Dr. S. Monty Ghosh, Physician, Assistant Clinical Professor at the University of Calgary and University of Alberta.

Dr Jeff Turnbull, Physician, Medical Director, Ottawa Inner City Health

Dr. Noni MacDonald, Physician, Professor of Pediatrics, Dalhousie University

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Dr. Andrew Bond, Physician, Medical Director of Inner City Health Associates in Toronto

Dr Aaron Orkin, Physician, Population Health lead for Inner City Health Associates in Toronto

Adults who experience homelessness are at increased risk of poor outcomes from COVID-19 compared to the regular population. Immunizing this population is urgent, but achieving this goal can be difficult due to the transient nature of this population, as well as the fear and stigma about engaging with health resources. There is often deep-seated mistrust of the system, and a need to protect autonomy, all compounded by mental health and substance use concerns. Additionally, those experiencing homelessness often have other different and more urgent priorities than vaccination, such as housing, income support, and food insecurity.

Traditional models of typical vaccination centres, where clients go to obtain a vaccine, do not meet the needs for this population so appropriate strategies meeting these vulnerable individuals on their terms. However, as no single approach would work a variety of innovative strategies are key to ensuring adequate vaccine uptake by our clients.

The following recommendations come from the initial results of a rapid scoping review using both peer-reviewed and grey literature, a jurisdictional scan, as well as consensus from key individuals providing support for those who experience homelessness. These recommendations are intended for health care and service providers who work with this population, as well as our health care authorities and provincial and federal policy makers.

1. Preparedness:

Determine local resources and determine immunization need:

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· To ensure maximal uptake discuss vaccination plans with local shelters and social services to find out how many individuals there are to vaccinate, most popular times for shelter usage, and the frequency individuals use the shelter system.

· Determine if local shelters, public health, and health care partners are able to provide the vaccine, and if local shelter workers can administer it. If necessary, provide education to nursing or health staff for vaccine administration and support.

· Where possible, learn where common encampments are situated geographically and determine strategies for providing vaccine outreach at these locations.

· Use current counts to determine the size of the population requiring vaccinations. Leverage existing client databanks to help provide more contextual details on individuals who require the vaccine and help formulate a vaccination registry.

Communication:

Previous literature has identified two types of nonadherence to vaccination recommendations. Intentional nonadherence, where individuals, generally to protect their autonomy, actively do not want to obtain a vaccine. More passive, or unintentional nonadherence occurs where vaccine programs do not or cannot deliver immunization on suitably convenient or accessible terms, or where individuals do not know the importance of it, or where to get it. Efforts to reduce both of these nonadherence aspects can be very helpful in supporting clients. Strategies to address this include:

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· Provide baseline education regarding the types of vaccines, effects, and importance to shelter staff and lived experience ambassadors.

· Begin education campaigns to individuals experiencing homelessness regarding the need and necessity for vaccines. Where necessary, provide outreach to individuals who do not access the shelter system to provide education.

· Leverage a variety of communication strategies including posters, overhead messaging, flyers, social media and other modalities. Visual and illustration strategies for individuals who have limited literacy are crucial. Provide additional information to help debunk common myths and rumors regarding the vaccine.

· Ensure all communication regarding the vaccine and client engagement is developed and co-designed through a trauma-informed and culturally sensitive lens.

· Partner with community-based providers, such as shelter staff, as well as with vaccine ambassadors to have one on one honest conversations with clients regarding vaccine need and importance.

· Empower members of the homeless community to help develop strategies to obtain vaccines and educate service sectors on how to best reach and support clients.

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· If clients decline the vaccine, determine why and attempt to clarify any misinformation. Provide motivational interviewing strategies to improve patient understanding, self-reflection and uptake. Focus on the positives of obtaining a vaccine.

· It is important to stay engaged with clients who are hesitant over the vaccine. Some individuals may not initially want it but will warm up to the idea over time.

Additional items for preparedness.

· If possible, begin the consent process to determine who would be early adopters of the vaccine.

· If vaccine supplies are limited and demand is high, consider prioritization and triaging of individuals who are at highest risk for poor outcomes from COVID-19 infection, such as those with cardiovascular risk factors, old age, and immunodeficiency. Additional prioritization can occur for individuals with severe mental health or substance use concerns.

2. Build and leverage trusting relationships with those experiencing homelessness:

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In order to reduce vaccine hesitancy, building trust and leveraging existing relationships is crucial. Individuals who experience homelessness often mistrust new individuals or groups or those who engage with them irregularly. Many clients often already have relationships with those who work at shelter sites, including front line and medical staff at shelters, so these individuals are primed to educate them on the importance of vaccinations, as well as debunk myths and address their concerns. Lastly, where possible, using this staff to provide the vaccination would be key and crucial.

· Determine if shelter staff and existing health care staff can be leveraged to provide the vaccination or help with the administrative responsibilities of vaccination.

· Utilize people of lived experience of homelessness who are early adopters of the vaccine to provide vaccine education, or act as ambassadors and vaccine navigators to help clients access the vaccine.

3. Key aspects of a vaccination campaign

Special vaccination events often see poor attendance and uptake, with many clients still not wanting to get the vaccine. Therefore, organizers should be prepared for a lengthy vaccination campaign and as coming to existing vaccination centres is not practical with this population the vaccine should be brought to where clients are most likely to be found and engaged, or locations frequented by clients. This includes shelter spaces, meal distribution facilities, social service agencies, justice facilities, pharmacies, supervised consumption services, emergency departments, addiction and mental health clinics, specialized primary clinics which support this population, and lastly atypical locations such as libraries, bottle depots, and liquor stores. Additionally, outreach should be conducted to include individuals who do not access any of these services.

· An initial large vaccination drive may help capture early adopters however it may not encompass all individuals so smaller, nimble, vaccination teams maybe required on an ongoing basis.

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· Consider having a recurrent standard on-site clinic, where clients know the exact time and location for obtaining a vaccination.

· Flexibility of vaccine administration is essential, and factors such as vaccine storage, vaccine expiry upon reconstitution, and dosing schedules for first and second doses should be examined when choosing the best vaccine for those experiencing homelessness.

Consider vaccinating staff and clients at the same time:

· Due to shared risk of COVID-19 between shelter clients and staff, consider using left over doses, to ensure no wastage, for staff if they have not already been vaccinated.

· It may be beneficial to stagger the vaccination for staff in case they feel sick or unwell post vaccination and require time off.

Reaching populations that are rough sleeping or in encampments:

· Where possible leverage municipal outreach teams who already work with rough sleeping or encamped individuals to provide vaccination information to clients, and provide vaccination teams support for administration of the vaccine.

Consider the use of Case Management:

· Provide case management, in which shelter, vaccine ambassadors, or public health staff actively seek out specific clients and provide management and navigation supports not only for obtaining the vaccine, but providing access to other health and social service resources. This will help increase likelihood of further stability and improvement in quality of life as well as increasing the incentivization of obtaining a second dose of vaccine where applicable.

Consider the use of Incentives and bundling other services into immunization:

· Bundling services with immunization, including food, coffee, or giveaways such as gift cards can be used to encourage individuals to obtain the vaccine.

· Reinforce that further incentives may be available if the client should return for their second dose of vaccine where applicable.

Reduce or remove barriers

Often sited barriers to obtaining a vaccine include knowledge of where to obtain the

vaccine, concerns about transportation to reach vaccination facilities, and how to

schedule vaccine appointments.

· Whenever possible limit barriers though initiatives such as providing free transport. Provide phones or data vouchers for individuals to know how to get a second dose of vaccine where applicable.

Ensure proper data collection

· Ensure data on who had obtained the vaccine, which vaccine and if a second dose is required are properly collected

· Ensure these data is shared with public health authorities for appropriate data tracking.

· Evaluate the data collected on a regular basis to see which clients still require the vaccine, and their possible geographic location or whereabouts.

· Maintain a residual list of clients who initially consented to the vaccine but changed their minds, or who refused all together so they can be contacted for further follow up and outreach.

4. Provide Post Vaccination Supports

Managing adverse effects from the vaccine for this population is key, especially if a second dose is required. Prior bad experiences may increase vaccine hesitancy, and as such, the provision of post vaccination supports may help reduce this. Some post vaccination supports include:

· Ensure adequate supports are in place in outreach sites and shelters to manage adverse reactions to the vaccine. This can include rest spaces or observation spaces.

· Consider the provision of resting mats for clients post vaccination to allow them to rest or spend the day or night especially if they feel unwell post vaccination.

· Consider medical respite support for select clients, where available, especially for those who feel significantly unwell post vaccine.

· Utilize the vaccination process to inquire about further supports including access to other social services such as housing and income, as well as other health supports including options for treating other health concerns and disorders.

· Provide information regarding second dosing of the vaccine where applicable. Provide locations and numbers where clients can come for their second dose, and determine ways to provide reminders for second doses including reminder cards, text messages, or alerts when clients check into a shelter space.

· Ensure clients who maybe lost are located and provided support using existing outreach teams, or groups familiar with the client to follow up for the second vaccine.

· Continue to provide case management for clients to obtain the second dose of the vaccine (if needed) as well obtain supports for other health or social services.

· Provide education to staff and clients about the importance of continuing to maintain key prevention strategies such as masking, cohorting, and symptom identification.

· Do not bar individuals from accessing services including shelter spaces because they did not obtain the vaccine. Continue to invest in building trust with clients so that they may potentially obtain the vaccine.

5. Special Population Considerations

Identification and Aliases:

· Many individuals may not have government-issued photo identification or a Health Care Card. This should not be a barrier to obtaining the vaccine, however some basic information may be required from clients including first and last name, gender, and date of birth.

· This basic information should be matched to their health care number or other existing information databases like electronic medical records if available.

· Clients may prefer to use an alias or street name on a day-to-day basis and this should not be a barrier to obtaining the vaccine. If possible, politely request if they can provide a Government Registered name, which can be used to match with their health care number for appropriate vaccine documentation.

· If clients are using an alias, ensure that both the alias and their government registered names are recorded and linked in vaccine tracking databases.

· For clients without identification, effort should be made to help clients obtain identification after they have received the vaccine.

Consent:

· While obtaining consent, be sure to determine if clients understand why they are obtaining the vaccine, how it is administered as well as its benefits and risks.

· There may be moments where capacity may be questioned due to severe cognitive concerns, acute mental health issues such as active psychosis, and acute substance toxicity. In these situations, it is best to delay providing the vaccine. An appointed alternate decision-maker can help provide guidance for individuals with cognition concerns. Management of acute mental health psychosis until the client clears, and waiting post-acute intoxication to obtain consent are key strategies.

· Where necessary obtain psychiatric support to further determine capacity for consent with these individuals.