LOWER PREVALENCE OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) INFECTION AMONG PEOPLE EXPERIENCING HOMELESSNESS TESTED IN ...

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Clinical Infectious Diseases
    MAJOR ARTICLE

Lower Prevalence of Severe Acute Respiratory Syndrome
Coronavirus 2 (SARS-CoV-2) Infection Among
People Experiencing Homelessness Tested in Outdoor
Encampments Compared With Overnight Shelters:

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Denver, Colorado, June–July 2020
Sarah E. Rowan,1,2 David W. McCormick,3,4 Karen A. Wendel,1,2 Tracy Scott,1 Jesse Chavez-van de Hey,1 Kay Wilcox,1,5 Sarah A. Stella,1,2 Kevin Kamis,1
William J. Burman,1,2 and Grace E. Marx1,2,4
1
 Denver Public Health, Denver Health and Hospital Authority, Denver, Colorado, USA; 2Division of Infectious Diseases, University of Colorado Denver, Aurora, Colorado, USA; 3Epidemic Intelligence
Service, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; 4National Center for Emerging and Zoonotic Infectious
Diseases, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA; and 5Public Health Associate Program, Centers for Disease Control and
Prevention, Atlanta, Georgia, USA

   Background. A better understanding of the risk for coronavirus disease 2019 (COVID-19) that people experiencing homeless-
ness (PEH) face in congregate shelters versus unsheltered encampments is critical for an effective pandemic response.
   Methods. We analyzed factors associated with current and past severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
infection among PEH in day and overnight shelters and encampments in Denver, Colorado, during June 2–July 28, 2020, and con-
structed multivariable logistic regression models to examine risk factors for SARS-CoV-2 RNA and seropositivity with age, race/
ethnicity, testing location, testing month, and symptom status as predictor variables.
   Results. A total of 823 participants were tested for SARS-CoV-2 RNA, and 276 individuals were tested for SARS-CoV-2 anti-
bodies. A greater percentage of PEH at overnight shelters tested positive for SARS-CoV-2 RNA (8.6% vs 2.5%, P < .01) and anti-
bodies (21.5% vs 8.7%, P = .03) compared with encampments. In regression models, testing at an overnight shelter compared with
testing at encampments (odds ratio [OR] = 3.03, 95% confidence interval [CI]: 1.16–9.02) had increased odds of a positive SARS-
CoV-2 RNA result. Age >60 years compared with age 500 000 people in the United States experi-                                          factor for COVID-19, and PEH experience a disproportionate
enced homelessness on a single night in January 2020, 39% of                                         burden of comorbidities, placing them at increased risk for
whom (>220 000 individuals) were staying in unsheltered lo-                                          severe COVID-19, including hospitalization and death [2].
cations, such as on the streets or in other locations not meant                                      Preventing severe acute respiratory syndrome coronavirus 2
for habitation [1]. The coronavirus disease 2019 (COVID-                                             (SARS-CoV-2) transmission and related morbidity and mor-
19) pandemic has adversely impacted people experiencing                                              tality among PEH is a critical public health priority, with im-
                                                                                                     plications extending far beyond the current pandemic. The
                                                                                                     heterogeneity of settings where PEH congregate must be con-
  Received 26 November 2021; editorial decision 12 January 2022; published online 18 January         sidered when designing strategies to mitigate the impact of
2022.
  Correspondence: S. E. Rowan, Denver Health and Hospital Authority, 601 Broadway, Denver,           COVID-19 among PEH.
CO 80203, USA (Sarah.rowan@dhha.org).                                                                   Congregate shelters for PEH are often crowded indoor en-
Clinical Infectious Diseases®  2022;XX(XX):1–8                                                       vironments with poor ventilation through which hundreds of
© The Author(s) 2022. Published by Oxford University Press for the Infectious Diseases Society
of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.              people may pass each day, eating and sleeping in close prox-
https://doi.org/10.1093/cid/ciac039                                                                  imity. The frequency of close contact with others in this

                                                  Severe Acute Respiratory Syndrome Coronavirus 2 in Encampments and Shelters • CID 2022:XX (XX XX) • 1
high-density indoor environment greatly increases the risk of       as PEH staying in encampments. PEH who participated in
transmission of respiratory pathogens. Moreover, SARS-CoV-2         testing were offered $15 gift cards to a local grocery store
can be transmitted from asymptomatic or presymptomatic              chain.
hosts, making it difficult to identify and isolate those who may
be contagious [3]. Reports of SARS-CoV-2 prevalence in over-        SARS-CoV-2 Testing
night shelters have ranged 11% from 67% of guests tested in         SARS-CoV-2 reverse transcription polymerase chain reaction
shelters in Seattle, Boston, and San Francisco [4–6]. The com-      (RT-PCR) testing was performed on nasopharyngeal swabs
bination of increased risk of SARS-CoV-2 transmission and in-       and conducted in the laboratory at the Colorado Department
creased risk for poor COVID-19 outcomes among those who             of Public Health and Environment using the CDC 2019-Novel
contract the virus leaves shelter guests in the precarious posi-    Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic
tion of deciding whether to stay in overnight shelters and risk     Panel assay protocol. SARS-CoV-2 immunoglobulin G anti-

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illness from COVID-19 or seek other options, which may also         body testing was performed on venous blood samples at Denver
present serious risks to health and safety such as hypothermia      Health Medical Center using either the Thunderbolt (Gold
or physical assault [7].                                            Standard Diagnostics, Davis, CA) or Access (Beckman Coulter,
   In many cities, PEH congregate in encampments, defined           Brea, CA) assays according to the manufacturers’ instructions.
as a group of people experiencing unsheltered homelessness          Delivery of testing results and subsequent support for safely
together [8]. In 2020, a cross-sectional count estimated 6104       isolating diagnosed cases were coordinated with staff members
individuals were experiencing homelessness in the greater           from the Colorado Coalition for the Homeless, a local organiza-
metropolitan Denver area, including 1561 experiencing un-           tion that serves PEH. All testing occurred between June 2, 2020,
sheltered homelessness [9]. The US Centers for Disease Control      and July 28, 2020.
and Prevention (CDC) has issued guidance that advises pol-
icymakers to allow individuals to remain in encampments             Data Collection
to maintain connections with service providers and prevent          At each testing event, a short questionnaire was administered
spread of COVID-19 [10]. This guidance may be difficult for         to participants who registered for testing. The questionnaire
state and local governmental organizations to follow in the face    asked about the following sociodemographic factors: age, self-
of competing demands and uncertainty around COVID-19                identified gender, and self-identified race and ethnicity; and
prevalence in encampments.                                          any of the following symptoms they had experienced in the past
   To better respond to the needs of all PEH during the ongoing     2 weeks: cough, fever, shortness of breath, loss of taste or smell.
pandemic, it is crucial to understand how COVID-19 affects
PEH staying in a variety of settings, such as encampments, day      Statistical Methods
shelters (services offered during the day, without sleeping quar-   Factors associated with positive RT-PCR and antibody test re-
ters), and overnight shelters (services with sleeping quarters).    sults were compared across testing settings. Continuous vari-
Although ongoing work has assessed SARS-CoV-2 screening             ables are expressed as median and interquartile ranges (IQRs),
and COVID-19 management and mitigation strategies in over-          and categorial data are expressed as counts and percentages. We
night shelters, there has been less focus on SARS-CoV-2 trans-      did not impute missing data. The Mann-Whitney U test was
mission among PEH who are unsheltered. In this study, we            used to compare continuous variables, and the χ2 test was used
analyzed factors associated with current and past SARS-CoV-2        to compare categorical variables; Fisher exact test was used if
infection among PEH staying in day and overnight shelters and       the expected cell count was ≤5. Analysis of variance was used
encampments in Denver, Colorado, during the early COVID-19          to compare age between day shelters, overnight shelters, and
pandemic.                                                           encampments. An α of 0.05 was considered significant. All
                                                                    statistical tests are 2-sided. Data were initially entered into
                                                                    Microsoft Excel (Microsoft, Redmond, WA); all statistical cal-
METHODS
                                                                    culations were performed using R version 4.0.2 (R Foundation
Setting                                                             for Statistical Computing) [11].
Denver Public Health (DPH) is a public health agency                   Individuals who had previously tested positive for SARS-
within the Denver Health and Hospital Authority safety-net          CoV-2 by RT-PCR were not eligible for repeat viral testing but
healthcare system. To meet community-based testing needs            were still eligible for antibody testing. Duplicate testing events
among Denver’s population of PEH, the DPH Prevention and            were excluded from statistical analysis; for persons with more
Outreach Team collaborated with local community leaders to          than 1 RT-PCR testing event, the first testing event recorded
identify 4 homeless shelters and 3 outdoor encampments for          during the study period was included in the analysis. Persons
SARS-CoV-2 RNA and antibody testing. Testing was volun-             with indeterminate RT-PCR or antibody test results were ex-
tary and available for all guests and staff at shelters as well     cluded from further analyses.

2 • CID 2022:XX (XX XX) • Rowan et al
We constructed 2 logistic regression models to examine risk        Hispanic, 20.1% were non-Hispanic Black, and 3.9% were non-
factors for SARS-CoV-2 RT-PCR and antibody positivity. In             Hispanic American Indian or Alaskan Native. Of the 871 par-
the first model, the outcome of interest was a positive SARS-         ticipants, 61.8% were tested in overnight shelters, 30.7% were
CoV-2 RT-PCR result; in the second, the outcome of interest           tested in encampments, and 7.2% were tested in a day shelter.
was a positive antibody assay. In both models, equivocal or in-       Participants’ age, gender, and race/ethnicity varied by testing
determinate laboratory results were excluded. Predictor vari-         location (Table 1).
ables of interest were gender; race/ethnicity; categorical age; a
composite variable for presence or absence of any one of the          SARS-CoV-2 RT-PCR Results
following self-reported symptoms within the previous 2 weeks:         SARS-CoV-2 RT-PCR results were available for 823 individuals:
subjective or measured fever, cough, or shortness of breath;          54 tests (6.5%) were positive, 757 (92.0%) were negative, and
month of sample collection (June or July); and setting in which       12 (1.5%) were indeterminate. SARS-CoV-2 RT-PCR positive

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the participant was tested (overnight shelter or encampment).         results were more common among men than women (7.7%
Age was categorized as  60 years (OR = 6.99; 95% CI: 2.43–20.9), persons testing at
and RT-PCR testing were available during 5 testing events,            overnight shelters (OR = 2.89; 95% CI: 1.43–6.28), Hispanic
whereas 6 testing events had only RT-PCR testing available.           persons (OR = 2.94; 95% CI: 1.23–7.18), and non-Hispanic
Participant characteristics are listed in Table 1. Median partic-     Black persons (OR = 2.89; 95% CI: 1.16–7.27) had significantly
ipant age was 46 years (IQR 36–55 years). Among 870 partici-          higher odds of antibody positivity (Table 3). In the multivariable
pants with available information regarding their gender, 82.3%        model, persons aged >60 years (OR = 5.92; 95% CI: 1.83–20.3),
were men. Among 812 participants who self-reported their              Hispanic persons (OR = 3.43; 95% CI: 1.36–8.95), non-Hispanic
race/ethnicity, 46.4% were non-Hispanic White, 22.0% were             Black persons (OR = 3.07; 95% CI: 1.16–8.26), and testing at an

                                   Severe Acute Respiratory Syndrome Coronavirus 2 in Encampments and Shelters • CID 2022:XX (XX XX) • 3
Table 1. Demographic Characteristics, Symptom Status, and Testing Location for Participants Tested for SARS-CoV-2 RNA and/or antibodies, Denver,
June–July 2020

                                                          Overall (N = 871)       Overnight Shelter (N = 541)         Encampment (N = 267)            Day Shelter (N = 63)         P Valuea

Age in years (median, IQR)                                     46, 36–55                     48, 38–56                         41, 32–51                     50, 37–56
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Figure 1. Severe acute respiratory syndrome coronavirus 2 reverse transcriptase-polymerase chain reaction positivity and antibody positivity by location type and gender.

   PEH sometimes move between shelters or from other con-                              that age is a risk factor for severe COVID-19 and additional
gregate settings with high SARS-CoV-2 risk (eg, respite care,                          measures to protect older individuals experiencing homeless-
jails). However, exposures during the prior 14 days were not                           ness may be warranted.
asked of our participants, so it is unknown whether exposures                             Data about SARS-CoV-2 infection rates in homeless shel-
from other settings could have contributed to the higher infec-                        ters suggest that prevalence varies widely depending in part on
tion rates among individuals in our study. However, a previous                         whether a cluster of cases had been identified before widespread
study in Toronto, Canada, found that individuals in shelters                           screening. A review of SARS-CoV-2 testing in 3 US cities early
who tested positive were less likely to have been in a different                       in the pandemic revealed an average positivity rate of 37% in
shelter in the prior 14 days [18], suggesting that infections were                     shelters which had identified ≥2 cases in the preceding 2 weeks
acquired in the shelter in which individuals were tested rather                        and 4% to 5% in shelters, which had 0 or 1 reported case in
than from an outside source.                                                           the preceding 2 weeks [19]. The overall current infection preva-
   PEH tested at overnight shelters had a higher prevalence                            lence of 9% in shelters in our study reflects the heterogeneity of
of antibodies against SARS-CoV-2, suggesting that overnight                            prevalent cases in the shelters tested, though except for 2 testing
shelters have a higher risk of SARS-CoV-2 transmission; this                           events at encampments, all testing events during the study pe-
association remained significant in the adjusted models. PEH                           riod identified at least 2 new cases of active SARS-CoV-2 infec-
with prior SARS-CoV-2 infection tended to be older than in-                            tion, with some events identifying as many as 12 cases.
dividuals without evidence of prior infection. This association                           The generalizability of these findings is limited by several fac-
remained when controlling for testing location type, age, race/                        tors. First, this study is observational and thus subject to un-
ethnicity, symptom status, and testing month; participants who                         measured differences in populations by testing location type.
were tested in overnight shelters were older on average than                           Second, our results may have been influenced by selection bias
those tested in encampments. Although the reasons for the                              because testing was voluntary and represents only individuals
higher prevalence of past infection in older individuals are not                       who opted in for testing. Third, movement of participants be-
readily apparent, the finding has concerning implications given                        tween shelters and encampments was not measured, and it is

                                            Severe Acute Respiratory Syndrome Coronavirus 2 in Encampments and Shelters • CID 2022:XX (XX XX) • 5
Table 2. Demographic Characteristics, Symptom Status, and Testing Location of Participants Stratified by SARS-CoV-2 RT-PCR and SARS-CoV-2 Antibody
Results, Denver, June–July 2020

                                                                         SARS-CoV-2 RT-PCR (N = 811)                                     SARS-CoV-2 Antibody (N = 276)

                                                              Positive                 Negative                                Positive                  Negative
                                                              (N = 54)                 (N = 757)             P Value           (N = 42)                  (N = 229)              P Value

Age (median, IQR)                                             49, 41–56                46, 36–55              .16              54, 48–58                 43, 34–53
Table 3. Association Between SARS-CoV-2 RT-PCR Positivity (Left 2 Columns) and SARS-CoV-2 Antibody Status (Right 2 Columns) Using Logistic
Regression Models, Denver, June–July 2020

                                   SARS-CoV-2 RT-PCR Positivity as Outcome of Interest                             SARS-CoV-2 Antibody Positivity as Outcome of Interest

                           Univariable Model; OR, 95% CI           Multivariable Model; OR, 95% CI          Univariable Model; OR, 95% CI         Multivariable Model; OR, 95% CI

Categorical age, y
 
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