Morbidity and mortality in a prospective cohort of people who were homeless during the COVID-19 pandemic.

Introduction: Certain living conditions, such as homelessness, increase health risks in epidemic situations. We conducted a prospective observational cohort study to investigate the impact of the COVID-19 pandemic on morbidity and mortality in adult people who were homeless. Methods: The study population comprised around 40% of the entire population experiencing homelessness in Marseille. They were enrolled at 48 different locations during the first pandemic wave (June to August 2020) and were followed up 3 and 6 months later. Rapid serological screening for SARS-CoV-2 was performed by community outreach teams at each follow-up, who also conducted interviews. Death registers and hospital administrative databases were consulted. Results: A total of 1,332 participants [mean age 40.1 years [SD 14.2], women 339 (29.9%)] were enrolled in the cohort. Of these, 192 (14.4%) participants were found positive for COVID-19 and were propensity score matched (1:3) and compared with 553 non-COVID-19 cases. Living in emergency shelters was associated with COVID-19 infection. While 56.3% of the COVID-19-infected cohort reported no symptoms, 25.0% were hospitalized due to the severity of the disease. Presence of three or more pre-existing comorbidities was associated with all-cause hospitalization. Among COVID-19 cases, only older age was associated with COVID-19 hospitalization. Three deaths occurred in the cohort, two of which were among the COVID-19 cases. Conclusion: The study provides new evidence that the population experiencing homelessness faces higher risks of infection and hospitalization due to COVID-19 than the general population. Despite the efforts of public authorities, the health inequities experienced by people who are homeless remained major. More intensive and appropriate integrated care and earlier re-housing are needed.