Abstract
BackgroundPeople experiencing homelessness face a high risk of SARS-CoV-2 infection and transmission, as well as health complications and death due to COVID-19. Despite being prioritised for receiving the COVID-19 vaccine in many regions, little data are available on vaccine uptake in this vulnerable population. Using population-based health-care administrative data from Ontario, Canada—a region with a universal, publicly funded health system—we aimed to describe COVID-19 vaccine coverage (ie, the estimated percentage of people who have received a vaccine) and determinants of vaccine receipt among individuals with a recent history of homelessness.MethodsWe conducted a retrospective, population-based cohort study of adults (aged ≥18 years) with a recent experience of homelessness, inadequate housing, or shelter use as recorded in routinely collected health-care databases between June 14, 2020, and June 14, 2021 (a period within 6 months of Dec 14, 2020, when COVID-19 vaccine administration was initiated in Ontario). Participants were followed up from Dec 14, 2020, to Sept 30, 2021, for the receipt of one or two doses of a COVID-19 vaccine using the province's real-time centralised vaccine information system. We described COVID-19 vaccine coverage overall and within predefined subgroups. Using modified Poisson regression, we further identified sociodemographic factors, health-care usage, and clinical factors associated with receipt of at least one dose of a COVID-19 vaccine.Findings23 247 individuals with a recent history of homelessness were included in this study. Participants were predominantly male (14 752 [63·5%] of 23 247); nearly half were younger than 40 years (11 521 [49·6%]) and lived in large metropolitan regions (12 123 [52·2%]); and the majority (18 226 [78·4%]) visited a general practitioner for an in-person consultation during the observation period. By Sept 30, 2021, 14 271 (61·4%; 95% CI 60·8–62·0) individuals with a recent history of homelessness had received at least one dose of a COVID-19 vaccine and 11 082 (47·7%; 47·0–48·3) had received two doses; in comparison, over the same period, 86·6% of adults in the total Ontario population had received a first dose and 81·6% had received a second dose. In multivariable analysis, factors positively associated with COVID-19 uptake were one or more outpatient visits to a general practitioner (adjusted risk ratio [aRR] 1·37 [95% CI 1·31–1·42]), older age (50–59 years vs 18–29 years: 1·18 [1·14–1·22], ≥60 years vs 18–29 years: 1·27 [1·22–1·31]), receipt of an influenza vaccine in either of the two previous influenza seasons (1·25 [1·23–1·28]), being identified as homeless via a visit to a community health centre versus exclusively a hospital-based encounter (1·13 [1·10–1·15]), receipt of one or more SARS-CoV-2 tests between March 1, 2020, and Sept 30, 2021 (1·23 [1·20–1·26]), and the presence of chronic health conditions (one condition: 1·05 [1·03–1·08]; two or more conditions: 1·11 [1·08–1·14]). By contrast, living in a smaller metropolitan region (aRR 0·92 [95% CI 0·90–0·94]) or rural location (0·93 [0·90–0·97]) versus large metropolitan regions were associated with lower uptake.InterpretationIn Ontario, COVID-19 vaccine coverage among adults with a recent history of homelessness has lagged and, as of Sept 30, 2021, was 25 percentage points lower than that of the general adult population in Ontario for a first dose and 34 percentage points lower for a second dose. With high usage of outpatient health services among individuals with a recent history of homelessness, better utilisation of outpatient primary care structures might offer an opportunity to increase vaccine coverage in this population. Our findings underscore the importance of leveraging existing health and service organisations that are accessed and trusted by people who experience homelessness for targeted vaccine delivery.FundingThe Public Health Agency of Canada.TranslationFor the French translation of the abstract see Supplementary Materials section.
Highlights
Implications of all the available evidence people experiencing homelessness were denoted by the provincial government as a priority population to receive a COVID-19 vaccine, this study shows that coverage among individuals with a recent history of homelessness has lagged in comparison with that of the general population of Ontario, Canada
People experiencing homelessness, regardless of age, were prioritised for COVID-19 vaccine receipt in the second phase of Ontario’s COVID-19 vaccine roll-out, which was scheduled to begin in April, 2021,8 with some health regions receiving authorisation to initiate targeted efforts in late February, 2021.9,10 preliminary reports arising from that time period suggested barriers to vaccine delivery in people expe riencing homelessness, including vaccine hesitancy,[11] mistrust of organisations leading vaccination clinics,[12] and various logistical barriers to offering clinics at shelters undergoing SARS-CoV-2 outbreaks.[13]
Vaccine coverage has been well documented in other populations prioritised for early COVID-19 vaccine distribution and in the general population in Ontario,[14,15] little has been reported on vaccine uptake among people experiencing homelessness
Summary
A survey administered by Nanos Research early in the COVID-19 pandemic (July, 2020) found that one in 20 Canadians, or an estimated 1·6 million Canadians, have experienced homelessness at some point in their lives, described as “the situation without safe, permanent, or appropriate housing, or the immediate prospect of acquiring it”.1 People experiencing home lessness commonly face physical and mental health challenges, increased health-care usage, morbidity, and premature mortality.[2,3] Unsurprisingly, numerous reports have documented high rates of SARS-CoV-2 infection and transmission, as well as health complications and mortality due to COVID-19 in this population.[4–7] In the Canadian province of Ontario, a population-based analysis found that between January and July, 2020, individuals with a recent history of homelessness were times more likely to be admitted to hospital, ten times more likely to require critical care, and five times more likely to die within days of a SARS-CoV-2 infection, compared to communitydwelling adults in Ontario.[5]. In the Canadian province of Ontario, a population-based analysis found that between January and July, 2020, individuals with a recent history of homelessness were times more likely to be admitted to hospital, ten times more likely to require critical care, and five times more likely to die within days of a SARS-CoV-2 infection, compared to communitydwelling adults in Ontario.[5]. Recognising these risks, e367 www.thelancet.com/public-health Vol 7 April 2022.
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
