ABSTRACT
Background Few global data exist regarding COVID-19 vaccine coverage in people experiencing homelessness (PEH) or precariously housed (PH) who are at high risk for COVID-19 infection, hospitalization, and death. Given the absence of documented French data, we aimed to determine COVID-19 vaccine coverage in PEH/PH in France, and its drivers. Methods We carried out a cross-sectional study following a two-stage cluster-sampling design in Ile-de-France and Marseille, France, in late 2021. Participants aged over 18 years were recruited where they slept the previous night and then stratified for analysis into three housing groups (Streets, Accommodated, and Housed). Interviews were conducted face-to-face in the participant's preferred language. Multilevel univariate and multivariable logistic regression models were built. Findings 3,690 individuals were surveyed: 855 in the Housed stratum, 2,321 in the Accommodated stratum and 514 in the Streets stratum. 76.2% (95%CI 74.3-78.1) reported receiving at least one COVID-19 vaccine dose. Vaccine uptake varied by stratum, with uptake highest (85.6%; reference) in Housed, followed by Accommodated (75.4%; AOR=0.79; 95%CI 0.51-1.09 vs Housed) and lowest in Streets (42.0%; AOR=0.38; 95%CI 0.25-0.57 vs Housed). Use for vaccine certificate, socioeconomic drivers, and vaccine hesitancy explained vaccine coverage. Interpretation In France, PEH/PH are less likely than the general population likely to receive COVID-19 vaccines; with the most excluded being the least likely. The influence of both structural drivers and vaccine beliefs in PEH/PH reinforce the importance of targeted outreach, on-site vaccination and sensitisation activities to further vaccine uptake. Funding Sante Publique France, Agence Nationale de Recherches sur le Sida/Capnet, Agence Regionale de Sante-Ile de France, Medecins Sans Frontieres, and Societe de Pathologie Infectieuse de Langue Francaise.
Subject(s)
COVID-19 , DeathABSTRACT
ABSTRACT Introduction French nursing homes were deeply affected by the first wave of the COVID-19 pandemic, with 38% of all residents infected and 5% dying. Yet, little was done to prepare these facilities for the second pandemic wave, and subsequent outbreak response strategies largely duplicated what had been done in the spring of 2020, regardless of the unique needs of the care home environment. Methods A cross-sectional, mixed-methods study using retrospective, quantitative data from residents of 14 nursing homes between November 2020 and mid-January 2021. Four facilities were purposively selected as qualitative study sites for additional in-person, in-depth interviews in January and February 2021. Results The average attack rate in the 14 participating nursing facilities was 39% among staff and 61% among residents. One-fifth (20) of infected residents ultimately died from COVID-19 and its complications. Failure-to-Thrive-Syndrome (FTTS) was diagnosed in 23% of COVID-positive residents. Those at highest risk of death were men (HR=1.78; IC95: 1.18 – 2.70; p=0.006) with FTTS (HR=4.04; IC95: 1.93 – 8.48; p<0.001) in facilities with delayed implementation of universal FFP2 masking policies (HR=1.05; IC95: 1.02 – 1.07; p<0.001). The lowest mortality was found in residents of facilities with a partial (HR=0.30; IC95: 0.18 – 0.51; p<0.001) or full-time physician on staff (HR=0.20; IC95: 0.08 – 0.53; p=0.001). Significant themes emerging from qualitative analysis centered on (i) the structural, chronic neglect of nursing homes, (ii) the negative effects of the top-down, bureaucratic nature of COVID-19 crisis response, and (iii) the counterproductive effects of lockdowns on both residents and staff. Conclusion Despite high resident mortality during the first pandemic wave, French nursing homes were ill-prepared for the second, with risk factors (especially staffing, lack of medical support, isolation/quarantine policy etc) that affected case fatality and residents’ and caregivers’ overall well-being and mental health. SUMMARY BOX What is already known? Though much was learned about COVID-19 in nursing homes during the first pandemic wave (Spring 2020), descriptions of the second wave in these facilities is nearly absent from the scientific literature. Prior COVID-19 research in nursing homes has rarely been qualitative and has almost never interviewed care home residents themselves. First-wave research indicated that much stronger outbreak and infection prevention was urgently needed to bolster nursing facilities’ preparedness. Higher staff-to-resident ratios, less staff turnover, more masks, better organization, more medical support, and more epidemiological tools were found to reduce COVID-19’s impact. What are the new findings? Our results document a lack of preparedness for the second wave, with attack rates among staff (39% overall) and residents (61% overall) similar to levels seen during the first wave peak. Despite authorities’ claims to have reinforced these structures’ readiness, and despite much research into the needs in these environments, preventive measures (like strict lockdowns) remained largely unchanged and had a direct impact on residents, with 23% of COVID-positives also diagnosed with Failure-to-Thrive Syndrome. Qualitative results detailed how ill-suited and inflexible some preventive measures were for residents and staff alike. Participants described precarious and understaffed living and working conditions as substantial and long-standing difficulties that became critical risks during the COVID-19 outbreak, and compromised the response. What do the new findings imply? These results suggest that knowledge gained during the first pandemic wave was not consistently applied to care home policy or practice in France, and that these nursing homes were not always safe environments that considered residents’ mental health and well-being alongside infection prevention. Despite the high mortality of the first pandemic wave, French nursing homes were ill-prepared for the second. As a 5 th wave descends on France (albeit with much higher COVID-19 vaccination rates), applying the lessons from previous periods (especially with regard to staffing, isolation of the elderly, medical supplies, standard of care procedures) must be prioritized.
Subject(s)
COVID-19 , Failure to ThriveABSTRACT
BackgroundA nationwide lockdown was implemented in France on 17 March 2020 to control the COVID-19 pandemic. People living in precarious conditions were relocated by the authorities to emergency shelters, hotels and large venues. Medecins sans Frontieres (MSF) then intervened to provide medical care in several of these locations in Paris and in Seine-Saint-Denis, one of its suburbs, between March and June 2020. A seroprevalence survey was conducted to assess the level of exposure to COVID-19 among the population living in the sites. To our knowledge, this is the first assessment of the impact of the pandemic on populations living in insecure conditions in Europe. MethodsWe conducted a cross-sectional seroprevalence study in the food distribution sites, emergency shelters and workers residences supported by MSF in Paris and Seine-Saint-Denis, to determine the extent of COVID-19 exposure as determined by SARS-CoV2 antibody seropositivity. The detection of SARS-COV2 antibodies in serum was performed at the Institut Pasteur of Paris using two LuLISA (Luciferase-Linked Immunosorbent Assay) assays and a Pseudo Neutralization Test. A questionnaire covering sociodemographic characteristics, living conditions, adherence to sanitary recommendations and symptom manifestations was also completed. We describe here the seroprevalence site by site and identify the risk factors for seropositivity using a multivariable logistic regression model with site random effects. We also investigated associations between seropositivity and symptoms eventually reported. FindingsOverall, 426/818 individuals tested positive in the 14 sites investigated. Seroprevalence varied significantly with the type of site (chi2 p<0.001). It was highest at 88.7% (95%CI 81.8-93.2) among individuals living in workers residences, followed by 50.5% (95%CI 46.3-54.7) in emergency shelters and 27.8 % (95%CI 20.8-35.7) among individuals recruited from the food distribution sites. Seroprevalence also varied significantly between sites of the same type. Among other risk factors, the odds for seropositivity were higher among individuals living in crowded sites (medium: adj. OR 2.7, 95%CI 1.5-5.1, p=0.001; high: adj. OR 3.4, 95%CI 1.7-6.9, p<0.001) compared with individuals from low crowding sites and among those who reported transit accommodation in a gymnasium before the lockdown (adj. OR 3.1, 95%CI 1.2-8.1, p=0.023). More than two-thirds of the seropositive individuals (68.3%; 95%CI 64.2-72.2) did not report any symptoms during the recall period. InterpretationThe results demonstrate rather high exposure to SARS-COV-2 with important variations between study sites. Living in crowded conditions was identified as the most important explanatory factor for differences in levels of exposure. This study describes the key factors which determine the risk of exposure and illustrates the importance of identifying populations at high risk of exposure in order to orient and adapt prevention and control strategies to their specific needs.