COVID-19 vaccination amongst persons experiencing homelessness: practices and learnings from UK, Canada and the US.

As previously described, persons experiencing homelessness (PEH) have faced intersecting crises during the COVID-19 pandemic. A study in the province of Ontario, Canada, found that individuals with a recent history of homelessness were 20 times more likely to be hospitalized for COVID-19 and five times more likely to die after testing positive for COVID-19 than individuals in the general population. During the pandemic, many Western countries have managed to offer shelters to rough sleepers at a pace unseen before, albeit these have tended to be temporary alternative care sites and hotels as opposed to supportive housing. Vaccinating PEH is an effective strategy for infection outbreak mitigation in such shelters which often reflect congregate living and social environments. Here we aim to describe current practices and learnings from vaccination efforts in the UK, Canada and the US, where a combined population of approximately 2 million experience homelessness every year.

In the UK, after lobbying from local city authority housing leaders and a recommendation by the Joint Vaccination and Immunisation, the UK Government in March 2021 included PEH amongst ‘priority six’ group alongside ‘adults 16–65 with health problems’ to be vaccinated at a national level. While the initial strategy was aimed at getting as many PEH to register with a general practice, which in turn would offer them the vaccines, there was fear that important timelines would be missed in such a lengthy route to vaccine access by PEH. Some city authorities made their own initiatives to vaccinate PEH in their accommodations before the government advice, with the first reported vaccination of a homeless couple in Oldham council in England in January, 2021. Currently, reports of mass vaccination in homeless shelters are taking place. Homeless charities, otherwise involved in food and essentials to PEH have also organised mass vaccination hubs. Provisions in the UK which allows community pharmacists to administer vaccines offers another community route to vaccination.

In Canada, vaccination efforts are directed by provincial health authorities. Authorities have generally recognised the importance of prioritizing PEH for COVID-19 vaccination. Unfortunately, a Canada-wide vaccine supply shortage in early 2021 greatly slowed the initial rollout of vaccinations in this population. More recently, successful initiatives have implemented pop-up vaccination clinics at shelters and encampments involving a close collaboration of shelter staff, community outreach workers and local healthcare organizations. In particular, the presence of community-based frontline workers who have previously established relationships of trust with PEH has been critical to these efforts. The proportion of PEH that has received a first dose of vaccine continues to lag behind that of the general population, and future efforts will likely require a substantial intensification of dedicated time, energy and resources.

In the US, prioritization schema for COVID-19 vaccinations is determined state by state. Only about two-thirds of states have explicitly prioritized homeless individuals in congregate settings, despite the known COVID-19 infection risk posed by these environments.

The development of partnerships among public health departments, hospitals and health and homeless service agencies has defined vaccine rollout to homeless individuals in the US. Given the material limitations imposed by homelessness, scheduling appointments through public vaccination websites and arranging transportation to centralized clinics produces barriers to vaccination. On-demand vaccinations — including pop-up and mobile clinics, and those sited directly at congregate shelters, have been critical to reaching this population.

Given histories of racism in the healthcare system, homeless healthcare providers and public health departments have sought to advance equitable access to COVID-19 vaccines. Some states and local jurisdictions have increased allocations of doses to communities with higher social vulnerability. Increasingly, communities are utilizing vaccine ambassadors and other peer outreach strategies to promote vaccine confidence.

In summary, given their known exclusion from healthcare, many PEH are less likely to have access to vaccinations being delivered in primary health care or hospital settings. At the same time, a high prevalence of multimorbidity, coupled with the COVID-19 infection risk produced by congregate shelter settings, requires public health entities to develop tailored strategies to vaccinate PEH. Outreach-based vaccinations seem to be an effective strategy in getting as many PEH vaccinated in the shortest possible timeframe. Well-trained outreach workers, peer advocacy, dismantling fear and myths and relationship building are key to success. Agencies responsible for producing vaccination timelines should acknowledge the vulnerability of PEH and include them in the high priority list as early as possible. Although vaccination centres have pressing demands for efficiency, vaccination campaigns where possible should also maximise the opportunity to screen PEH for undiagnosed health conditions and offer early interventions. Ideally, vaccinations can be delivered through long-term, trusting relationships with healthcare teams, where other health and survival needs are acknowledged and addressed.