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Adverse SARS-CoV-2 Associated Outcomes Among People Experiencing Homelessness, Imprisonment, Supported Psychiatric Housing, Mental Disorders, Substance Abuse or Chronic Medical Disorders: A Population-Based Cohort Study Among 4.4 Million People

31 Pages Posted: 29 Sep 2021

See all articles by Sandra Feodor Nilsson

Sandra Feodor Nilsson

Mental Health Centre Copenhagen - Copenhagen Research Center for Mental Health – CORE

Thomas Munk Laursen

Aarhus University - The National Centre for Register-Based Research

Merete Osler

University of Copenhagen - Section of Epidemiology

Carsten Hjorthøj

University of Copenhagen, Faculty of Health and Medical Sciences, Department of Public Health

Michael Eriksen Benros

Mental Health Centre Copenhagen - CORE – Copenhagen Research Centre for Mental Health

Steen Ethelberg

Statens Serum Institut - Infectious Disease Epidemiology & Prevention

Kåre Mølbak

Statens Serums Institut - Department of Infectious Disease Epidemiology

Merete Nordentoft

Mental Health Centre Copenhagen - Danish Research Institute for Suicide Prevention; Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH)

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Abstract

Background: Marginalised or deprived groups may be at high risk of a serious COVID-19 outcome. We examined adverse outcomes associated with SARS-CoV-2 infection among vulnerable segments of society. 

Methods: Using health and administrative registers, we performed a population-based cohort study of 4.38 million Danes, 27 February 2020­ to 6 April 2021. Main predictors were experiences of 1) homelessness, 2) imprisonment, 3) supported psychiatric housing, 4) mental disorder, 5) substance abuse, and 6) chronic medical condition. COVID-19-related outcomes were: 1) hospitalisation, 2) intensive care, 3) 30-day mortality, and 4) overall mortality. PCR-confirmed SARS-CoV-2 infection and PCR-testing were also studied. Vulnerable groups were compared with the general population (using adjusted incidence and mortality rate ratios: IRRs, MRRs). 

Findings: Among individuals with a positive PCR-test experiencing homelessness and supported psychiatric housing, 8∙6% (95% CI 6∙9-10∙4) and 11% (7∙8-14∙7), respectively, were admitted to hospital within two weeks and 1∙8% (1∙1-2∙7) and 2∙9% (1∙4-5∙1), respectively, had died within 30 days. The probability of hospitalisation was higher for all predictors compared with the general population (p=<0∙0001). After adjustments, vulnerable housing situations, i.e. homelessness, imprisonment, and supported psychiatric housing, increased the risk of adverse outcomes 1∙7 to 3∙2-times; highest 30-day MRR after COVID-19 was for homelessness (3∙2, 95% CI 2∙0-5∙1) and supported psychiatric housing: (2∙7, 1∙4-5∙2). Mental disorder, substance abuse, and chronic medical conditions were associated with 1∙1 (mental disorder and intensive care, p=0∙37) to 2∙0-times increased risk of adverse outcomes (30-day MRR for substance abuse: 2∙0, 1∙8-2∙3). Overall mortality during the study period was increased for all predictors and highest for homelessness combined with a PCR-confirmed SARS-CoV-2 infection (MRR 22∙1, 15∙2-32∙2). 

Interpretation: This study highlights that pandemic preparedness should address inequalities in health, including infection prevention and vaccination of vulnerable groups. Higher awareness of people in vulnerable living situations is needed. 

Funding Information: This study was funded by a grant from the Novo Nordisk Foundation to MN (grant number NFF20SA0063142).

Declaration of Interests: We declare no competing interests.

Ethics Approval Statement: Permission was obtained from Statistics Denmark and the Danish Health Data Authority. Ethical permission was not required for this study according to Danish regulations.

Keywords: COVID-19, SARS-CoV-2 infection, Homeless Persons, Mental Health, Supported Housing, Public Health, Imprisonment, Substance Abuse, Alcohol Use Disorder, Drug Use Disorder, Chronic Medical Disorders, Obesity, Infection, Out-of-home Placement, Epidemiology, Register Data, Adverse Outcomes, Mortality, Hospitalisation, Intensive Care, Death, Predictors, Risk-factors, Morbidity, Cohort Study

Suggested Citation

Nilsson, Sandra Feodor and Laursen, Thomas Munk and Osler, Merete and Hjorthøj, Carsten and Benros, Michael Eriksen and Ethelberg, Steen and Mølbak, Kåre and Nordentoft, Merete, Adverse SARS-CoV-2 Associated Outcomes Among People Experiencing Homelessness, Imprisonment, Supported Psychiatric Housing, Mental Disorders, Substance Abuse or Chronic Medical Disorders: A Population-Based Cohort Study Among 4.4 Million People. Available at SSRN: https://ssrn.com/abstract=3932954 or http://dx.doi.org/10.2139/ssrn.3932954

Sandra Feodor Nilsson (Contact Author)

Mental Health Centre Copenhagen - Copenhagen Research Center for Mental Health – CORE ( email )

Thomas Munk Laursen

Aarhus University - The National Centre for Register-Based Research ( email )

Nordre Ringgade 1
DK-8000 Aarhus C, 8000
Denmark

Merete Osler

University of Copenhagen - Section of Epidemiology ( email )

Denmark

Carsten Hjorthøj

University of Copenhagen, Faculty of Health and Medical Sciences, Department of Public Health ( email )

Michael Eriksen Benros

Mental Health Centre Copenhagen - CORE – Copenhagen Research Centre for Mental Health ( email )

Steen Ethelberg

Statens Serum Institut - Infectious Disease Epidemiology & Prevention ( email )

Kåre Mølbak

Statens Serums Institut - Department of Infectious Disease Epidemiology

Ørestads Boulevard 5
Copenhagen, 2300S
Denmark

Merete Nordentoft

Mental Health Centre Copenhagen - Danish Research Institute for Suicide Prevention ( email )

Copenhagen
Denmark

Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH) ( email )

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