By Carol A. Kemper, MD, FACP

Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center

SOURCE: Cha S, Henry A, Montgomery MP, et al. Morbidity and mortality among adults experiencing homelessness hospitalized with COVID-19. J Infect Dis 2021;224:425-429.

Cha et al examined risk factors and outcomes for homeless adults admitted to an acute care hospital with COVID-19. Using the COVID-NET population-based surveillance system for acute care hospitalizations in 10 different states, plus the Influenza Hospital Surveillance Project for four additional states, data on laboratory-confirmed COVID-19 hospitalizations were collected. Among nearly 29,000 hospitalizations, only 8,728 cases had sufficient documentation regarding housing at the time of admission. Of these, 199 were homeless adults. The median age was 53 years, and 84% were Black, Latino, or other non-Hispanic other race/ethnicity. Most patients (83%) had at least one significant health condition, 32% had diabetes, and 24% were considered obese; tobacco use (46%) and alcohol abuse (34%) were common; and 8% had mental health issues. A majority (54%) of these homeless patients were hospitalized for > 4 days, 17% were admitted to the ICU, and 11% required mechanical ventilation. Six patients died, five of whom were age 50 years or older. As has been observed previously, disease severity was associated with increasing age.

COMMENTARY

Despite the anticipated poor outcomes, I was surprised this homeless cohort performed this well. Mortality for COVID-19 cases admitted to the hospital early during the pandemic was reportedly as high as 12% to 18%. A 2020 study of 11,210 COVID-19 admissions to 92 acute care hospitals across 12 states (many of which were included in this homeless study) revealed an all-cause mortality of 20.3%, and 31.8% required mechanical ventilation.1 More recent data suggest hospital mortality from COVID-19 may have improved. In a 2021 study of 192,550 adult hospitalizations with COVID-19 at 555 acute care hospitals in the United States, 13.6% of adults died during the index hospitalization and another 3% were transitioned to hospice care.2 Since February 2020, our community hospital in Mountain View, CA, has provided care for 1,000 COVID-19 patients, with an overall mortality of 9.3%. One-fourth of admissions required ICU care and one-fourth of those died. That the homeless cohort in this study experienced much better outcomes than any of these data suggests they may have been admitted for other complicating health reasons or perhaps for psychosocial concerns.

The COVID-19 pandemic has heightened the need for better care and planning for homeless persons. Those who are homeless, especially people who reside in camps or shelters, are at higher risk for COVID-19 infection; their hygiene, dentition, and general health suffer as the result of their homelessness, and their poor health belies their years, putting them at risk for more severe COVID-19. It also makes COVID-19 discharge planning a challenge; thankfully, our public health department has invested in several “COVID hotels” with private rooms, hot showers, and meals as needed.

The first step would be screening for homeless status on admission to any acute care hospital. Only 30% of admissions identified in this study had adequate documentation of housing. In January 2019, California Senate Bill 1152 was created, requiring acute care hospitals to screen for homelessness on admission and to offer appropriate vaccinations, such as hepatitis A and influenza, as well as screening for appropriate infectious diseases, such as HIV, hepatitis B, and tuberculosis. Originally intended to halt an outbreak of hepatitis A in the homeless populations in several California counties, this extra screening in care for homeless persons is helping solve many problems, including the administration of COVID-19 vaccination to this vulnerable population.

REFERENCES

  1. Yehia BR, Winegar A, Fogel R, et al. Association of race with mortality among patients hospitalized with coronavirus disease 2019 (COVID-19) at 92 US hospitals. JAMA Netw Open 2020;3:e2018039.
  2. Nguyen NT, Chinn J, Nahmias J, et al. Outcomes and mortality among adults hospitalized with COVID-19 at US medical centers. JAMA Netw Open 2021;4:e210417.