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.

Cumulative incidence of SARS-CoV-2 infection within the homeless population: insights from a city-wide longitudinal study.

OBJECTIVES: The aim of this study was to determine the risk factors associated with SARS-CoV-2 infection in a cohort of homeless people using survival analysis. Seroprevalence in the homeless community was also compared with that of the general population. DESIGN: Cohort study. SETTING: Data were collected across two testing sessions, 3 months apart, during which each participant was tested for anti-SARS-CoV-2 antibodies and completed a face-to-face survey. PARTICIPANTS: All homeless adults sleeping rough, in slums or squats, in emergency shelters or transitional accommodation in Marseille were eligible. PRIMARY OUTCOME MEASURES: Occurrence of a seroconversion event defined as a biologically confirmed SARS-CoV-2 infection. Local data from a national seroprevalence survey were used for comparison between homeless people and the general population. RESULTS: A total of 1249 people were included. SARS-CoV-2 seroprevalence increased from 6.0% (4.7-7.3) during the first session to 18.9% (16.0-21.7) during the second one, compared with 3.0% (1.9-4.2) and 6.5% (4.5-8.7) in the general population. Factors significantly associated with an increased risk of COVID-19 infection were: having stayed in emergency shelters (1.93 (1.18-3.15)), being an isolated parent (1.64 (1.07-2.52)) and having contact with more than 5-15 people per day (1.84 (1.27-2.67)). By contrast, smoking (0.46 (0.32-0.65)), having financial resources (0.70 (0.51-0.97)) and psychiatric or addictive comorbidities (0.52 (0.32-0.85)) were associated with a lower risk. CONCLUSION: We confirm that homeless people have higher infection rates than the general population, with increased risk in emergency shelters. There is growing evidence that, in addition to usual preventive measures, public policies should pay attention to adapt the type of accommodation and overall approach of precariousness. TRIAL REGISTRATION NUMBER: NCT04408131.

Un modèle innovant d'intervention, de dépistage et de prise en charge mobile de la COVID-19 chez les personnes sans-abri à Marseille.

INTRODUCTION: Homeless people are particularly at risk of becoming infected with COVID-19 because their precarious living conditions make prevention measure difficult. OBJECTIVE: We describe an innovative approach with the aim of implementing testing and monitoring adapted to the needs of the homeless people of Marseille (inhabitants of slums, squats or those living on the street). RESULTS: The intervention included 1) the coordination of 18 support organizations for homeless people, 2) the training and the provision of rapid serological and antigenic tests, 3) a mobile outreach team with community mediators in order to provide tests, including COVID-19 PCR on point of care, prevention and monitoring of positive cases. Acceptability of the intervention by participants, field organization was good. The lack of adapted places of accommodation was an important restricting factor for optimal care and support. CONCLUSION: The emergence of COVID-19 has highlighted discontinuities in health care among homeless people. Specific mobile outreach teams could limit the impact on this high-risk population.

Seroprevalence of SARS-CoV-2 antibodies among homeless people living rough, in shelters and squats: A large population-based study in France.

BACKGROUND: Overcrowded housing, as well as inadequate sanitary conditions, contribute to making homeless people particularly vulnerable to the SARS-CoV-2 infection. We aimed to assess the seroprevalence of the SARS-CoV-2 infection among people experiencing homelessness on a large city-wide scale in Marseille, France, taking into account different types of accommodation. METHODS: A consortium of outreach teams in 48 different locations including streets, slums, squats, emergency or transitional shelters and drop-in centres participated in the inclusion process. All participants consented to have a validated rapid antibody assay for immunoglobulins M (IgM) and G (IgG) and to answer a questionnaire on medical health conditions, comorbidities, and previous COVID-19 symptoms. Information on their housing conditions since the COVID-19 crisis was also collected from the participants. RESULTS: From June 01 to August 05, 2020, 1,156 homeless participants were enrolled in the study and tested. The overall seroprevalence of SARS-CoV-2 IgG/IgM antibodies was 5.6% (95%CI 2.3-7.0), ranging from 2.2% in people living on the streets to 8.1% in people living in emergency shelters (P = 0.009). Around one third of the seropositive participants reported COVID-19 symptoms. Compared to the general population in Marseille (3.6%), the homeless population living in the same urban area experienced a significantly increased risk of SARS-CoV-2 infection (|z| = 3.65 > 1.96). CONCLUSION: These findings highlight the need for regular screening among the homeless to prevent clustering in overcrowded or inadequate accommodations. It is also necessary to provide essential resources to keep homeless people healthy, the vast majority of whom have cumulative risk factors for SARS-CoV-2 infection.

SARS-CoV-2 rapid serological tests for field-based healthcare workers in homeless communities: A mixed-methods exploratory analysis.

OBJECTIVES: The high risk of SARS-CoV-2 transmission in homeless communities requires adapted prevention strategies for field-based healthcare workers (HCWs). Rapid serological tests (RSTs) could be an invaluable tool for HCWs to control COVID-19 transmission. This study assesses the benefits of RSTs for HCWs in Marseille, France. STUDY DESIGN: Mixed-methods exploratory analysis. METHODS: A mixed-methods approach was used, combining quantitative and qualitative data, to prospectively analyse acceptability of RSTs, prevalence of SARS-CoV-2 antibodies and prevention behaviours in 106 HCWs from 18 non-governmental organisations (NGOs) and health or social institutions in Marseille from June 1 to July 31, 2020. For the qualitative dimension, semi-structured individual interviews were conducted with 21 HCWs from 7 of 18 NGOs and institutions. RESULTS: Most of the 106 HCWs in the quantitative study reported better prevention measures at work than in their homes. Despite this, the majority reported that they felt unsafe at work in terms of COVID-19 infection risk. SARS-CoV-2 antibody seroprevalence among the study population was 6.1%. Only four HCWs refused to have an RST.The 21 qualitative interviews highlighted that HCWs were not afraid of RSTs or of any possible stigma associated with a positive serological status, although they were sometimes suspicious about RST validity. Downplaying their risk of infection was a coping strategy to keep both a sense of control and remain motivated at work. CONCLUSIONS: RSTs should be adopted as an additional tool in the strategy to protect both HCWs and healthcare service users. Additional follow-up of these observational findings is needed, especially with the increasing prevalence of vaccination in HCWs.