Testing, infection and complication rates of COVID-19 among people with a recent history of homelessness in Ontario, Canada: a retrospective cohort study

Background: People with a recent history of homelessness are believed to be at high risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and, when infected, complications of coronavirus disease 2019 (COVID-19). We describe and compare testing for SARS-CoV-2, test positivity and hospital admission, receipt of intensive care and mortality rates related to COVID-19 for people with a recent history of homelessness versus community-dwelling people as of July 31, 2020.

Methods: We conducted a population-based retrospective cohort study in Ontario, Canada, between Jan. 23 and July 31, 2020, using linked health administrative data among people who either had a recent history of homelessness or were dwelling in the community. People were included if they were eligible for provincial health care coverage and not living in an institutionalized facility on Jan. 23, 2020. We examined testing for SARS-CoV-2, test positivity and complication outcomes of COVID-19 (hospital admission, admission to intensive care and death) within 21 days of a positive test result. Extended multivariable Cox proportional hazard models were used to estimate adjusted hazard ratios (HRs) in 3 time periods: preshutdown (Jan. 23–Mar. 13), peak (Mar. 14–June 16) and reopening (June 17–July 31).

Results: People with a recent history of homelessness (n = 29 407) were more likely to be tested for SARS-CoV-2 in all 3 periods compared with community-dwelling people (n = 14 494 301) (preshutdown adjusted HR 1.61, 95% confidence interval [CI] 1.22–2.11; peak adjusted HR 2.95, 95% CI 2.88–3.03; reopening adjusted HR 1.45, 95% CI 1.39–1.51). They were also more likely to have a positive test result (peak adjusted HR 3.66, 95% CI 3.22–4.16; reopening adjusted HR 1.76, 95% CI 1.15–2.71). In the peak period, people with a recent history of homelessness were over 20 times more likely to be admitted to hospital for COVID-19 (adjusted HR 20.35, 95% CI 16.23–25.53), over 10 times more likely to require intensive care for COVID-19 (adjusted HR 10.20, 95% CI 5.81–17.93) and over 5 times more likely to die within 21 days of their first positive test result (adjusted HR 5.73, 95% CI 3.01–10.91).

Interpretation: In Ontario, people with a recent history of homelessness were significantly more likely to be tested for SARS-CoV-2, to have a positive test result, to be admitted to hospital for COVID-19, to receive intensive care for COVID-19 and to die of COVID-19 compared with community-dwelling people. People with a recent history of homelessness should continue to be considered particularly vulnerable to SARS-CoV-2 infection and its complications.