COVID-19 among people experiencing homelessness in England: a modelling study

Dan Lewer*, Isobel Braithwaite, Miriam Bullock, Max T. Eyre, Peter White, Robert W. Aldridge, Alistair Story, Andrew C. Hayward

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

16 Citations (Scopus)

Abstract

Background: People experiencing homelessness are vulnerable to COVID-19 due to the risk of transmission in shared accommodation and the high prevalence of comorbidities. In England, as in some other countries, preventive policies have been implemented to protect this population. We aimed to estimate the avoided deaths and health-care use among people experiencing homelessness during the so-called first wave of COVID-19 in England—ie, the peak of infections occurring between February and May, 2020—and the potential impact of COVID-19 on this population in the future. Methods: We used a discrete-time Markov chain model of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that included compartments for susceptible, exposed, infectious, and removed individuals, to explore the impact of the pandemic on 46 565 individuals experiencing homelessness: 35 817 living in 1065 hostels for homeless people, 3616 sleeping in 143 night shelters, and 7132 sleeping outside. We ran the model under scenarios varying the incidence of infection in the general population and the availability of prevention measures: specialist hotel accommodation, infection control in homeless settings, and mixing with the general population. We divided our scenarios into first wave scenarios (covering Feb 1–May 31, 2020) and future scenarios (covering June 1, 2020–Jan 31, 2021). For each scenario, we ran the model 200 times and reported the median and 95% prediction interval (2·5% and 97·5% quantiles) of the total number of cases, the number of deaths, the number hospital admissions, and the number of intensive care unit (ICU) admissions. Findings: Up to May 31, 2020, we calibrated the model to 4% of the homeless population acquiring SARS-CoV-2, and estimated that 24 deaths (95% prediction interval 16–34) occurred. In this first wave of SARS-CoV-2 infections in England, we estimated that the preventive measures imposed might have avoided 21 092 infections (19 777–22 147), 266 deaths (226–301), 1164 hospital admissions (1079–1254), and 338 ICU admissions (305–374) among the homeless population. If preventive measures are continued, we projected a small number of additional cases between June 1, 2020, and Jan 31, 2021, with 1754 infections (1543–1960), 31 deaths (21–45), 122 hospital admissions (100–148), and 35 ICU admissions (23–47) with a second wave in the general population. However, if preventive measures are lifted, outbreaks in homeless settings might lead to larger numbers of infections and deaths, even with low incidence in the general population. In a scenario with no second wave and relaxed measures in homeless settings in England, we projected 12 151 infections (10 718–13 349), 184 deaths (151–217), 733 hospital admissions (635–822), and 213 ICU admissions (178–251) between June 1, 2020, and Jan 31, 2021. Interpretation: Outbreaks of SARS-CoV-2 in homeless settings can lead to a high attack rate among people experiencing homelessness, even if incidence remains low in the general population. Avoidance of deaths depends on prevention of transmission within settings such as hostels and night shelters. Funding: National Institute for Health Research, Wellcome, and Medical Research Council.

Original languageEnglish
Pages (from-to)1181-1191
Number of pages11
JournalThe Lancet Respiratory Medicine
Volume8
Issue number12
DOIs
Publication statusPublished - Dec 2020

Bibliographical note

Funding Information:
Homeless Link provided data on the number and size of homeless hostels in England. St Mungo's provided data on the demographics of their clients, who they worked with in housing-related support services. The Greater London Authority provided data on the number and size of homeless night shelters in London. University College London Hospitals (Find & Treat) provided testing data from homeless settings in London. UCL Collaborative Centre for Inclusion Health provided self-report surveillance data from homeless settings in London. DL is funded by the National Institute for Health Research (NIHR; Doctoral Research Fellowship DRF-2018-11-ST2-016). IB is funded by an NIHR Academic Clinical Fellowship. This paper presents independent research. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the UK Department of Health and Social Care. MTE is funded by a studentship from the UK Medical Research Council (MRC). PJW acknowledges funding from the UK MRC Centre for Global Infectious Disease Analysis (MR/R015600/1); this award is jointly funded by the MRC and the UK Foreign, Commonwealth & Development Office (FCDO) under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the EU. RWA is supported by Wellcome through a Wellcome Clinical Research Career Development Fellowship (number 206602).

Funding Information:
Homeless Link provided data on the number and size of homeless hostels in England. St Mungo's provided data on the demographics of their clients, who they worked with in housing-related support services. The Greater London Authority provided data on the number and size of homeless night shelters in London. University College London Hospitals (Find & Treat) provided testing data from homeless settings in London. UCL Collaborative Centre for Inclusion Health provided self-report surveillance data from homeless settings in London. DL is funded by the National Institute for Health Research (NIHR; Doctoral Research Fellowship DRF-2018-11-ST2-016). IB is funded by an NIHR Academic Clinical Fellowship. This paper presents independent research. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the UK Department of Health and Social Care. MTE is funded by a studentship from the UK Medical Research Council (MRC). PJW acknowledges funding from the UK MRC Centre for Global Infectious Disease Analysis (MR/R015600/1); this award is jointly funded by the MRC and the UK Foreign, Commonwealth & Development Office (FCDO) under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the EU. RWA is supported by Wellcome through a Wellcome Clinical Research Career Development Fellowship ( number 206602 ).

Publisher Copyright:
© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

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