Deaths of profound despair: A retrospective cohort study of mortality among people experiencing homelessness.

INTRODUCTION: The number of people dying while unhoused is increasing nationally. In Santa Clara County (SCC), deaths of unhoused people have almost tripled in 9 years. This is a retrospective cohort study examining mortality trends among unhoused people in SCC. The objective of the study is to characterize mortality outcomes in the unhoused population, and compare these to the SCC general population. MATERIALS AND METHODS: We obtained data from the SCC Medical Examiner-Coroner's Office on unhoused people's deaths that occurred between 2011-2019. We analyzed demographic trends and cause of death, compared to mortality data on the SCC general population obtained from CDC databases. We also compared rates of deaths of despair. RESULTS: There were a total of 974 unhoused deaths in the SCC cohort. The unadjusted mortality rate among unhoused people is higher than the general population, and unhoused mortality has increased over time. The standardized mortality ratio for unhoused people is 3.8, compared to the general population in SCC. The most frequent age of death among unhoused people was between 55-64 years old (31.3%), followed by 45-54 (27.5%), compared to 85+ in the general population (38.3%). Over ninety percent of deaths in the general population were due to illness. In contrast, 38.2% of unhoused deaths were due to substance use, 32.0% illness, 19.0% injury, 4.2% homicide, and 4.1% suicide. The proportion of deaths of despair was 9-fold higher in the unhoused cohort compared to the housed cohort. DISCUSSION: Homelessness has profound impacts on health, as people who are unhoused are dying 20 years younger, with higher rates of injurious, treatable, and preventable causes, than people in the general population. System-level, inter-agency interventions are needed. Local governments need to systematically collect housing status at death to monitor mortality patterns among unhoused people, and adapt public health systems to prevent rising unhoused deaths.

Introduction, Transmission Dynamics, and Fate of Early Severe Acute Respiratory Syndrome Coronavirus 2 Lineages in Santa Clara County, California.

We combined viral genome sequencing with contact tracing to investigate introduction and evolution of severe acute respiratory syndrome coronavirus 2 lineages in Santa Clara County, California, from 27 January to 21 March 2020. From 558 persons with coronavirus disease 2019, 101 genomes from 143 available clinical samples comprised 17 lineages, including SCC1 (n = 41), WA1 (n = 9; including the first 2 reported deaths in the United States, with postmortem diagnosis), D614G (n = 4), ancestral Wuhan Hu-1 (n = 21), and 13 others (n = 26). Public health intervention may have curtailed the persistence of lineages that appeared transiently during February and March. By August, only D614G lineages introduced after 21 March were circulating in Santa Clara County.

Evidence for Limited Early Spread of COVID-19 Within the United States, January-February 2020.

From January 21 through February 23, 2020, public health agencies detected 14 U.S. cases of coronavirus disease 2019 (COVID-19), all related to travel from China (1,2). The first nontravel-related U.S. case was confirmed on February 26 in a California resident who had become ill on February 13 (3). Two days later, on February 28, a second nontravel-related case was confirmed in the state of Washington (4,5). Examination of four lines of evidence provides insight into the timing of introduction and early transmission of SARS-CoV-2, the virus that causes COVID-19, into the United States before the detection of these two cases. First, syndromic surveillance based on emergency department records from counties affected early by the pandemic did not show an increase in visits for COVID-19-like illness before February 28. Second, retrospective SARS-CoV-2 testing of approximately 11,000 respiratory specimens from several U.S. locations beginning January 1 identified no positive results before February 20. Third, analysis of viral RNA sequences from early cases suggested that a single lineage of virus imported directly or indirectly from China began circulating in the United States between January 18 and February 9, followed by several SARS-CoV-2 importations from Europe. Finally, the occurrence of three cases, one in a California resident who died on February 6, a second in another resident of the same county who died February 17, and a third in an unidentified passenger or crew member aboard a Pacific cruise ship that left San Francisco on February 11, confirms cryptic circulation of the virus by early February. These data indicate that sustained, community transmission had begun before detection of the first two nontravel-related U.S. cases, likely resulting from the importation of a single lineage of virus from China in late January or early February, followed by several importations from Europe. The widespread emergence of COVID-19 throughout the United States after February highlights the importance of robust public health systems to respond rapidly to emerging infectious threats.