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      SARS-CoV-2 screening among people living in homeless shelters in Brussels, Belgium

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          Abstract

          Background

          Subgroups of precarious populations such as homeless people are more exposed to infection and at higher risk of developing severe forms of COVID-19 compared to the general population. Many of the recommended prevention measures, such as social distancing and self-isolation, are not feasible for a population living in shelters characterised by physical proximity and a high population density. The objective of the study was to describe SARS-CoV-2 infection prevalence in homeless shelters in Brussels (Belgium), and to identify risk factors and infection control practices associated with SARS-CoV-2 positivity rates.

          Methods

          A total of 1994 adults were tested by quantitative PCR tests in 52 shelters in Brussels (Belgium) between April and June, 2020, in collaboration with Doctors of the World. SARS-CoV-2 prevalence is here described site by site, and we identify risk factors associated with SARS-CoV-2 positivity rates. We also investigate associations between seropositivity and reported symptoms.

          Results

          We found an overall prevalence of 4.6% for the period, and a cluster of high rates of SARS-CoV-2 positivity (20–30% in two shelters). Among homeless people, being under 40 years of age (OR (CI95%) 2.3 (1.2–4.4), p = 0.02), having access to urgent medical care (AMU) (OR(CI95%): 2.4 (1.4–4.4)], p = 0.02), and sharing a room with someone who tested positive (OR(CI95%): 5.3 (2.9–9.9), p<0.0001) were factors associated with SARS-CoV-2 positivity rates. 93% of those who tested positive were asymptomatic.

          Conclusion

          This study shows high rates of SARS-COV-2 infection positive tests in some shelters, with a high proportion of asymptomatic cases. The survey reveals how important testing and isolation measures are, together with actions taken by medical and social workers during the outbreak.

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          Most cited references19

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          Social determinants of health inequalities.

          The gross inequalities in health that we see within and between countries present a challenge to the world. That there should be a spread of life expectancy of 48 years among countries and 20 years or more within countries is not inevitable. A burgeoning volume of research identifies social factors at the root of much of these inequalities in health. Social determinants are relevant to communicable and non-communicable disease alike. Health status, therefore, should be of concern to policy makers in every sector, not solely those involved in health policy. As a response to this global challenge, WHO is launching a Commission on Social Determinants of Health, which will review the evidence, raise societal debate, and recommend policies with the goal of improving health of the world's most vulnerable people. A major thrust of the Commission is turning public-health knowledge into political action.
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            COVID-19: a potential public health problem for homeless populations

            Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is infecting people throughout the world. It is probable that coronavirus disease (COVID-19) will be transmitted to people experiencing homelessness, which will become a major problem in particular in North America where there are sizable populations of people experiencing homelessness in nearly every metropolitan city in the USA and Canada. In the USA, more than 500 000 people were reported to be experiencing homelessness on any given night over the past decade (2007–19). 1 The State of Homelessness in Canada 2016 report 2 estimated 35 000 people are experiencing homelessness on any given night in Canada. People experiencing homelessness live in environments that are conducive to a disease epidemic. Many people experiencing homelessness live in congregate living settings—be it formal (ie, shelters or halfway houses) or informal (ie, encampments or abandoned buildings)—and might not have regular access to basic hygiene supplies or showering facilities, all of which could facilitate virus transmission. People experiencing homelessness are a vulnerable group, and their potential exposure to COVID-19 might negatively affect their ability to be housed, and their mental and physical health. People experiencing homelessness aged younger than 65 years have all-cause mortality that is 5–10 times higher than that of the general population. 3 COVID-19 infection might further increase this mortality disparity. Many people experiencing homelessness have chronic mental and physical conditions, 4 engage in high rates of substance abuse (including sharing of needles), 5 and have often less access to health care, 6 all of which could lead to potential problems with screening, quarantining, and treating people who might have COVID-19. Such problems have occurred as recently as last year, when outbreaks of typhus, hepatitis A, tuberculosis, trench fever, and Shigella bacteria were reported among people experiencing homelessness in US cities with large homeless populations. 7 There are some additional issues, which are unique to people experiencing homelessness, to consider with regards to COVID-19. Homeless populations might be more transient and geographically mobile than individuals in the general population, 8 making it difficult to track and prevent transmission and to treat those who need care. COVID-19 was recently found to be transmittable via the oral–faecal route. 9 Some major US cities with large homeless populations, like San Francisco, have experienced issues with public defecation, which might pose an additional transmission risk for people experiencing homelessness and other individuals. Together, the multitude of potential vulnerabilities and risks for people experiencing homelessness in becoming infected, needing care, and transmitting COVID-19 cannot be ignored and must be planned for. Some lessons can be learned from the response to severe acute respiratory syndrome among homeless service providers nearly two decades ago. 10 Testing kits and training on how to recognise COVID-19 should be widely disseminated to homeless service providers and deployed in shelters, encampments, and street outreach. Alternative spaces might be needed to quarantine and treat people experiencing homelessness. If cities impose a lockdown to prevent COVID-19 transmission, there are few emergency preparedness plans to transport and provide shelter for the large number of people experiencing homelessness. In lockdowns, public spaces are closed, movement outside homes are restricted, and major roads of transport might be closed, all of which might negatively affect people experiencing homelessness. It is unclear how and where unsheltered people experiencing homelessness will be moved to if quarantines and lockdowns are implemented. In such a scenario, closures of shelters and other high-density communal settings (eg, drop-in centres and soup kitchens) are possible, which could increase the number of unsheltered people experiencing homelessness and reduce their access to needed services. Lockdowns and disease containment procedures might also be deleterious to the mental health of people experiencing homelessness, many of whom have fears around involuntary hospitalisation and incarceration. 11 In response to COVID-19, the State of Washington has declared a state of emergency, allowing cities to take extraordinary measures, which has included King County moving people infected with COVID-19 to housing units that were originally intended to provide housing for people experiencing homelessness. 12 As other cities follow suit, these actions might further displace people experiencing homelessness and put them at greater risk of COVID-19. Another complicating matter is that in December, 2019, the US Supreme Court declined to review the case of Martin v City of Boise, upholding a ruling that cities cannot arrest or punish people for sleeping on public property unless cities have provided adequate and accessible indoor accommodations. This legal precedent prevents the criminalisation of homelessness, but it is unclear if and how it will be applied during COVID-19 outbreaks. Cities with large homeless populations might face unique challenges while trying to contain COVID-19 and addressing homelessness, with the potential for both issues to exacerbate one another.
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              Asymptomatic patients as a source of COVID-19 infections: A systematic review and meta-analysis

              Highlights • Asymptomatic patients with COVID-19 tend to be younger and may be more socially active. • Laboratory findings in most asymptomatic cases were unremarkable. • Around half of the cases had lung opacities, most frequently ground glass opacities. • Patients with normal CT were younger than patients with abnormal CT.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Funding acquisitionRole: Supervision
                Role: ConceptualizationRole: Data curationRole: Resources
                Role: Data curationRole: Formal analysisRole: Methodology
                Role: Resources
                Role: Funding acquisitionRole: Project administrationRole: Validation
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                15 June 2021
                2021
                15 June 2021
                : 16
                : 6
                : e0252886
                Affiliations
                [1 ] Médecins du Monde, Brussels, Belgium
                [2 ] Bruss’help, Brussels, Belgium
                [3 ] Research Center in Epidemiology, Biostatistics and Clinical Research, School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium
                [4 ] Chair of Health and Precarity, Faculty of Medicine, Université Libre de Bruxelles (ULB), Brussels, Belgium
                Dasman Diabetes Institute, KUWAIT
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                https://orcid.org/0000-0002-1266-0191
                Article
                PONE-D-21-03602
                10.1371/journal.pone.0252886
                8205130
                34129635
                41b88786-f58d-455e-9d2f-23c96759821b
                © 2021 Roland et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 2 February 2021
                : 25 May 2021
                Page count
                Figures: 0, Tables: 3, Pages: 11
                Funding
                The authors received no specific funding for this work.
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