Incidence of SARS-CoV-2 Infection Among People Experiencing Homelessness in Toronto, Canada.

Importance: People experiencing homelessness are at high risk of SARS-CoV-2 infection. Incident infection rates have yet to be established in these communities and are needed to inform infection prevention guidance and related interventions. Objective: To quantify the SARS-CoV-2 incident infection rate among people experiencing homelessness in Toronto, Canada, in 2021 and 2022 and to assess factors associated with incident infection. Design, Setting, and Participants: This prospective cohort study was conducted among individuals aged 16 years and older who were randomly selected between June and September 2021 from 61 homeless shelters, temporary distancing hotels, and encampments in Toronto, Canada. Exposures: Self-reported housing characteristics, such as number sharing living space. Main Outcomes and Measures: Prevalence of prior SARS-CoV-2 infection in summer 2021, defined as self-reported or polymerase chain reaction (PCR)- or serology-confirmed evidence of infection at or before the baseline interview, and SARS-CoV-2 incident infection, defined as self-reported or PCR- or serology-confirmed infection among participants without history of infection at baseline. Factors associated with infection were assessed using modified Poisson regression with generalized estimating equations. Results: The 736 participants (415 of whom did not have SARS-CoV-2 infection at baseline and were included in the primary analysis) had a mean (SD) age of 46.1 (14.6) years; 486 (66.0%) self-identified as male. Of these, 224 (30.4% [95% CI, 27.4%-34.0%]) had a history of SARS-CoV-2 infection by summer 2021. Of the remaining 415 participants with follow-up, 124 experienced infection within 6 months, representing an incident infection rate of 29.9% (95% CI, 25.7%-34.4%), or 5.8% (95% CI, 4.8%-6.8%) per person-month. Report after onset of the SARS-CoV-2 Omicron variant was associated with incident infection, with an adjusted rate ratio (aRR) of 6.28 (95% CI, 3.94-9.99). Other factors associated with incident infection included recent immigration to Canada (aRR, 2.74 [95% CI, 1.64-4.58]) and alcohol consumption over the past interval (aRR, 1.67 [95% CI, 1.12-2.48]). Self-reported housing characteristics were not significantly associated with incident infection. Conclusions and Relevance: In this longitudinal study of people experiencing homelessness in Toronto, SARS-CoV-2 incident infection rates were high in 2021 and 2022, particularly once the Omicron variant became dominant in the region. Increased focus on homelessness prevention is needed to more effectively and equitably protect these communities.

Providing Housing First services for an underserved population during the early wave of the COVID-19 pandemic: A qualitative study.

OBJECTIVE: We assessed the critical role of Housing First (HF) programs and frontline workers in responding to challenges faced during the first wave of the COVID-19 pandemic. METHOD: Semi-structured interviews were conducted with nine HF frontline workers from three HF programs between May 2020 and July 2020, in Toronto, Canada. Information was collected on challenges and adjustments needed to provide services to HF clients (people experiencing homelessness and mental disorders). We applied the Analytical Framework method and thematic analysis to our data. RESULTS: Inability to provide in-person support and socializing activities, barriers to appropriate mental health assessments, and limited virtual communication due to clients' lack of access to digital devices were among the most salient challenges that HF frontline workers reported during the COVID-19 pandemic. Implementing virtual support services, provision of urgent in-office or in-field support, distributing food aid, connecting clients with online healthcare services, increasing harm reduction education and referral, and meeting urgent housing needs were some of the strategies implemented by HF frontline workers to support the complex needs of their clients during the pandemic. HF frontline workers experienced workload burden, job insecurity and mental health problems (e.g. distress, worry, anxiety) as a consequence of their services during the first wave of the COVID-19 pandemic. CONCLUSION: Despite the several work-, programming- and structural-related challenges experienced by HF frontline workers when responding to the needs of their clients during the first wave of the COVID-19 pandemic, they played a critical role in meeting the communication, food, housing and health needs of their clients during the pandemic, even when it negatively affected their well-being. A more coordinated, integrated, innovative, sustainable, effective and well-funded support response is required to meet the intersecting and complex social, housing, health and financial needs of underserved and socio-economically excluded groups during and beyond health emergencies.

Effect of Portable Rent Subsidies and Mentorship on Socioeconomic Inclusion for Young People Exiting Homelessness: A Community-Based Pilot Randomized Clinical Trial.

Importance: There have been no published randomized clinical trials with a primary outcome of socioeconomic inclusion for young people who have experienced homelessness. Objective: To explore whether young people exiting homelessness who received rent subsidies and adult mentorship experienced more socioeconomic inclusion relative to young people who received only rent subsidies. Design, Setting, and Participants: This was a convergent mixed-methods, unblinded, 2-group, parallel randomized clinical trial with 1:1 allocation embedded within a community-based framework in 3 cities in Ontario, Canada. Participants were enrolled between March 1 and September 30, 2019, and were followed up through March 31, 2022. Interventions: Participants (n = 24) were randomly assigned adult mentors (n = 13) who had been recruited and screened by community partner agencies. All participants received portable rent subsidies (subsidy not tied to a specific location) for 2 years. Main Outcomes and Measures: Primary quantitative outcomes were self-reported measures of community integration (psychological and physical) and self-esteem-proxy indicators of socioeconomic inclusion. Community integration was measured with the Community Integration Scale, with a score range of 1 to 7 for the physical component and 4 to 20 for the psychological component; higher scores indicate higher integration. Self-esteem was measured with the Rosenberg Self-Esteem Scale, with a score range of 0 to 30; higher scores indicate greater self-esteem. Secondary quantitative outcomes included social connectedness, hopelessness, and academic and vocational participation. All analyses followed the intention-to-treat principle. Results: A total of 24 youths (12 women [50.0%]; mean [SD] age, 21.8 [2.2] years [range, 18-26 years]; race and ethnicity: 10 White [41.7%], 8 Black [33.3%], 2 Asian [8.3%], 2 Indigenous [8.3%], and 2 different choice [8.3%]) transitioned out of homelessness and into market-rent housing. All youths in the group that received mentorship and in the group that did not receive mentorship had stable or nonsignificant improvements in all study outcomes at the primary end point of 18 months compared with baseline (mean [SD] Community Integration Scale psychological score: mentorship group, 11.3 [2.6] at baseline and 11.2 [3.9] at 18 months; no-mentorship group, 10.8 [4.1] at baseline and 13.2 [2.9] at 18 months; mean [SD] Rosenberg Self-Esteem Scale score: mentorship group, 16.0 [4.6] at baseline and 18.1 [5.2] at 18 months; no-mentorship group, 16.3 [6.1] at baseline and 19.6 [5.7] at 18 months). However, there were no significant differences between the 2 groups in the Community Integration Scale psychological score (adjusted mean difference, -2.0; 95% CI, -5.0 to 1.0; P = .18) and Rosenberg Self-Esteem Scale score (adjusted mean difference, -1.4; 95% CI, -5.0 to 2.3; P = .44) 18 months after randomization. Ancillary analysis suggested that youths with informal mentors (mentors outside the study) at baseline felt more psychologically integrated at 18 months relative to those with no informal mentors at baseline (adjusted mean difference, 3.6; 95% CI, 0.4-6.8; P = .03). Conclusions and Relevance: In this randomized clinical trial, COVID-19 pandemic-related restrictions made it challenging for mentors and mentees to connect, which may have affected the findings. Steady socioeconomic outcomes-potentially attributable to portable rent subsidies-are noteworthy, given the socioeconomic inequities this population has faced during the COVID-19 pandemic. The possible benefit of informal mentorship warrants further investigation. This small pilot study was designed with the intention of generating data and hypotheses for a full-scale study; findings should be interpreted with caution. Trial Registration: ClinicalTrials.gov Identifier: NCT03779204.

Exploring COVID-19 vaccine uptake, confidence and hesitancy among people experiencing homelessness in Toronto, Canada: protocol for the Ku-gaa-gii pimitizi-win qualitative study.

INTRODUCTION: People experiencing homelessness are at high risk for COVID-19 and poor outcomes if infected. Vaccination offers protection against serious illness, and people experiencing homelessness have been prioritised in the vaccine roll-out in Toronto, Canada. Yet, current COVID-19 vaccination rates among people experiencing homelessness are lower than the general population. This study aims to characterise reasons for COVID-19 vaccine uptake and hesitancy among people experiencing homelessness, to identify strategies to overcome hesitancy and provide public health decision-makers with information to improve vaccine confidence and uptake in this priority population. METHODS AND ANALYSIS: The Ku-gaa-gii pimitizi-win qualitative study (formerly the COVENANT study) will recruit up to 40 participants in Toronto who are identified as experiencing homelessness at the time of recruitment. Semistructured interviews with participants will explore general experiences during the COVID-19 pandemic (eg, loss of housing, social connectedness), perceptions of the COVID-19 vaccine, factors shaping vaccine uptake and strategies for supporting enablers, addressing challenges and building vaccine confidence. ETHICS AND DISSEMINATION: Approval for this study was granted by Unity Health Toronto Research Ethics Board. Findings will be communicated to groups organising vaccination efforts in shelters, community groups and the City of Toronto to construct more targeted interventions that address reasons for vaccine hesitancy among people experiencing homelessness. Key outputs will include a community report, academic publications, presentations at conferences and a Town Hall that will bring together people with lived expertise of homelessness, shelter staff, leading scholars, community experts and public health partners.

Ku-gaa-gii pimitizi-win, the COVID-19 cohort study of people experiencing homelessness in Toronto, Canada: a study protocol

Introduction Initial reports suggest people experiencing homelessness (PEH) are at high risk for SARS-CoV-2 infection and associated morbidity and mortality. However, there have been few longitudinal evaluations of the spread and impact of COVID-19 among PEH. This study will estimate the prevalence and incidence of COVID-19 infections in a cohort of PEH followed prospectively in Toronto, Canada. It will also examine associations between individual-level and shelter-level characteristics with COVID-19 infection, adverse health outcomes related to infection and vaccination. Finally, the data will be used to develop and parameterise a mathematical model to characterise SARS-CoV-2 transmission dynamics, and the transmission impact of interventions serving PEH. Design, methods and analysis Ku-gaa-gii pimitizi-win will follow a random sample of PEH from across Toronto (Canada) for 12 months. 736 participants were enrolled between June and September 2021, and will be followed up at 3-month intervals. At each interval, specimens (saliva, capillary blood) will be collected to determine active SARS-CoV-2 infection and serologic evidence of past infection and/or vaccination, and a detailed survey will gather self-reported information, including a detailed housing history. To examine the association between individual-level and shelter-level characteristics on COVID-19-related infection, adverse outcomes, and vaccination, shelter and healthcare administrative data will be linked to participant study data. Healthcare administrative data will also be used to examine long-term (up to 5 years) COVID-19-related outcomes among participants. Ethics and dissemination Ethical approval was obtained from the Unity Health Toronto and University of Toronto Health Sciences Research Ethics Boards (# 20-272). Ku-gaa-gii pimitizi-win was designed in collaboration with community and service provider partners and people having lived experience of homelessness. Findings will be reported to groups supporting Ku-gaa-gii pimitizi-win, Indigenous and other community partners and service providers, funding bodies, public health agencies and all levels of government to inform policy and public health programs.

COVID-19 Vaccine Coverage and Sociodemographic, Behavioural and Housing Factors Associated with Vaccination among People Experiencing Homelessness in Toronto, Canada: A Cross-Sectional Study.

People experiencing homelessness were prioritized for COVID-19 vaccination in Toronto, Canada, due to the high risk of infection and associated complications relative to the general population. We aimed to ascertain COVID-19 vaccine coverage in this population and explore factors associated with the receipt of at least one dose. We collected survey and blood sample data from individuals ages 16+ recruited by random selection at 62 shelters, hotels and encampment sites between 16 June 2021 and 9 September 2021. We report vaccine coverage by dose number and explored sociodemographic, behavioral, health and housing factors associated with vaccination using multivariable modified Poisson regression. In total, 80.4% (95% CI 77.3-83.1%) received at least one vaccine dose, and 63.6% (CI 60.0-67.0%) received two or more doses. Vaccination was positively associated with age (every 10 years adjusted rate ratio (aRR) 1.05 [95% CI 1.03-1.08]), and receipt of influenza vaccination (aRR 1.19 [95% CI 1.11-1.27]). Factors negatively associated with vaccination included female gender (aRR 0.92 [95% CI 0.85-1.0]), Black racial self-identification (aRR 0.89 [95% CI 0.80-0.99]) and low frequencies of masking in public places (aRR 0.83 [95% CI 0.72-0.95]). COVID-19 vaccine coverage is very high among people experiencing homelessness in Toronto, suggesting advocacy and outreach efforts may have been effective.

Increases in human papillomavirus vaccine coverage over 12 months among a community-recruited cohort of gay, bisexual, and other men who have sex with men in Canada.

BACKGROUND: Starting in 2015/16, most Canadian provinces introduced publicly-funded human papillomavirus (HPV) vaccination programs for gay, bisexual, and other men who have sex with men (GBM) aged ≤ 26 years. We estimated 12-month changes in HPV vaccine coverage among community-recruited GBM from 2017 to 2021 and identified baseline factors associated with vaccine initiation (≥1 dose) or series completion (3 doses) among participants who were unvaccinated or partially vaccinated at baseline. METHODS: We recruited sexually-active GBM aged ≥ 16 years in Montreal, Toronto, and Vancouver, Canada, from 02/2017 to 08/2019 and followed them over a median of 12 months (interquartile range = 12-13 months). We calculated the proportion who initiated vaccination (≥1 dose) or completed the series (3 doses) by 12-month follow-up. Analyses were stratified by city and age-eligibility for the publicly-funded programs at baseline (≤26 years or > 26 years). We used multivariable logistic regression to identify baseline factors associated with self-reported incident vaccine initiation or series completion. RESULTS: Among 165 unvaccinated participants aged ≤ 26 years at baseline, incident vaccine initiation (≥1 dose) during follow-up was 24.1% in Montreal, 33.3% in Toronto, and 38.9% in Vancouver. Among 1,059 unvaccinated participants aged > 26 years, incident vaccine initiation was 3.4%, 8.9%, and 10.9%, respectively. Higher education and trying to access pre-exposure prophylaxis for HIV were associated with incident vaccination among those aged ≤ 26 years, while younger age, residing in Vancouver (vs. Montreal), being diagnosed with anogenital warts, having both government and private extended medical insurance, and being vaccinated against influenza were associated with incident vaccination among those aged > 26 years. CONCLUSIONS: We observed substantial gains in HPV vaccine coverage among young GBM within 5 + years of targeted program implementation, but gaps remain, particularly among older men who are ineligible for publicly-funded programs. Findings suggest the need for expanded public funding or insurance coverage for HPV vaccines.

Hospitalizations During the COVID-19 Pandemic Among Recently Homeless Individuals: a Retrospective Population-Based Matched Cohort Study.

BACKGROUND: Hospitalizations fell precipitously among the general population during the COVID-19 pandemic. It remains unclear whether individuals experiencing homelessness experienced similar reductions. OBJECTIVE: To examine how overall and cause-specific hospitalizations changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control. DESIGN: Population-based cohort study conducted in Ontario, Canada, between September 30, 2018, and September 26, 2020. PARTICIPANTS: In total, 38,617 IRHH, 15,022,368 housed individuals, and 186,858 low-income housed individuals matched on age, sex, rurality, and comorbidity burden. MAIN MEASURES: Primary outcomes included medical-surgical, non-elective (overall and cause-specific), elective surgical, and psychiatric hospital admissions. KEY RESULTS: Average rates of medical-surgical (rate ratio: 3.8, 95% CI: 3.7-3.8), non-elective (10.3, 95% CI: 10.1-10.4), and psychiatric admissions (128.1, 95% CI: 126.1-130.1) between January and September 2020 were substantially higher among IRHH compared to housed individuals. During the peak period (March 17 to June 16, 2020), rates of medical-surgical (0.47, 95% CI: 0.47-0.47), non-elective (0.80, 95% CI: 0.79-0.80), and psychiatric admissions (0.86, 95% CI: 0.84-0.88) were significantly lower among housed individuals relative to equivalent weeks in 2019. No significant changes were observed among IRHH. During the re-opening period (June 17-September 26, 2020), rates of non-elective hospitalizations for liver disease (1.41, 95% CI: 1.23-1.69), kidney disease (1.29, 95% CI: 1.14-1.47), and trauma (1.19, 95% CI: 1.07-1.32) increased substantially among IRHH but not housed individuals. Distinct hospitalization patterns were observed among IRHH even in comparison with more medically and socially vulnerable matched housed individuals. CONCLUSIONS: Persistence in overall hospital admissions and increases in non-elective hospitalizations for liver disease, kidney disease, and trauma indicate that the COVID-19 pandemic presented unique challenges for recently homeless individuals. Health systems must better address the needs of this population during public health crises.

Drug Overdoses During the COVID-19 Pandemic Among Recently Homeless Individuals.

AIMS: To examine how weekly rates of emergency department (ED) visits for drug overdoses changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the pre-pandemic, peak, and re-opening periods of the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control. DESIGN: Population-based retrospective cohort study conducted between September 30, 2018 and September 26, 2020. SETTING: Ontario, Canada. PARTICIPANTS: A total of 38 617 IRHH, 15 022 369 housed individuals, and 186 858 low-income housed individuals matched on age, sex, rurality, and comorbidity burden. MEASUREMENTS: ED visits for drug overdoses of accidental and undetermined intent. FINDINGS: Average rates of ED visits for drug overdoses between January and September 2020 were higher among IRHH compared with housed individuals (rate ratio [RR], 148.0; 95% CI, 142.7-153.5) and matched housed individuals (RR, 22.3; 95% CI, 20.7-24.0). ED visits for drug overdoses decreased across all groups by ~20% during the peak period (March 17 to June 16, 2020) compared with corresponding weeks in 2019. During the re-opening period (June 17 to September 26, 2020), rates of ED visits for drug overdoses were significantly higher among IRHH (RR, 1.56; 95% CI, 1.44-1.69), matched housed individuals (RR, 1.25; 95% CI, 1.08-1.46), and housed individuals relative to equivalent weeks in 2019 (RR, 1.07; 95% CI, 1.02-1.11). The relative increase in drug overdose ED visits among IRHH was larger compared with both matched housed individuals (P = 0.01 for interaction between group and year) and housed individuals (P < 0.001) during this period. CONCLUSIONS: Recently homeless individuals in Ontario, Canada experienced disproportionate increases in ED visits for drug overdoses during the re-opening period of the COVID-19 pandemic compared with housed people.