"Access to healthcare is a human right": a constructivist study exploring the impact and potential of a hospital-community partnered COVID-19 community response team for Toronto homeless services and congregate living settings.

BACKGROUND: Individuals experiencing homelessness face unique physical and mental health challenges, increased morbidity, and premature mortality. COVID -19 creates a significant heightened risk for those living in congregate sheltering spaces. In March 2020, the COVID-19 Community Response Team formed at Women's College Hospital, to support Toronto shelters and congregate living sites to manage and prevent outbreaks of SARS-CoV-2 using a collaborative model of onsite mobile testing and infection prevention. From this, the Women's College COVID-19 vaccine program emerged, where 14 shelters were identified to co-design and support the administration of vaccine clinics within each shelter. This research seeks to evaluate the impact of this partnership model and its future potential in community-centered integrated care through three areas of inquiry: (1) vaccine program evaluation and lessons learned; (2) perceptions on hospital/community partnership; (3) opportunities to advance hospital-community partnerships. METHODS: Constructivist grounded theory was used to explore perceptions and experiences of this partnership from the voices of shelter administrators. Semi-structured interviews were conducted with administrators from 10 shelters using maximum variation purposive sampling. A constructivist-interpretive paradigm was used to determine coding and formation of themes: initial, focused, and theoretical. RESULTS: Data analysis revealed five main categories, 16 subcategories, and one core category. The core category "access to healthcare is a human right; understand our communities" emphasizes access to healthcare is a consistent barrier for the homeless population. The main categories revealed during a time of confusion, the hospital was seen as credible and trustworthy. However, the primary focus of many shelters lies in housing, and attention is often not placed on health resourcing, solidifying partnerships, accountability, and governance structures therein. Health advocacy, information sharing tables, formalized partnerships and educating health professionals were identified by shelter administrators as avenues to advance intersectoral relationship building. CONCLUSION: Hospital-community programs can alleviate some of the ongoing health concerns faced by shelters - during a time of COVID-19 or not. In preparation for future pandemics, access to care and cohesion within the health system requires the continuous engagement in relationship-building between hospitals and communities to support co-creation of innovative models of care, to promote health for all.

Adverse Childhood Experiences and Medication Overuse Headache: Burden and Treatment Impact.

Adverse childhood experiences (ACEs) are a risk factor for progression from episodic to chronic migraine. Risk factors for medication overuse headache (MOH) are incompletely understood, but opioid overuse may carry a higher risk than overuse of other medication types. We performed a retrospective chart review investigating the frequency and impact of ACEs in patients with MOH. Of 68 included patients, 37 (54.4%) reported ACEs. There was no significant inter-group difference in baseline migraine disability assessment (MIDAS) or monthly headache days. Patients with ACEs reported more opioid overuse, and worse headache-related disability at follow-up, despite similar monthly headache days. Patients with ACEs require complex, multidisciplinary treatment.

Development and assessment of a hospital-led, community-partnering COVID-19 testing and prevention program for homeless and congregate living services in Toronto, Canada: a descriptive feasibility study.

BACKGROUND: Outbreaks of SARS-CoV-2 in shelters and congregate living settings are a major concern because of overcrowding and because resident populations are often at high risk for infection. The objective of this study was to describe the development, implementation and assessment of the COVID-19 Community Response Team, a program that enabled Women's College Hospital in Toronto, Ontario, to work in partnership with shelters and congregate living settings to prevent outbreaks. METHODS: The Community Response Team, associated with Women's College Hospital, an academic ambulatory hospital, carried out mobile testing for SARS-CoV-2, supported outbreak management and prevention through ongoing onsite partnership with medical staff, and conducted infection prevention and control (IPC) training to shelter staff. We conducted a descriptive analysis of the sites supported by the program between Apr. 20, 2020, and Aug. 15, 2020. We also assessed the program's feasibility (number of completed needs assessments, mobile testing events and IPC training events, and median time from referral to service delivery), adoption (number of nasopharyngeal swabs, number of pre- and post-program outbreaks and IPC uptake) and acceptability or satisfaction. RESULTS: The Community Response Team supported 32 sites. Of those, 30 completed an intake needs assessment, 24 completed mobile testing for SARS-CoV-2 and 15 received IPC support. Mobile testing resulted in the collection of 1566 nasopharyngeal swabs, of which 64 were positive for SARS-CoV-2 infection. Three sites had confirmed outbreaks. The median time from referral to needs assessment was 4 days (interquartile range [IQR] 1-13 days), and the median time to the testing day was 9 days (IQR 1-49 days). The median time from referral to IPC staff training was 14 days (IQR 4-79 days), and 100% of respondents reported being pleased or very pleased with the training. During the follow-up period, the 3 facilities with outbreaks overcame those outbreaks. Three sites supported by the Community Response Team had further single cases, but no site reported subsequent or secondary outbreaks. INTERPRETATION: The Community Response Team program led to the transfer of IPC knowledge, allowed for the management and prevention of SARS-CoV-2 outbreaks, and demonstrated feasibility. Collaborative supports between hospitals and the community housing sector may serve as models for ongoing system integration beyond the COVID-19 pandemic.

Prevalence of SARS-CoV-2 infection among people experiencing homelessness in Toronto during the first wave of the COVID-19 pandemic.

OBJECTIVES: People experiencing homelessness are at increased risk of SARS-CoV-2 infection. This study reports the point prevalence of SARS-CoV-2 infection during testing conducted at sites serving people experiencing homelessness in Toronto during the first wave of the COVID-19 pandemic. We also explored the association between site characteristics and prevalence rates. METHODS: The study included individuals who were staying at shelters, encampments, COVID-19 physical distancing sites, and drop-in and respite sites and completed outreach-based testing for SARS-CoV-2 during the period April 17 to July 31, 2020. We examined test positivity rates over time and compared them to rates in the general population of Toronto. Negative binomial regression was used to examine the relationship between each shelter-level characteristic and SARS-CoV-2 positivity rates. We also compared the rates across 3 time periods (T1: April 17-April 25; T2: April 26-May 23; T3: May 24-June 25). RESULTS: The overall prevalence of SARS-CoV-2 infection was 8.5% (394/4657). Site-specific rates showed great heterogeneity with infection rates ranging from 0% to 70.6%. Compared to T1, positivity rates were 0.21 times lower (95% CI: 0.06-0.75) during T2 and 0.14 times lower (95% CI: 0.04-0.44) during T3. Most cases were detected during outbreak testing (384/394 [97.5%]) rather than active case finding. CONCLUSION: During the first wave of the pandemic, rates of SARS-CoV-2 infection at sites for people experiencing homelessness in Toronto varied significantly over time. The observation of lower rates at certain sites may be attributable to overall time trends, expansion of outreach-based testing to include sites without known outbreaks, and/or individual site characteristics.

RéSUMé: OBJECTIFS: Les personnes en situation d'itinérance courent un risque accru de contracter une infection par le SRAS-CoV-2. Notre étude rend compte de la prévalence ponctuelle des infections par le SRAS-CoV-2 au cours de tests de dépistage menés dans des lieux de services aux personnes en situation d'itinérance de Toronto au cours de la première vague de la pandémie de COVID-19. Nous avons aussi exploré l'association entre les caractéristiques de ces lieux et les taux de prévalence. MéTHODE: L'étude a inclus les personnes séjournant dans des refuges, des campements, des lieux de distanciation physique et des centres d'accueil et de répit et ayant subi un test de dépistage de proximité du SRAS-CoV-2 entre le 17 avril et le 31 juillet 2020. Nous avons examiné les taux de positivité des tests au fil du temps et nous les avons comparés aux taux dans la population générale de Toronto. Des analyses de régression binomiales négatives ont été effectuées pour étudier la relation entre chaque caractéristique au niveau des refuges et les taux de positivité au SRAS-CoV-2. Nous avons aussi comparé les taux de trois intervalles (I1: 17 au 25 avril; I2: 26 avril au 23 mai; I3: 24 mai au 25 juin). RéSULTATS: La prévalence globale des infections par le SRAS-CoV-2 était de 8,5 % (394/4 657). Les taux d'infection spécifiques aux lieux de services ont présenté une grande hétérogénéité, soit de 0 % à 70,6 %. Comparés au 1er intervalle (I1), les taux de positivité ont été 0,21 fois plus faibles (IC de 95% : 0,06 ­ 0,75) durant l'I2 et 0,14 fois plus faibles (IC de 95% : 0,04 ­ 0,44) durant l'I3. La plupart des cas ont été détectés lors d'un dépistage en cours d'éclosion (384/394 [97,5%]) et non lors d'une recherche active de cas. CONCLUSION: Au cours de la première vague de la pandémie, les taux d'infection par le SRAS-CoV-2 dans les lieux de services aux personnes en situation d'itinérance de Toronto ont varié de façon significative au fil du temps. L'observation de taux plus faibles dans certains lieux pourrait s'expliquer par les tendances temporelles globales, par l'expansion des activités de dépistage de proximité pour inclure les lieux sans éclosion connue et/ou par les caractéristiques individuelles des lieux.

Correction to: The Toronto cognitive assessment (TorCA): normative data and validation to detect amnestic mild cognitive impairment.

Upon publication of this article [1], it was brought to our attention that one of the 303 participants in the normative study should have been deleted from the database.

The Toronto Cognitive Assessment (TorCA): normative data and validation to detect amnestic mild cognitive impairment.

BACKGROUND: A need exists for easily administered assessment tools to detect mild cognitive changes that are more comprehensive than screening tests but shorter than a neuropsychological battery and that can be administered by physicians, as well as any health care professional or trained assistant in any medical setting. The Toronto Cognitive Assessment (TorCA) was developed to achieve these goals. METHODS: We obtained normative data on the TorCA (n = 303), determined test reliability, developed an iPad version, and validated the TorCA against neuropsychological assessment for detecting amnestic mild cognitive impairment (aMCI) (n = 50/57, aMCI/normal cognition). For the normative study, healthy volunteers were recruited from the Rotman Research Institute registry. For the validation study, the sample was comprised of participants with aMCI or normal cognition based on neuropsychological assessment. Cognitively normal participants were recruited from both healthy volunteers in the normative study sample and the community. RESULTS: The TorCA provides a stable assessment of multiple cognitive domains. The total score correctly classified 79% of participants (sensitivity 80%; specificity 79%). In an exploratory logistic regression analysis, indices of Immediate Verbal Recall, Delayed Verbal and Visual Recall, Visuospatial Function, and Working Memory/Attention/Executive Control, a subset of the domains assessed by the TorCA, correctly classified 92% of participants (sensitivity 92%; specificity 91%). Paper and iPad version scores were equivalent. CONCLUSIONS: The TorCA can improve resource utilization by identifying patients with aMCI who may not require more resource-intensive neuropsychological assessment. Future studies will focus on cross-validating the TorCA for aMCI, and validation for disorders other than aMCI.

Effect of immune response on transmission dynamics for sexually transmitted infections.

Transmission dynamics for sexually transmitted infections (STIs) exhibit a large degree of heterogeneity, much of which has been attributed to behavioral variability. However, because STI transmission concentrates among individuals who frequently change sex partners, immune responses also are likely to contribute to the heterogeneity in STI transmission dynamics. We review both theoretical and experimental data on the effects of immunity on STI transmission dynamics. We conclude that research should be directed more intensively toward the characterization of sexual network structures, together with qualitative and quantitative analyses of the immune responses of individuals who are identifiable within the network structure itself. Elucidation of the immunobiological and behavioral factors that shape STI transmission should inform better STI prevention and control programs.