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

Lucie Richard, Richard Booth, Jennifer Rayner, Kristin K. Clemens, Cheryl Forchuk and Salimah Z. Shariff
January 11, 2021 9 (1) E1-E9; DOI: https://doi.org/10.9778/cmajo.20200287
Lucie Richard
ICES Western (Richard, Shariff); Western University (Booth, Clemens, Forchuk), London, Ont.; Alliance for Healthier Communities (Rayner), Toronto, Ont.
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Richard Booth
ICES Western (Richard, Shariff); Western University (Booth, Clemens, Forchuk), London, Ont.; Alliance for Healthier Communities (Rayner), Toronto, Ont.
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Jennifer Rayner
ICES Western (Richard, Shariff); Western University (Booth, Clemens, Forchuk), London, Ont.; Alliance for Healthier Communities (Rayner), Toronto, Ont.
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Kristin K. Clemens
ICES Western (Richard, Shariff); Western University (Booth, Clemens, Forchuk), London, Ont.; Alliance for Healthier Communities (Rayner), Toronto, Ont.
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Cheryl Forchuk
ICES Western (Richard, Shariff); Western University (Booth, Clemens, Forchuk), London, Ont.; Alliance for Healthier Communities (Rayner), Toronto, Ont.
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Salimah Z. Shariff
ICES Western (Richard, Shariff); Western University (Booth, Clemens, Forchuk), London, Ont.; Alliance for Healthier Communities (Rayner), Toronto, Ont.
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    Figure 1:

    Diagram illustrating how the study cohort was built. Note: ALC = alternate level of care (a clinical designation identifying patients in Ontario hospitals who no longer require the intensity of resources provided in their current acute care setting and are waiting for discharge to an appropriate destination), DOLC = date of last contact, OHIP = Ontario Health Insurance Plan.

Tables

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    Table 1:

    Cohort characteristics at index, by group

    Characteristic at indexNo. (%) of patients*p valueStandardized difference, %
    People with a recent history of homelessness
    n = 29 407
    Community-dwelling population
    n = 14 494 301
    Sociodemographic characteristics
    Age, yr, median (IQR)38 (28–52)41 (23–59)< 0.0015
    Age group, yr< 0.001
     Youth (< 25)4789 (16.3)3 996 738 (27.6)28
     Young adults (25–39)10 526 (35.8)2 853 540 (19.7)37
     Older adults (40–64)11 898 (40.5)4 949 782 (34.1)13
     Seniors (≥ 65)2194 (7.5)2 694 241 (18.6)34
    Male19 994 (68.0)7 125 208 (49.2)< 0.00139
    Immigrated within past 10 yr†510 (1.7)624 664 (4.3)< 0.00115
    Immigrated as refugee†217 (0.7)106 997 (0.7)0.990
    Income quintile‡< 0.001
     1 (lowest)12 723 (43.3)2 724 338 (18.8)55
     26402 (21.8)2 791 099 (19.3)6
     35166 (17.6)3 354 429 (19.3)14
     42744 (9.3)2 873 618 (19.8)30
     5 (highest)2372 (8.1)2 750 817 (19.0)32
    Level of urbanicity< 0.001
     Large CMA (> 500 000 population)17 018 (57.9)8 802 812 (60.7)6
     Small to medium-sized urban centres (10 000–500 000 population10 082 (34.3)3 959 178 (27.3)15
     Areas with < 10 000 population1660 (5.6)1 280 134 (8.8)12
     Unknown or missing647 (2.2)452 177 (3.1)6
    Comorbidities and prior health care use
    Asthma or COPD7308 (24.9)2 344 954 (16.2)< 0.00122
    Diabetes3587 (12.2)1 486 515 (10.3)< 0.0016
    Congestive heart failure820 (2.8)264 745 (1.8)< 0.0016
    Hypertension4833 (16.4)3 072 844 (21.2)< 0.00112
    Care related to mental health in previous year21 905 (74.5)1 909 412 (13.2)< 0.001157
     Psychotic disorders9539 (32.4)171 880 (1.2)< 0.00192
     Nonpsychotic disorders16 683 (56.7)1 744 055 (12.0)< 0.001107
     Substance use disorders15 097 (51.3)204 393 (1.4)< 0.001137
    No. of primary care visits in previous year, median (IQR)19 (6–47)5 (1–11)< 0.00189
    • Note: Cells representing ≤ 5 individuals are suppressed to protect individual privacy. CMA = census metropolitan area, COPD = chronic obstructive pulmonary disease, IQR = interquartile range.

    • ↵* Unless indicated otherwise.

    • ↵† Immigration status defined based on presence of a landing date in the Immigration, Refugees and Citizenship Canada Permanent Resident Database from 2008 to 2018.

    • ↵‡ Income quintiles at the Dissemination Area level, derived from 2016 census data. Missing and unknown values were recoded to quintile 3.

    • View popup
    Table 2:

    Outcomes during follow-up

    OutcomeNo. of patientsRate per 100 person-years
    Tested for SARS-CoV-2
     People with a recent history of homelessness845162.10
     Community-dwelling people1 266 71617.24
    Tested positive for SARS-CoV-2
     People with a recent history of homelessness2742.01
     Community-dwelling people28 4300.39
    Admitted to hospital with COVID-19
     People with a recent history of homelessness1040.69
     Community-dwelling people36850.05
    Admitted to hospital with COVID-19 and required intensive care
     People with a recent history of homelessness150.10
     Community-dwelling people10530.01
    Died within 21 d of positive SARS-CoV-2 test
     People with a recent history of homelessness100.07
     Community-dwelling people7300.01
    • Note: COVID-19 = coronavirus disease 2019, SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.

    • View popup
    Table 3:

    Adjusted and unadjusted hazard of outcomes related to COVID-19 (Jan. 23 to July 31, 2020) for people with a recent history of homelessness

    CharacteristicHazard ratio (95% CI); outcome
    Tested*Positivity†Hospital admission‡Intensive care§Death¶
    Unadjusted analysis
    People with a recent history of homelessness (Ref. = community-dwelling people)
     Preshutdown period: Jan. 23 to Mar. 133.06 (2.33–4.03)NRNRNRNR
     Peak period: Mar. 14 to June 165.06 (4.93–5.19)5.07 (4.94–5.20)65.12 (53.45–79.34)33.75 (20.27–56.18)7.64 (4.09–14.24)
     Reopening period: June 17 to July 312.39 (2.30–2.49)1.05 (1.04–1.07)0.51 (0.17–1.59)NRNR
    Adjusted analysis
    People with a recent history of homelessness (Ref. = community-dwelling people)
     Preshutdown period: Jan. 23 to Mar. 131.61 (1.22–2.11)NRNRNRNR
     Peak period: Mar. 14 to June 162.95 (2.88–3.03)3.66 (3.22–4.16)20.35 (16.23–25.53)10.20 (5.81–17.93)5.73 (3.01–10.91)
     Reopening period: June 17 to July 311.45 (1.39–1.51)1.76 (1.15–2.71)0.38 (0.12–1.17)NRNR
    Age group, yr (Ref. = youth [18–24 yr])
     Young adults (25–39)2.02 (2.01–2.03)2.05 (1.97–2.13)3.47 (2.70–4.46)4.39 (2.37–8.14)4.99 (0.56–44.53)
     Older adults (40–64)2.03 (2.02–2.04)2.18 (2.10–2.26)9.84 (7.86–12.31)21.67 (12.45–37.73)44.24 (6.16–317.75)
     Seniors (≥ 65)1.90 (1.89–1.91)1.31 (1.25–1.37)17.66 (14.04–22.2)28.81 (16.40–50.61)321.6 (44.9–2299.9)
    Sex (Ref. = female)0.76 (0.76–0.76)0.91 (0.89–0.94)1.31 (1.23–1.40)1.88 (1.66–2.14)1.36 (1.18–1.58)
    Immigration status** (Ref. = not an immigrant)0.87 (0.86–0.87)1.83 (1.75–1.90)1.41 (1.22–1.63)1.64 (1.27–2.11)0.93 (0.57–1.51)
    Income quintile (Ref. = highest income quintile)††‡‡
     1 (lowest income)0.96 (0.95–0.96)2.01 (1.93–2.09)2.02 (1.82–2.25)1.93 (1.57–2.36)1.64 (1.30–2.08)
     20.95 (0.95–0.96)1.52 (1.46–1.58)1.38 (1.23–1.55)1.48 (1.20–1.83)1.22 (0.96–1.56)
     30.94 (0.94–0.95)1.42 (1.36–1.48)1.33 (1.18–1.49)1.27 (1.02–1.58)1.24 (0.97–1.58)
     40.94 (0.94–0.95)1.18 (1.13–1.23)1.19 (1.06–1.34)1.34 (1.08–1.67)1.00 (0.77–1.30)
    Urbanicity (Ref. = large CMA [> 500 000 population])
     Small to medium-sized urban centres (10 000–500 000 population1.13 (1.13–1.14)0.48 (0.47–0.50)0.44 (0.41–0.48)0.45 (0.39–0.53)0.51 (0.43–0.61)
     Areas with < 10 000 population1.11 (1.10–1.11)0.30 (0.28–0.32)0.25 (0.21–0.31)0.29 (0.21–0.41)0.27 (0.18–0.40)
     Unknown1.11 (1.10–1.13)0.68 (0.63–0.74)0.41 (0.32–0.54)0.50 (0.31–0.81)0.20 (0.09–0.45)
    Comorbidities at baseline (Ref. = no comorbidity)
     Asthma or COPD1.24 (1.24–1.25)1.06 (1.03–1.09)1.27 (1.18–1.37)1.32 (1.15–1.53)1.36 (1.17–1.59)
     Diabetes1.02 (1.01–1.03)1.38 (1.34–1.43)1.78 (1.66–1.92)2.22 (1.94–2.54)1.68 (1.44–1.95)
     Congestive heart failure1.48 (1.47–1.49)1.42 (1.32–1.52)1.92 (1.73–2.13)1.40 (1.13–1.74)2.51 (2.09–3.01)
     Hypertension1.10 (1.10–1.11)1.30 (1.26–1.34)1.63 (1.50–1.76)1.57 (1.36–1.81)2.35 (1.91–2.89)
    No. of outpatient visits in past year1.01 (1.01–1.01)1.01 (1.01–1.01)1.01 (1.01–1.01)1.01 (1.01–1.01)1.01 (1.01–1.01)
    Health care for mental health in past year1.40 (1.40–1.41)1.04 (1.01–1.08)1.22 (1.12–1.32)0.98 (0.83–1.16)1.37 (1.14–1.65)
    • Note: CI = confidence interval, CMA = census metropolitan area, COPD = chronic obstructive pulmonary disease, COVID-19 = coronavirus disease 2019, NR = insufficient outcomes in group to report, Ref. = reference category, SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.

    • ↵* Receipt of at least 1 test for SARS-CoV-2 that was not cancelled or rejected.

    • ↵† Receipt of at least 1 positive test for confirmed SARS-CoV-2 infection.

    • ↵‡ At least 1 hospital admission for confirmed COVID-19 or within 21 d of the first positive SARS-CoV-2 test result.

    • ↵§ At least 1 hospital admission requiring intensive care for confirmed COVID-19 or within 21 d of the first positive SARS-CoV-2 test result.

    • ↵¶ Death within 21 d of the first positive SARS-CoV-2 test result.

    • ↵** Immigration status defined on the basis of the presence of a landing date in the Immigration, Refugees and Citizenship Canada Permanent Resident Database between 2008 and 2018.

    • ↵†† Income quintiles at the Dissemination Area level, derived from census 2016 data.

    • ↵‡‡ Missing and unknown values recoded to quintile 3.

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Testing, infection and complication rates of COVID-19 among people with a recent history of homelessness in Ontario, Canada: a retrospective cohort study
Lucie Richard, Richard Booth, Jennifer Rayner, Kristin K. Clemens, Cheryl Forchuk, Salimah Z. Shariff
Jan 2021, 9 (1) E1-E9; DOI: 10.9778/cmajo.20200287

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Testing, infection and complication rates of COVID-19 among people with a recent history of homelessness in Ontario, Canada: a retrospective cohort study
Lucie Richard, Richard Booth, Jennifer Rayner, Kristin K. Clemens, Cheryl Forchuk, Salimah Z. Shariff
Jan 2021, 9 (1) E1-E9; DOI: 10.9778/cmajo.20200287
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