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Table.  Characteristics of Participants in a Study of the Prevalence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in a Homeless Shelter in Boston
Characteristics of Participants in a Study of the Prevalence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in a Homeless Shelter in Boston
1.
Henry  M, Watt  R, Mahathey  A, Ouellette  J, Sitler  A. The 2019 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: Point-in-Time Estimates of Homelessness. US Department of Housing and Urban Development; 2020.
2.
Interim guidance for homeless service providers to plan and respond to coronavirus disease 2019 (COVID-19). Centers for Disease Control and Prevention. Accessed April 2, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/plan-prepare-respond.html
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    1 Comment for this article
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    Follow up of These Patients?
    Daniel Le, MD | Monroe Clinic
    I would be very interested to see a follow up report on what happened to people who tested positive for covid who were apparently asymptomatic. I am not hearing of homeless people dying in large numbers in metro areas. If their mortality rate is comparable or even lower than non-homeless people, that would raise some very interesting questions. At the outset of the pandemic, many people, myself included, anticipated that the homeless population would be especially hard hit by covid. As the pandemic evolves, it seems like diabetes, hypertension, and obesity are the major comorbidities associated with poor outcomes. Glaringly absent from the list is COPD. In fact I recall a report suggesting that smokers had a better outcome (perhaps smokers tend to be less likely to be obese?).

    The observation that nursing home residents are so hard hit is intriguing. There has to be something unique about nursing homes that makes these people so susceptible to mortality. I am not totally convinced that it’s the comorbidities of these nursing home patients. In other words, what do all nursing home patients have in common (they get flu shots yearly and are up to date on their pneumococcal vaccines, etc). So why is this population so hard hit compared to the homeless (who have poor access to health care?). I think that if we could solve this puzzle, it would potentially be a breakthrough to this infection.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    April 27, 2020

    Prevalence of SARS-CoV-2 Infection in Residents of a Large Homeless Shelter in Boston

    Author Affiliations
    • 1Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
    • 2Division of General Internal Medicine, Massachusetts General Hospital, Boston
    JAMA. Published online April 27, 2020. doi:10.1001/jama.2020.6887

    In the United States, 567 715 people were homeless on a single night in January 2019.1 The congregate nature and hygienic challenges of shelter life create the potential for rapid transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in this vulnerable population.

    On March 13, 2020, the Boston Health Care for the Homeless Program (BHCHP), in partnership with city and state public health agencies and community partners, rolled out a coronavirus disease 2019 (COVID-19) response strategy that included respiratory symptom screening at shelter front doors, expedited referrals for SARS-CoV-2 testing and isolation for those with respiratory symptoms, dedicated treatment settings for individuals with positive test results, and contact tracing of confirmed COVID-19 cases.

    Between March 28, 2020, and April 1, 2020, BHCHP identified an increasing number of COVID-19 cases from a single large homeless shelter in Boston, prompting SARS-CoV-2 testing of all remaining shelter residents. We describe the results of this investigation.

    Methods

    Participants were adults aged at least 18 years residing in a large homeless shelter in Boston on April 2, 2020, and April 3, 2020. Residents diagnosed with COVID-19 prior to April 2, 2020 (n = 16), or concurrently diagnosed with COVID-19 at outside facilities on April 2, 2020, or April 3, 2020 (n = 6), had been removed from the shelter population and were excluded from this study.

    Participants were asked to report their age, sex, race, ethnicity, and history of cough and shortness of breath and were given the option to report other symptoms. Race and ethnicity were based on fixed response categories. Other reported symptoms were grouped into categories by the investigators. Body temperature measurements were obtained using oral thermometers, with fever defined as a body temperature of at least 100 °F (37.8 °C). Nasopharyngeal specimens were collected by BHCHP clinical staff using a polyester swab and sent to the Massachusetts Department of Public Health State Public Health Laboratory for SARS-CoV-2 polymerase chain reaction (PCR) testing.

    We used descriptive statistics to characterize the study sample, the percentage of positive PCR test results, and the symptom profile of individuals with PCR-confirmed infections. This study was exempted by the Partners HealthCare Human Research Committee with a waiver of informed consent.

    Results

    All individuals residing in the shelter (N = 408) underwent symptom assessment and SARS-CoV-2 PCR testing. There were no known refusals. The mean age of the participants was 51.6 years; 71.6% of participants were men, 33.1% were black or African American, and 18.6% were Hispanic or Latino (Table). Among all participants, 1.0% had fever; 8.1% reported cough; 0.7% reported shortness of breath; and 5.9% reported other symptoms, including 1.5% with nasal or sinus symptoms and 1.2% with diarrhea. Overall, 361 individuals (88.5%) reported no symptoms.

    A total of 147 participants (36.0%) had PCR test results positive for SARS-CoV-2. Men constituted 84.4% of individuals with PCR-positive results and 64.4% of individuals with PCR-negative results. Among individuals with PCR test results positive for SARS-CoV-2, cough (7.5%), shortness of breath (1.4%), and fever (0.7%) were all uncommon, and 87.8% were asymptomatic.

    Discussion

    Universal SARS-CoV-2 PCR testing of an adult homeless shelter population in Boston shortly after the identification of a COVID-19 case cluster yielded a 36% positivity rate. The majority of individuals with newly identified infections had no symptoms and no fever at the time of diagnosis, suggesting that symptom screening in homeless shelters2 may not adequately capture the extent of disease transmission in this high-risk setting. Limitations of this study include the cross-sectional nature of the study at a single shelter in Boston where several symptomatic individuals had been removed through prior symptom screening or self-referrals to outside care. These results support PCR testing of asymptomatic shelter residents if a symptomatic individual with COVID-19 is identified in the same shelter.

    Section Editor: Jody W. Zylke, MD, Deputy Editor.
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    Article Information

    Corresponding Author: Travis P. Baggett, MD, MPH, Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 (tbaggett@mgh.harvard.edu).

    Published Online: April 27, 2020. doi:10.1001/jama.2020.6887

    Conflict of Interest Disclosures: Dr Baggett reported receiving royalties from UpToDate for authorship of a topic review on homeless health care. Mr Keyes reported receiving nonfinancial support from the Massachusetts Department of Public Health and the shelter where the testing was conducted during the conduct of the study. No other disclosures were reported.

    Previous Posting: This manuscript was posted as a preprint on medRxiv.org on April 15, 2020. doi:10.1101/2020.04.12.20059618

    Additional Contributions: We thank Alfred DeMaria, MD, and colleagues at the Massachusetts Department of Public Health Bureau of Infectious Disease for facilitating the testing described in this article. We thank Joana Barbosa Teixeira, MA; Andrea Joyce, MA; Elijah Rodriguez, BA; Erin Ford, BA (Massachusetts General Hospital); and Alexei Alvarado, BA (Boston Health Care for the Homeless Program), for their assistance with data entry. None of these individuals were compensated for their contributions.

    References
    1.
    Henry  M, Watt  R, Mahathey  A, Ouellette  J, Sitler  A. The 2019 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: Point-in-Time Estimates of Homelessness. US Department of Housing and Urban Development; 2020.
    2.
    Interim guidance for homeless service providers to plan and respond to coronavirus disease 2019 (COVID-19). Centers for Disease Control and Prevention. Accessed April 2, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/plan-prepare-respond.html
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