(image credit: Ofure Itua)

By Jenissa Sunderji

Introduction

The novel coronavirus disease (COVID-19) has changed the way of life for people around the globe. However, individuals experiencing homelessness are disproportionately vulnerable to the current pandemic. In Canada, there are between 150,000 and 300,000 people homeless. Difficulty in implementing social distancing, inadequate access to sanitation and hygiene, and a high prevalence of chronic health conditions are only a few of the contributing factors affecting both the susceptibility to infection and the severity of the disease and make tackling COVID-19 in homeless populations a unique situation.

COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an infectious disease with resulting symptoms that include fever, coughing, fatigue, and difficulty breathing. Individuals who contract the disease can also remain asymptomatic. Mortality from COVID-19 can result from complications from the disease such as pneumonia, acute respiratory distress syndrome, viral sepsis, and kidney failure. Those who are at risk of being immunocompromised, such as having respiratory problems (chronic obstructive pulmonary disease (COPD), asthma, etc.), being a part of the elderly population (65 years and older)., or having other comorbidities (hypertension, diabetes) have also been shown in studies to play a role in the development of critical cases.

In addition, the pandemic has caused unemployment and eviction rates to surge. The federal government and provincial governments have implemented programs to help those who have been laid off of work, or had their hours reduced such as rent subsidies and the Canada Emergency Response Benefit (CERB). Despite these programs, there is still an increase in homelessness nationwide.

Transmission

COVID-19 is primarily transmitted when people are in close contact with one another, allowing the inhalation of small liquid droplets from an infected person (symptomatic or asymptomatic), or by means of airborne droplets through talking, coughing, sneezing, etc. Moreover, aerosols, smaller which are droplets that can remain in the air for an extended length of time, can also transmit the virus. One of the most effective ways to prevent the transmission of COVID-19 is to implement social distancing procedures- such as the  recommended distance of 2 metres (6 feet) between individuals.

However, these strategies are not always possible when it comes to individuals experiencing homelessness. Shelters, homeless camps, clinics, addiction centres, soup kitchens, and other facilities that provide aid for homeless people have always been at an increased risk for disease outbreaks and spreading. By their nature, there is often poor ventilation, crowding, and frequent movement of transient people, making adequate social distancing almost impossible. Therefore, if even one person in a homeless shelter contracts COVID-19, the chances of that case leading to a community outbreak are higher. This phenomenon was seen in a shelter in Worcester, Massachusetts where out of 114 residents, 49 tested positive. The shelter, like most, was overcrowded with different people coming and going, and little personal protective equipment (PPE). It has been shown numerous times that in places that had the ability to enforce physical distancing and mask wearing, the rapid spread of COVID-19 as seen in the Worcester shelter did not occur.

Additionally, in order to comply with public health and physical distancing rules, some shelters have been forced to reduce services or close entirely further straining already struggling homelessness resources and services. Without access to housing and other necessities, it can also be impractical for someone to prioritize or have access to other measures that limit transmission such as personal protective equipment (PPE – face masks, hand sanitizer, etc.), and facilities for more frequent handwashing. If someone is already worried about where they are going to sleep, if they are safe, and if they have food, they are most likely going to be less concerned about finding a mask or hand sanitizer.

Furthermore, when an individual is tested positive for COVID-19, isolation is crucial in attempts to stop further transmission of the virus. This brings about the obvious issue: where would someone isolate if they do not have access to safe housing or enough food for two weeks?

Health Complications

As aforementioned, individuals experiencing homelessness often have increased susceptibility to infection and a lack of access to health care. Homeless populations also face higher rates of mental health issues and substance use disorders with subsequent comorbidities and conditions such as HIV or hepatitis C. These conditions may compromise one’s immune system, leaving them both more vulnerable to infection and less able to fight an infection. In combination with generally poorer health caused by their lower standard of living and many of individuals facing homelessness are in the vulnerable age category (over 65 years), COVID-19 can not only spread fast among homeless populations, but the health outcomes can often be more detrimental compared to someone with access to adequate housing. Lower quality of health, drug addictions, and less access to health care can also cause mild symptoms of COVID-19 to go unnoticed- ‘normal’ maladies may mask the symptoms of COVID-19. This was seen in the aforementioned shelter in Worcester, Mass., where there was little indication of COVID-19, despite the very high rates of infection. Similarly, in Boston testing showed that 140 out of 350 residents of one shelter tested positive, all of whom were asymptomatic.

An Interesting Discovery – Downtown Eastside (Vancouver)

While it was originally thought that COVID-19 would be more devastating to individuals that experience the living conditions and healthcare situations of the homeless population , new studies have shown that particularly in the Downtown Eastside community in Vancouver, BC, this has not been the case. There are a few different thoughts as to why this community, who was initially thought to be very vulnerable, has been mostly spared by the virus so far.

The virus is less transmittable outdoors, which is where many homeless people spend most of their time during the day. Outside there is more space between people and less opportunity for human-to-human contact. Another important factor is that the homeless populations, especially in the Downtown Eastside, are fairly isolated from contact with people outside of their community. People experiencing homelessness may be transient, but usually only within a small area and population. There is little travel in and out of the community at large, thereby reducing possible sources of transmission.

As mentioned earlier, another possible explanation for the low number of COVID-19 cases in this homeless population is that there is a high rate of underlying medical conditions and substance abuse problems. This may cause mild symptoms, which comprise the majority of COVID-19 cases, and allow individuals unknowingly carrying the virus to be unaware of it. Therefore, it may not be that there are less infections in the homeless population of the Downtown Eastside compared to the general population, but a high number of missed cases. Information coming from the testing completed at the Boston shelter in particular has shown that there is a high possibility of numerous cases going unnoticed because they are completely asymptomatic.

The stark difference between the predicted rampage of COVID-19 in homeless areas and the reality that has been observed has sparked a new interest in widespread testing for both the virus and antibodies in these populations. The results of this test could help determine if the lifestyles of people facing homelessness (a community who are only transient within a defined and somewhat enclosed area and spend the majority of their days outside) are serving as protective factors against the virus, or if there are cases that are going unnoticed.

Conclusion

COVID-19 has the potential to devastate homeless communities due health issues and difficulty with physical distancing and PPE. While this has been seen in some cases, there are some protective factors of homeless populations that should be studied more, such as through antibody testing. Additionally, in order to protect this vulnerable population and ensure that they are being provided with the services necessary to slow the spread of COVID-19, there needs to be new efforts to adapt services to comply with current public health restrictions. This pandemic has shown to be indiscriminate of many social differences, and it is vital that we strive to protect every community.

References

Canada, P. H. A. of. (2020, July 20). Guidance for providers of services for people experiencing homelessness (in the context of COVID-19) [Guidance]. Aem. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/guidance-documents/homelessness.html

Concern for Downtown Eastside after U.S. tests find asymptomatic COVID-19 outbreaks among homeless. (n.d.). Global News. Retrieved July 29, 2020, from https://globalnews.ca/news/6845264/dtes-concerns-asymptomatic-covid-19-cases/

Conway, B., Truong, D., & Wuerth, K. (n.d.). COVID-19 in homeless populations: Unique challenges and opportunities. Future Virology. https://doi.org/10.2217/fvl-2020-0156

Ferreira, J. (2020, May 22). The toll COVID-19 is taking on Canada’s homeless. Coronavirus. https://www.ctvnews.ca/health/coronavirus/the-toll-covid-19-is-taking-on-canada-s-homeless-1.4950722

Perri, M., Dosani, N., & Hwang, S. W. (2020). COVID-19 and people experiencing homelessness: Challenges and mitigation strategies. CMAJ, 192(26), E716–E719. https://doi.org/10.1503/cmaj.200834

Transmission of COVID-19 virus by droplets and aerosols: A critical review on the unresolved dichotomy. (n.d.). Retrieved July 29, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293495/

Vancouver reopens 3 ‘vital’ Downtown Eastside community centres amid COVID-19. (n.d.). Global News. Retrieved July 23, 2020, from https://globalnews.ca/news/7181789/vancouver-reopens-dtes-community-centres-coronavirus/

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