COVID-19. However, health consequences of the pandemic extend far beyond those directly caused by the virus. This scoping review aimed to explore the impacts of the COVID-19 pandemic on the health and well-being of PEH in North America and Europe. A systematic search of academic and grey literature was conducted in September 2021. To be included, studies had to include primary data related to the impact of the pandemic on health or well-being of PEH and be written in English. All potentially relevant references were independently screened by two reviewers, and minor conflicts were settled with input of a third reviewer. A total of 96 articles met criteria for inclusion. Data extraction was completed for all included studies, and findings synthesised and presented thematically. Numerous health impacts of the pandemic on PEH were identified, including SARS-CoV-2 infection, morbidity, mortality, and hospitalisation, fear of infection, access to housing, hygiene, PPE, food, as well as mental health, substance use, other health-related outcomes and treatment services. Gaps in the literature relating to persons using alcohol, access to mental health support, and violence were also identified. Implications for future research are discussed.

Vaccinating Veterans Experiencing Homelessness for COVID-19: Healthcare and Housing Service Providers' Perspectives

This study examines challenges experienced during COVID-19 vaccination efforts, facilitating factors that increased vaccination, and lessons learned from healthcare providers and housing program staff who delivered healthcare and services to Veterans experiencing homelessness during the SARS-CoV-2 pandemic. Qualitative, semi-structured interviews were conducted with seven transitional housing program staff in northern California, southern California, Florida, Iowa, Kentucky, Massachusetts, and New Jersey (January-April 2021) and six primary care providers serving Veterans experiencing homelessness, four from clinics in California and two from a clinic in North Dakota (July-August 2021). Interviews were transcribed and analyzed using a rapid analysis approach. COVID-19 vaccination rates were between 40 and 60% among Veterans who received care from the primary care providers and between 20 and 90% among Veterans who were enrolled in the transitional housing programs. Barriers that providers and housing staff encountered when getting Veterans vaccinated for COVID-19 included lack of eligibility, the vaccine appointment scheduling process, transportation and communication challenges, Veterans' distrust in the government, vaccine mandates, and vaccine hesitancy among organization staff. Recommendations to increase COVID-19 vaccine uptake included making vaccination more convenient, using trusted sources such as homeless program staff or Veteran peers to provide educational information about the safety and efficacy of COVID-19 vaccines, and encouraging rather than mandating vaccination. These lessons will enable entities providing care to people experiencing homelessness to develop more effective policies and educational campaigns to improve vaccine acceptance and uptake among this vulnerable population.

Responding to COVID-19 While Serving Veterans Experiencing Homelessness: The Pandemic Experiences of Healthcare and Housing Providers

The U.S. Department of Veterans Affairs (VA) provides essential care through transitional housing and healthcare for Veterans experiencing homelessness through the Grant and Per Diem (GPD) program and the Homeless Patient Aligned Care Team (HPACT), respectively. At the onset of the SARS-CoV-2 pandemic, GPD organizations and HPACT clinics faced the challenge of being essential providers tasked with ensuring the well-being of Veterans under their care. Through semi-structured interviews with 13 providers (6 HPACT health care providers representing 2 HPACT programs, and 7 GPD staff members) across the U.S., this study explored their experiences navigating the tasks of keeping Veterans safe and providing ongoing care from the start of the pandemic up to the 2021 interview dates. Both GPD and HPACT providers reported amplified safety concerns about COVID-19 infection among staff at the start of the pandemic, which diminished to a lower, stable level after a few months as adaptations made for safety became embedded in their routines. However, ongoing challenges included isolation and mental health challenges among Veterans, inherent limitations of telehealth as a care delivery avenue, provider frustration and burnout due to increased workload and frequent change, and the logistics of administering testing for Veterans to enter GPD housing. Enhanced pandemic preparedness planning for GPD organizations, funding for personal protective equipment (PPE) and providing technology to facilitate Veterans' telehealth access, and strategies for preventing provider burnout are critical to both sustaining homeless providers' capabilities during this pandemic and enhancing readiness to respond to the next public health emergency.

Inequalities in coverage of COVID-19 vaccination: A population register based cross-sectional study in Wales, UK

The COVID-19 pandemic has highlighted existing health inequalities for ethnic minority groups and those living in more socioeconomically deprived areas in the UK. With higher levels of severe outcomes in these groups, equitable vaccination coverage should be prioritised. The aim of this study was to identify inequalities in coverage of COVID-19 vaccination in Wales, UK and to highlight areas which may benefit from routine enhanced surveillance and targeted interventions. Records within the Wales Immunisation System (WIS) population register were linked to the Welsh Demographic Service Dataset (WDSD) and central list of shielding patients, held within the Secure Anonymised Information Linkage (SAIL) Databank. Ethnic group was derived from the 2011 census and over 20 administrative electronic health record (EHR) data sources. Uptake of first dose of any COVID-19 vaccine was analysed over time, with the odds of being vaccinated as at 25th April 2021 by sex, health board of residence, rural/urban classification, deprivation quintile and ethnic group presented. Using logistic regression models, analyses were adjusted for age group, care home resident status, health and social care worker status and shielding status. This study included 1,256,412 individuals aged 50 years and over. Vaccine coverage increased steadily from 8th December 2020 until mid-April 2021. Overall uptake of first dose of COVID-19 vaccine in this group was 92.1%. After adjustment the odds of being vaccinated were lower for individuals who were male, resident in the most deprived areas, resident in an urban area and an ethnic group other than White. The largest inequality was seen between ethnic groups, with the odds of being vaccinated 0.22 (95 %CI 0.21-0.24) if in any Black ethnic group compared to any White ethnic group. Ongoing monitoring of inequity in uptake of vaccinations is required, with better targeted interventions and engagement with deprived and ethnic communities to improve vaccination uptake.