Financial Incentives for COVID-19 Vaccines Among People Experiencing Homelessness.

INTRODUCTION: Novel strategies are needed to address barriers to COVID-19 vaccination among people experiencing homelessness (PEH), a population that faces increased COVID-19 risk. Although growing evidence suggests that financial incentives for vaccination are acceptable to PEH, their impact on uptake is unknown. This study aimed to assess whether offering $50 gift cards was associated with the uptake of the first doses of COVID-19 vaccine among PEH in Los Angeles County. METHODS: Vaccination clinics began on March 15, 2021; the financial incentive program was implemented from September 26, 2021 to April 30, 2022. Interrupted time-series analysis with quasi-Poisson regression was used to evaluate the level and slope change in the number of weekly first doses administered. Time-varying confounders included the weekly number of clinics and the weekly number of new cases. Demographic characteristics were compared for PEH vaccinated before and after the implementation of the incentive program using chi-square tests. RESULTS: Offering financial incentives was associated with the administration of 2.5 times (95% CI=1.8, 3.1) more first doses than would have been expected without the program. Level (-0.184, 95% CI= -1.166, -0.467) and slope change (0.042, 95% CI=0.031, 0.053) were observed. Individuals who were unsheltered, aged <55 years, and identified as Black or African American accounted for a higher percentage of those vaccinated during the post-intervention period than during the pre-intervention period. CONCLUSIONS: Financial incentives may be an effective tool for increasing vaccine uptake among PEH, but important ethical considerations must be made to avoid coercion of vulnerable populations.

Race and Ethnicity and Sex Variation in COVID-19 Mortality Risks Among Adults Experiencing Homelessness in Los Angeles County, California.

Importance: Few studies have used precise age-specific data to construct age-standardized estimates of the relative risks (RRs) of COVID-19 mortality for people experiencing homelessness (PEH) vs the general population, and none to date has addressed race and ethnicity and sex variations in COVID-19 mortality among PEH with COVID-19 infection. Objective: To measure age-standardized mortality rate ratios for PEH vs the general population overall and by sex and race and ethnicity. Design, Setting, and Participants: In this cross-sectional study, crude and age-specific COVID-19 mortality rates per 100 000 people were calculated using 5-year age groups and standardized mortality ratios for PEH and the general population aged 25 years and older, assessing differences by race and ethnicity and sex, from January 1, 2020, to November 1, 2021. Mortality and population estimates came from COVID-19 mandatory case reporting conducted by the Los Angeles County Department of Public Health, the annual point-in-time homeless count, and the US Census. Main Outcomes and Measures: The main outcome was COVID-19 deaths sourced from clinician reports, death certificates, medical examiner reports, and vital records deaths. PEH status was determined using the US Department of Housing and Urban Development definitions for homelessness at the time of COVID-19 diagnosis or symptom onset. Results: The study population included 25 441 deaths among an estimated 6 382 402 general population individuals and 256 deaths among an estimated 52 015 PEH. The race and ethnicity of the PEH sample was as follows: 15 539 Black (29.9%), 18 057 Hispanic (34.7%), 14 871 female (28.6%), 37 007 male (71.3%), and 3380 aged 65 years or older (6.5%), compared with the estimated general population of 6 382 402, which was 591 003 Black (9.3%), 2 854 842 Hispanic (44.7%), 3 329 765 female (52.2%), 3 052 637 male (47.8%), and 1 190 979 aged 65 years or older (18.7%). Crude death rates were 0.49% for PEH and 0.40% for the general population, but PEH experienced age-specific COVID-19 mortality risk 2.35 (95% CI, 2.08-2.66) times higher than the general population. There was significant risk associated with PEH status compared with their counterparts in the general population for Black PEH (RR, 1.69; 95% CI, 1.31-2.18), Hispanic PEH (RR, 2.34; 95% CI, 1.96-2.79), White PEH (RR, 8.33; 95% CI, 6.37-10.88), female PEH (RR, 3.39; 95% CI, 2.56-4.48), and male PEH (RR, 1.74; 95% CI, 1.52-2.00). Conclusions and Relevance: This cross-sectional study of COVID-19 mortality among PEH with COVID-19 infection provides evidence suggesting excess risk of age-adjusted COVID-19 mortality among PEH compared with the general population. This study furthers understanding of the intersectional association between homelessness and race and ethnicity, as higher levels of mortality but narrower racial disparities among PEH than in the general population were observed.

Evaluation of the Homeless Management Information System for COVID-19 Surveillance Among People Experiencing Homelessness.

BACKGROUND: Variable and incomplete reporting of housing status creates challenges in the surveillance of coronavirus disease 2019 (COVID-19) among the homeless population in Los Angeles County (LA County) and nationwide. METHODS: We developed standard investigation procedures to assess the housing status of LA County COVID-19 patients. Using data sharing procedures, we matched COVID-19 patients to Homeless Management Information System (HMIS) client profiles and supplemented with additional data sources for contributory data points and to further housing status ascertainment. RESULTS: We identified 10 586 COVID-19 patients among people experiencing homelessness (PEH) between 30 March 2020 and 30 December 2021; 2801 (26.5%) patients were first identified from HMIS profile matches, 1877 (17.7%) from quarantine/isolation housing intake rosters, 573 (5.4%) from hospital records, 749 (7.1%) from case and contact interviews, 3659 (34.6%) directly from PEH medical and service providers, and 927 (8.8%) had unknown sources. Among COVID-19 patients matched to HMIS profiles, 5351 (42.5%) were confirmed to be PEH at the time of COVID-19 diagnosis. CONCLUSIONS: Interoperability between public health data, HMIS, and external partners have been critical components in evaluating the impact of COVID-19 among the LA County homeless population. No one data source was complete for COVID-19 surveillance in this population.

COVID-19 Mortality Rates in Los Angeles County Among People Experiencing Homelessness, March 2020-February 2021.

OBJECTIVE: Understanding COVID-19-related mortality among the large population of people experiencing homelessness (PEH) in Los Angeles County (LA County) may inform public health policies to protect this vulnerable group. We investigated the impact of COVID-19 on PEH compared with the general population in LA County. METHODS: We calculated crude COVID-19 mortality rates per 100 000 population and mortality rates adjusted for age, race, and sex/gender among PEH and compared them with the general population in LA County from March 1, 2020, through February 28, 2021. RESULTS: Among adults aged ≥18 years, the crude mortality rate per 100 000 population among PEH was 20% higher than among the general LA County population (348.7 vs 287.6). After adjusting for age, the mortality rate among PEH was 570.7 per 100 000 population. PEH had nearly twice the risk of dying from COVID-19 as people in the general LA County population; PEH aged 18-29 years had almost 8 times the risk of dying compared with their peers in the general LA County population. PEH had a higher risk of mortality than the general population after adjusting for race (standardized mortality ratio [SMR] = 1.4; 95% CI, 1.2-1.6) and sex/gender (SMR = 1.3; 95% CI, 1.1-1.5). CONCLUSIONS: A higher risk of COVID-19-related death among PEH compared with the general population indicates the need for public health policies and interventions to protect this vulnerable group.