Without a Home, Without a Vaccine: The UK Vaccination Programme Must Prioritise the Homeless Community.

Jatinder Hayre is a medical student, researcher and campaigner, with an acute interest in health inequalities and the social determinants of health. Recently he co-authored ‘SAGE Report 21: COVID-19 and Health Inequalities’. He is also a member and spokesperson for Keep Our NHS Public and partakes in journalism. He is on Twitter: @JatinderHayre_

Alack of home is a lack of agency. The home takes a multidimensional role in our lives: a venue for contact with the most prominent members of one’s social network; and for most of society, a representation of major financial and personal investment. It would appear that a home is also a dictating factor in eligibility to receive the COVID-19 vaccine. This excludes some of the most clinically vulnerable groups in the UK: homeless people. Homelessness in the UK represents the most public display of the decade long austerity agenda of the UK; the past decade has seen rough sleeping increase by 141%.¹ Rough sleeping is indicated to be 5-times higher than the official figures suggest, with councils cumulatively reporting 25,000 people sleeping rough at least once in the prior year, in England alone.¹ General Practitioners (GP’s) are pillars of their local community and should lead initiatives to end the “vaccine exclusion” of the homeless.

Infectious diseases represent a communitarian science; individual health and behaviour is pertinent to wider population health. The two are inseparable. Though, given the itinerant lifestyle homeless people are subject to, they are at greater risk of contracting and spreading SARS-CoV-2. Seroprevalence data from France suggests the incidence of COVID-19 is greatly exacerbated in vulnerable communities in precarious housing arrangements. Incidence rates range from 23% to 62% in the emergency shelters, 18% and 35% in the food distribution points, and 82% and 94% in the workers’ hostels.² The UK’s health system has been underfunded for the previous decade, the implications of such widespread COVID-19 infectivity in a hyper-mobile group, such as homeless people, could be catastrophic for our hospital capacity. According to PHE modelling, had authorities not housed and not acted on homelessness the prevalence of Covid-19 would be 34% in people living in hostels and sleeping rough, which would have led to an additional 4,000 hospital admissions during the first lockdown.³ Intensive care units have recently been near maximum capacity across the UK. To protect the wider population, we must focus on the health and social needs of the homeless.

The health outcomes in homeless people are the worst in society. The poor health outcomes can be illustrated by the prevalence of COPD being 14% amongst homeless people; yet, substantially lower at 2% in deprived households.⁴ The homeless population exist on the most extreme end of the socioeconomic gradient, leading to a myriad of health problems. A study into Covid-19 patients requiring hospitalisation in acute care hospitals in the UK, between 6 February to 10 April 2020 recorded co-morbidities that increased mortality risk in patients presenting with COVID-19. These co-morbidities include liver disease, respiratory disease, cancer, and cardiovascular disease.⁵ All these co-morbidities are overexpressed in the homeless population. Therefore, homeless people are at the extreme end of clinical vulnerability, yet without adequate prioritisation in vaccination.

The Joint Committee on Vaccination and Immunisation (JCVI) has omitted mention of homeless people. To be eligible for the COVID-19 vaccine the current regressive policy necessitates registeration with a GP. With only 65.5% of rough sleepers registered with a GP, compared to 98% of the general population, many will be excluded from vaccination.⁶ Though it is encouraging to see some Local Authorities, such as Oldham, in Greater Manchester, taking a more inclusive direction in their vaccination programme. This has been a GP-led initiative to vaccinate clinically vulnerable homeless people who are not registered with a general practice.

“The great equaliser”? The worst burden of the COVID-19 pandemic has been shouldered by the most vulnerable. Far from being the great equaliser, the pandemic has simply exacerbated health and social inequalities. However, we have the chance to institute a targeted vaccination programme which is both equitable and inclusive. The homeless community must be central to this given their precarious accommodation and pernicious health inequalities. The Oldham GP-led initiative is a cause of optimism and highlights the need for GP’s to support locally delivered policies in vaccinating the homeless. The following policy recommendations can reduce the disparity in vaccination roll out:

1. Partnerships between the voluntary sector, CCGs and GP surgeries should be sought to identify the location of homeless people and to utilise pre-existing outreach infrastructures.
2. Relaxation of GP registration requirements and utilising local authority teams and charities to direct homeless people to GP registration.

References

1. Wainwright D. Homelessness: Rough sleeping five times higher than official figure: BBC News; 2020 [Available from: https://www.bbc.co.uk/news/uk-england-51398425.
2. Capai L, Ayhan N, Masse S, Canarelli J, Priet S, Simeoni M-H, et al. Seroprevalence of SARS-CoV-2 IgG Antibodies in Corsica (France), April and June 2020. Journal of Clinical Medicine. 2020;9(11).
3. Lewer D, Braithwaite I, Bullock M, Eyre M, Aldridge R. COVID-19 and homelessness in England: a modelling study of the COVID-19 pandemic among people experiencing homelessness, and the impact of a residential intervention to isolate vulnerable people and care for people with symptoms2020.
4. Lewer D, Aldridge RW, Menezes D, Sawyer C, Zaninotto P, Dedicoat M, et al. Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: a cross-sectional study in London and Birmingham, England. BMJ Open. 2019;9(4):e025192.
5. Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L, et al. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. BMJ (Clinical research ed). 2020;369:m1985-m.
6. Elwell-Sutton T, Fok J, Albanese F, Mathie H, Holland R. Factors associated with access to care and healthcare utilization in the homeless population of England. Journal of Public Health. 2017;39(1):26-33.

Featured photo by Nick Fewings on Unsplash