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      SARS-Cov-2 prevalence, transmission, health-related outcomes and control strategies in homeless shelters: Systematic review and meta-analysis

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          Abstract

          Background

          People experiencing homelessness (PEH) may be at risk for COVID19. We synthesised evidence on SARS-Cov-2 infection, transmission, outcomes of disease, effects of non-pharmaceutical interventions (NPI), and the effectiveness of strategies for infection prevention and control (IPC).

          Methods

          Systematic review of articles, indexed in electronic databases (EMBASE, WHO—Covid19, Web of Science), institutional websites and the Norwegian Institute of Public Health's live map of COVID-19 evidence, and published from December 1st, 2019, to March 3rd, 2021. Empirical papers of any study design addressing Covid-19 and health(-related) outcomes in PEH or shelters’ staff were included. (PROSPERO-2020-CRD42020187033)

          Findings

          Of 536 publications, 37 studies were included (two modelling, 31 observational, four qualitative studies). Random-effect meta-analysis yields a baseline SARS-Cov-2 prevalence of 2•32% (95% Confidence-Interval, 95%CI=1•30–3•34) in PEH and 1•55% (95%CI=0•79–2•31) in staff. In outbreaks, the pooled prevalence increases to 31•59% (95%CI=20•48–42•71) in PEH and 14•80% (95%CI=10•73–18•87) in staff. Main IPC strategies were universal rapid testing, expansion of non-congregate housing, and in-shelter measures (bed spacing, limited staff rotation, reduction in number of residents).

          Interpretation

          32% of PEH and 15% staff are infected during outbreaks of SARS-Cov-2 in homeless shelters. Most studies were conducted in the USA. No studies were found quantifying health-related outcomes of NPI. Overview and evaluation of IPC strategies for PEH, a better understanding of disease transmission, and reliable data on PEH within Covid-19 notification systems are needed. Qualitative studies may serve to voice PEH and shelter staff experiences, and guide future evaluations and IPC strategies.

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          Most cited references61

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          Measuring inconsistency in meta-analyses.

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            Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.

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              Bias in meta-analysis detected by a simple, graphical test.

              Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30% of the trial); analysis of funnel plots from 37 meta-analyses identified from a hand search of four leading general medicine journals 1993-6 and 38 meta-analyses from the second 1996 issue of the Cochrane Database of Systematic Reviews. Degree of funnel plot asymmetry as measured by the intercept from regression of standard normal deviates against precision. In the eight pairs of meta-analysis and large trial that were identified (five from cardiovascular medicine, one from diabetic medicine, one from geriatric medicine, one from perinatal medicine) there were four concordant and four discordant pairs. In all cases discordance was due to meta-analyses showing larger effects. Funnel plot asymmetry was present in three out of four discordant pairs but in none of concordant pairs. In 14 (38%) journal meta-analyses and 5 (13%) Cochrane reviews, funnel plot asymmetry indicated that there was bias. A simple analysis of funnel plots provides a useful test for the likely presence of bias in meta-analyses, but as the capacity to detect bias will be limited when meta-analyses are based on a limited number of small trials the results from such analyses should be treated with considerable caution.
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                Author and article information

                Journal
                EClinicalMedicine
                EClinicalMedicine
                EClinicalMedicine
                The Author(s). Published by Elsevier Ltd.
                2589-5370
                23 July 2021
                23 July 2021
                : 101032
                Affiliations
                [a ]Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, P.O. Box: 10 01 31, 33501 Bielefeld, Germany
                [b ]Section for Health Equity Studies and Migration, Department of General Practice and Health Services Research, Heidelberg University Hospital, Germany
                [c ]Institute for Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University Munich, Germany
                Author notes
                [* ]Corresponding author at: Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, P.O. Box: 10 01 31, 33501 Bielefeld, Germany.
                Article
                S2589-5370(21)00312-6 101032
                10.1016/j.eclinm.2021.101032
                8298932
                34316550
                c1ac533a-8f28-4be7-82a5-2802edf115af
                © 2021 The Author(s)

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 8 January 2021
                : 2 July 2021
                : 2 July 2021
                Categories
                Article

                people experiencing homelessness,homeless shelters,sars-cov-2,covid-19,systematic review,meta-analysis

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