People experiencing homelessness died more frequently from COVID-19 than the general population

During the COVID-19 pandemic, numerous claims surfaced downplaying the reality or severity of COVID-19. However, Science Feedback previously demonstrated how scientific data directly contradicts these assertions. At the time of writing, COVID-19 has caused over one million deaths in the U.S. and more than seven million deaths worldwide since the pandemic began in 2020.

Although these numbers demonstrate COVID-19’s lethality, claims doubting the public health threat posed by COVID-19 have persisted. One example can b found in an August 2024 Threads post, which claimed that COVID-19 spared the lives of most people experiencing homelessness (PEH) and implied that the virus wasn’t as deadly as reported. The post also referenced natural immunity, suggesting that relying on infection-induced immunity was an appropriate method for managing COVID-19 given the disease’s allegedly low lethality.

But this is misleading, since infection-induced immunity is less predictable and more risky than vaccine-induced immunity, as Science Feedback explained in earlier reviews. Moreover, the claim that PEH were spared from COVID-19 doesn’t hold up under scrutiny, as we will explain below.

A virus doesn’t need to wipe out an entire population to be deadly

The argument that the continued presence of PEH after the pandemic somehow suggests that COVID-19 wasn’t deadly is fundamentally flawed. By that logic, one could argue that the plague wasn’t deadly simply because many people survived the pandemic in the Middle Ages—when in reality it killed an estimated 25 million people.

Moreover, it’s important to recognize that individuals who weren’t experiencing homelessness prior to the pandemic may have lost their housing during the crisis, contributing to a rise in the number of PEH as reported by media outlets. Thus one couldn’t assess how many PEH survived after the pandemic without taking that factor into consideration. Therefore, the number of PEH alone cannot be used as evidence to downplay the severity of COVID-19.

Lack of COVID-19 mortality data for PEH reflects a long-standing challenge in public health research

Some initial figures about the COVID-19 deaths among PEH were surprisingly low, ostensibly supporting the claim that PEH were better at fending off the disease.

However, absence of evidence is not evidence of absence, and a lack of data on PEH mortality doesn’t mean their mortality is actually lower. In a later article from March 2021, experts working with or studying populations of PEH told the health news website STAT that there was a “vast undercount” of COVID-19 mortality among PEH.

Cause of death in PEH has been a public health blind spot since well before the start of the pandemic, STAT reported. Housing situations usually don’t appear on death certificates and autopsies aren’t usually performed on people found dead in public places when there’s been no sign of foul play. Thus, there could have been many PEH who died from COVID-19 whose deaths weren’t officially recognized as COVID-19 deaths.

Furthermore, characteristics unique to PEH render prospective studies difficult. Such studies require systematically monitoring the same individuals over time for health outcomes such as COVID-19 and death, but this is harder to accomplish when a person is experiencing housing instability. This difficulty was highlighted by the authors of one prospective study^[1] of PEH during the pandemic:

“The main limitation of this study was the lack of systematic follow-up data from the homeless cohort during the different waves and lockdowns due to their movements from one place of accommodation to another, or from one place of isolation for COVID-19 infection to a squat or shelter.”

Available data show that PEH are at a higher risk of dying from COVID-19 than the general population

In spite of the difficulties related to gathering data on PEH mortality, some studies managed to shed some light on COVID-19 outcomes among this group.

One systematic literature review identified 41 studies^[2], five of which contained data on mortality. All five studies on mortality found a higher COVID-19 mortality rate among PEH compared to the general population.

That said, the authors noted that most of the studies were of low or moderate quality, owing to the lack of data or imprecision tied to the definition of homelessness.

Other studies not included in that review reached similar conclusions. One study of PEH in Los Angeles County from January 2020 to November 2021 found that the age-adjusted mortality rate among PEH was 2.35 times higher compared to the general population^[3].

Another study followed approximately 30,000 people over the course of six months who had a recent history of homelessness in Ontario, Canada. The study reported that COVID-19 hospitalization was over 20 times higher in people with a recent history of homelessness compared to people with secure housing. The former group also had a five-fold higher risk of COVID-related death within 21 days of a positive COVID-19 test compared to the latter^[4].

Studies from France and the Netherlands didn’t investigate COVID-19 mortality but registered a higher rate of COVID-19 hospitalization among PEH, which the authors attributed to a higher prevalence of risk factors in this group compared to the general population^[1,5].

Finally, the Coalition For The Homeless carried out a survey of the mortality of PEH in New York City shelters from the beginning of the pandemic to February 2021. After adjusting for age—since the PEH population is younger than the general NYC population—the survey found that the COVID-19 death rate among sheltered PEH was 436 deaths per 100,000 people, which was 49% higher than the death rate in the general population.

Thus, in spite of difficulties researchers face when studying PEH, available data established that PEH died more frequently from COVID-19 compared to the general population. The underlying reason for this may be that PEH are a more vulnerable population who face disparities in terms of access to food, shelter, and healthcare.

Furthermore, PEH experience a higher prevalence of health issues that are associated with a higher risk of severe COVID-19, such as diabetes and cardiovascular conditions. This manifests in shorter life expectancy: On average, PEH die 12 years sooner than the individuals from the general U.S. population.

Conclusion

People who experience homelessness form a vulnerable segment of the population. They often have limited access to resources and healthcare, and suffer from higher rates of medical conditions that may elevate the risk of severe COVID-19.

Conducting research among PEH is a long-standing public health challenge. Data related to COVID-19 outcomes among PEH is, as a consequence, scant However, the data that we do have shows that PEH have a higher COVID-19 mortality compared to the general population. Thus, it’s inaccurate to claim that PEH were spared by the COVID-19 pandemic. On the contrary, the data from PEH supports the fact that the COVID-19 pandemic has been a particularly deadly health crisis. The COVID-19 pandemic caused substantial excess mortality worldwide.

REFERENCES:

• 1 – Loubiere et al. (2023) Morbidity and mortality in a prospective cohort of people who were homeless during the COVID-19 pandemic. Frontiers in Public Health.
• 2 – Ogbonna et al. (2023) The Impact of Being Homeless on the Clinical Outcomes of COVID-19: Systematic Review. International Journal of Public Health.
• 3 – Porter et al. (2022) Race and Ethnicity and Sex Variation in COVID-19 Mortality Risks Among Adults Experiencing Homelessness in Los Angeles County, California. JAMA Network Open.
• 4 – Richard et al. (2021) Testing, infection and complication rates of COVID-19 among people with a recent history of homelessness in Ontario, Canada: a retrospective cohort study. Canadian Medical Association journal Open.
• 5 – Mennis et al. (2024) COVID-19 related morbidity and mortality in people experiencing homelessness in the Netherlands. Plos One.