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Dr. S. Monty Ghosh, assistant clinical professor at the University of Calgary and University of Alberta; Dr Jeff Turnbull, medical director, Ottawa Inner City Health; Dr. Noni MacDonald, professor of pediatrics, Dalhousie University; Dr. Andrew Bond, medical director of Inner City Health Associates in Toronto; Dr Aaron Orkin, physician, and population health lead for Inner City Health Associates in Toronto

As Canadians look forward to COVID vaccination, public health strategies are adjusting to maximize its benefit. One group that would benefit profoundly from immunization is a population often neglected: individuals, specifically adults, who experience homelessness. However, standard approaches to immunization may not work for this group so creative and innovative strategies are required if we are to avoid a future where COVID outbreaks in adult homeless shelters are routine.

First, we need to prioritize those experiencing homelessness for vaccination. Not only are the homeless more likely to be infected, but they are also more likely to die from COVID. In comparison to stably housed adults, their baseline health is typically worse, making them 20 times more likely to be hospitalized with COVID, 10 times more likely to require intensive care support, and 5 times more likely to die of COVID than other Canadians (1). With numerous outbreaks in homeless shelters throughout the country, one key way of controlling this would be through urgent immunization programs, as overcrowding in these environments, is an ongoing reality.

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Second, a targeted, flexible, contextual, and unique approach to vaccination is required to meet the needs of this group (2). Until today, the conventional vaccine campaign for shelters has operated a giant one-day blitz where public health and health care officials appear on-site as a complex and imposing circus. These blitzes are already underway in some Canadian cities, and while they are delivering vaccines, they also contribute to vaccine hesitancy, deepen fears of health authorities, and are having surprisingly limited uptake — sometimes well below 30%. For people who face a history of marginalization and a well-founded mistrust of healthcare, a softer touch is in order. Shelters need flexible access to immunization strategies using small, mobile, and community-based teams. Nimble teams providing services at a large number of locations quickly and inconspicuously allows for clients to warm up to the concept of vaccination. While this may seem like a slow approach, it is the ideal way to maximizing the trust that is a prerequisite to immunization acceptance and uptake.

The stigma of homelessness leaves deep scars for our clients, with many feeling the sting of discrimination and the burn of shame. Trust with the greater “system” is often severed, and confidence and comfort need to be reestablished. This can take time to foster, thus leveraging existing trusting relationships with this group is essential and can expedite the acceptance and administration of the vaccine. This can be accomplished by having front line shelter workers and shelter health providers, (i.e. those whom clients are already familiar with and regularly work with this population) give the vaccine, with public health workers providing support behind the sceneS (3). One can also leverage relationships between clients by supporting community members to work alongside healthcare workers. These “immunization ambassadors” can promote the vaccine, diminish vaccine misinformation, and reduce vaccine hesitancy.

Information, education, and understanding with a highly skeptical and hesitant population involves a multimodal approach. With limited literacy, information regarding the vaccine can be shared using not only the immunization ambassadors, but also mixed media approaches including infographics, videos, announcements, and posters (4). Safe and honest discussions regarding the vaccine need to be conducted (5). Myth-busting and debunking along with strategies to enhance client motivation to obtain the vaccine can be the deciding factor if a client wants to obtain a vaccine or not.

Those who experience homelessness are highly mobile and often transition not only between shelters and the streets, but between various service sectors such as health, social, and justice services, thus a low threshold mechanism of providing the vaccine at various touchpoints is key. . This can include providing the vaccine at emergency departments, isolation facilities, supervised consumption services, pharmacies, and justice services, as well as outreach programs to reach clients who are rough sleeping (6). Traditional scheduling for these individuals with appointments is ineffective and tracking where these individuals are and determining their vaccination status can be tedious and administratively prohibitive. Where possible, a robust data system is crucial to ensure clients, many of whom are transient, are identified, offered, and provided the vaccine if they have not received it. It can help keep track of which clients have yet to receive the vaccine, who has received the vaccine, and who requires another dose. Leveraging existing databases for this population to support this work can be helpful. Therefore, ease of access to the vaccine at various touchpoints in the system can enhance vaccination uptake.

There may also be a need to use incentives in some circumstances. Broader society is incentivized to receive the vaccine for re-entry into work and normalcy and to access greater work and social opportunities. This population should also be provided with reasons to receive the vaccine. Soft incentives such as gift cards, meals, and coffee encourage vaccination exploration and perhaps eventually, vaccination uptake (7). Incentives are important, equitable and ethical. Incentives provide support for those who experience economic insecurity, especially when there are many incentives enjoyed by other members of society.

There are worries that factors such as limited cognition and understanding of the virus, and

severe mental health and substance use may impact vaccine uptake. There are concerns that tracking individuals down in shelter settings for a second dose (for those who have only the Moderna and Pfizer vaccine available) is a fool’s errand. There are concerns about the capacity for individuals to consent to the vaccine, especially when this may not be a high priority. These issues have long been tackled by the health care system. Evidence-based strategies and the availability of single-dose vaccinations like Johnson & Johnson’s, once employed, can address these concerns and can increase vaccination rates, which in the long run can save lives and reduce population risk.

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With more than 235,000 individuals experiencing homelessness in Canada, and with the risk this virus places on them, Canada faces two possible futures right now. The first is a future where we fail to develop and deliver a truly innovative and assertive plan to immunize people experiencing homelessness. In this future, COVID-19 joins a tragic list of other vaccine-preventable diseases, such as the seasonal flu, Hepatitis A, and meningococcal disease, that plague people who experience homelessness and that continue to result in predictable and periodic outbreaks. This is the predictable, but preventable future. The second future is one where we develop something truly innovative, commit to live-saving immunization, and use COVID as a springboard to immunize people who experience homelessness not only against COVID 19 but also against the host of other conditions that plague this population so inequitably. We as a society set the moral tone by who we provide supports for, and who we prioritize. It’s imperative that we protect the most vulnerable. We call on all Canadians, health authorities, and public health agencies to join us.

REFERENCES:

(1) Richard L, Booth R, Rayner J, Clemens KK, Forchuk C, Shariff SZ. Testing, infection and complication rates of COVID-19 among people with a recent history of homelessness in Ontario, Canada: a retrospective cohort study. CMAJ Open. 2021 Jan 11;9(1):E1-E9. doi: 10.9778/cmajo.20200287. PMID: 33436450; PMCID: PMC7843074.

(2)Ompad DC, Galea S, Vlahov D. Distribution of influenza vaccine to high-risk groups. Epidemiol Rev. 2006;28:54–70. Epub 2006 May 17.:54–70

(3) David Vlahov, Micaela H. Coady, Danielle C. Ompad, Sandro Galea Strategies for Improving Influenza Immunization Rates among Hard-to-Reach Populations J Urban Health. 2007 Jul; 84(4): 615–631. Published online 2007 Jun 12. doi: 10.1007/s11524-007-9197-z

(4) Alexander Doroshenko, Jill Hatchette, Scott A Halperin, Noni E MacDonald, Janice E Graham

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Challenges to immunization: the experiences of homeless youth BMC Public Health. 2012; 12: 338. Published online 2012 Jul 4. doi: 10.1186/1471-2458-12-338

(5) Elaine Vaughan, Timothy Tinker Effective Health Risk Communication About Pandemic Influenza for Vulnerable Populations Am J Public Health. 2009 Oct; 99(Suppl 2): S324–S332. doi: 10.2105/AJPH.2009.162537

(6) Weisfuse IB, Berg D, Gasner R, Layton M, Misener M, Zucker JR. Pandemic influenza planning in New York City. J Urban Health

(7) Wood, S.P.. (2012). Vaccination Programs among Urban Homeless Populations: A Literature Review. Journal of Vaccines & Vaccination. 03. 10.4172/2157-7560.1000156.

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