COVID-19 vaccinations for people who are homeless

The Welsh Government published its national strategy in January 2021 setting out how the vaccination programme in Wales will be delivered as fast and as safely as possible. The strategy explains the groups of people who are considered a priority to receive the vaccination and follows the UK’s independent expert Joint Committee on Vaccination and Immunisation’s (JCVI) agreed list to be prioritised for vaccination. This approach is being taken by all four nations in the UK. The JCVI list is at Annex 1.

The list prioritises those individuals where the data has shown they are at increased risk of being severely ill if they contract COVID-19. The aim of prioritising people for vaccination is to reduce the number of hospitalisations and deaths.

People who are, or have been homeless will often have a lower than average life expectancy, the physical health of a much older person as well significant physical and mental health problems. These health vulnerabilities, along with the risks associated with congregate settings of emergency or supported accommodation, difficulties with adherence to COVID-19 related restrictions, mental health, trauma and substance use issues, provide rationale behind prioritisation for the vaccination as part of priority group 6.

Identifying people who are, or have been homeless from health records, may be challenging and could lead to some individuals who are clinically vulnerable to COVID-19 not being identified for vaccination. Homelessness service providers will always look to help the people they support to register with health services. However, there are significant concerns that many people who are homeless will not be registered, or will not have up-to-date health records, due to their time on the streets, movement across different parts of Wales (or the UK) and/or fear and mistrust of services.

It is very likely that many people who are, or have been homeless may qualify for vaccine priority group 4 or 6 anyway, but may not be known to health services and therefore will potentially not be offered the vaccine. Our national approach is to ensure that no one is missed and no one is left behind.

It is also recognised that not all people who are, or have been homeless would automatically qualify for vaccination in a particular priority group. However, given the strong evidence base of the health impacts on the homeless population, we are adopting the principle and value of being more, rather than less, inclusive to avoid missing those vulnerable people who should be vaccinated.

The Welsh Government is taking an inclusion approach to the identification of people who are, or have been homeless. We expect this to result in more individuals being prioritised under priority group 6 than might otherwise be the case based on a strict interpretation of the JCVI guidance. We are providing practitioners with discretion to ensure no vulnerable person in these groups is missed or left behind.

Health Boards are responsible for delivery of the vaccination programme working with partner organisations, including GPs, local authorities and third sector organisations.

Health Boards can utilise the local knowledge of third sector homelessness and housing-support providers, local authority homelessness coordination cells and housing support grant leads, support provider representative bodies, and where appropriate, specialist services such as substance misuse services, to identify people who are eligible to be added to the priority group 6 list.

Employing professional discretion across these teams will ensure those considered in scope are identified and put forward for vaccination while also helping to keep any potential abuse of the system to a minimum.  Additionally, clinical discretion may also be required to add individuals to priority group 6, who may be eligible but not listed in the national system.

In using professional judgement and any clinical discretion, the following risk factors will be helpful to consider:

• clinically vulnerability and frailty
• the presence of pre-existing / co-occurring health conditions and level of complexity of those health conditions
• ethnicity
• socio-economic factors
• type of accommodation: Living in a communal setting, for example, in supported or emergency temporary accommodation
• unable to practise consistently, protective behaviours such as social distancing, wearing a mask and hand hygiene  (potentially due to trauma, mental health problems and substance use issues)
• ability to adhere to treatment routine and tolerate intervention

This blended approach to identifying people is in line with approaches being implemented in other UK countries.

The Welsh Government recommends that vaccines are primarily given to people who are homeless in the places where they live, rather than expecting people with experience of homelessness to attend mass vaccination centres. 

The Centres for Disease Control and Prevention (CDC) has published useful guidance which recognises the difficulties that people experiencing homelessness have in accessing medical services in traditional settings, and recommends that

vaccine distribution plans should include strategies to bring vaccines to people experiencing homelessness, including homeless service sites like shelters, day programs, or food service locations.

Where a vaccination team vaccinate at a setting, the approach should be that all eligible people are vaccinated in that sitting, rather than for multiple visits to be undertaken.  This will improve efficiency for Health Boards and also help ensure the trust and confidence of the residents and their support staff. It also has the potential to secure greater second dose uptake. However, the transient nature of the population may require additional visits so a pragmatic and flexible approach will be required.

However, there may of course be circumstances where people who have experienced homelessness can attend mass vaccination centres or their GP practice (if registered).  Consideration should also be given to use of other clinical settings, such as secondary health care clinics, in order to facilitate access to vulnerable groups and maximise up-take.

Therefore a blended approach may be appropriate but local discretion and flexibility across health boards, local authorities and support providers will be necessary. 

Consideration should be given to how to most effectively communicate the benefits of the vaccination programme to people with experience of homelessness in advance of the vaccination team visiting the accommodation setting, working with key partners such as local authorities and support providers.

Considering an individual from this group to have ‘opted out’ of vaccination should only be made where there is clear information the individual has chosen not to be vaccinated, and their decision is, as best as possible, recognised as an informed decision. Consideration should be given to the impact of people’s experience of trauma, mental health problems and/or substance use on their decision. Our national ‘no one left behind’ approach will be significant in ensuring those with experience of homelessness have further opportunities to benefit from the vaccination programme.

Reasonable adjustments will need to be identified and put in place to enable individuals to be supported and to feel confident to attend and receive their vaccination; this should include taking the individual and/or family preferences into account wherever possible.

Some people with experience of homelessness and trauma may find it difficult to engage with unfamiliar services, but have built positive, trusting relationships with their support workers. Health Boards should work with third sector support providers to build on these relationships, increase confidence in the process and maximise uptake.

This priority list is being followed by all four nations in the UK.

The list prioritises those individuals where the data has shown they are at increased risk of being severely ill if they contract COVID-19. The aim of prioritising people for vaccination is to reduce the number of hospitalisations and deaths.

1. People living in a care home for older adults and their staff carers.
2. All those 80 years of age and older and frontline health and social care workers.
3. All those 75 years of age and over.
4. All those 70 years of age and over and people who are extremely clinically vulnerable (also known as the “shielding” group) – people in this group will previously have received a letter from the Chief Medical Officer advising them to shield.
5. All those 65 years of age and over.
6. All individuals aged 16 years to 64 years with underlying health conditions (1), which put them at higher risk of serious disease and mortality.
7. All those 60 years of age and over.
8. All those 55 years of age and over.
9. All those 50 years of age and over.

(1)    Underlying health conditions:

• Chronic heart disease (and vascular disease)
• Chronic kidney disease
• Chronic liver disease
• Chronic neurological disease including epilepsy
• Severe and profound learning disability
• Diabetes
• Solid organ, bone marrow and stem cell transplant recipients
• People with specific cancers
• Immunosuppression due to disease or treatment
• Asplenia and splenic dysfunction
• Morbid obesity
• Severe mental illness