Abstract
Background
The consideration of unique social housing needs has largely been absent from the COVID-19 response, particularly in tailoring strategies to improve access to testing and vaccine uptake among vulnerable and high-risk populations in Ontario. Given the growing population of social housing residents, this study aimed to compare SARS-CoV-2 testing, positivity, and vaccination rates in a social housing population with those in a general population cohort in Ontario, Canada.
Methods
This population-based cohort study used administrative health data from Ontario to examine SARS-CoV-2 testing, positivity and vaccination rates in social housing residents compared with the general population from 1 January 2020 to 31 December 2021. All comparisons were unadjusted, stratified by sex and age and evaluated using standardised differences.
Results
The rates of SARS-CoV-2 PCR testing were lower among younger age groups and higher among older adults within the social housing cohort, compared with the general population cohort. SARS-CoV-2 test positivity was higher in social housing than in the general population among individuals aged 60–79 years (7.9% vs 5.3%, respectively) and 80 years and older (12.0% vs 7.9%, respectively). Overall, 34.3% of social housing residents were fully vaccinated, compared with 29.6% of the general population cohort. However, a smaller proportion of social housing residents had received a booster vaccine (36.7%) compared with the general population (52.4%).
Conclusion
Improved and targeted outreach strategies are needed to increase the uptake of COVID-19 booster vaccines among social housing residents.
Keywords: COVID-19, VACCINATION, COHORT STUDIES, Health inequalities
WHAT IS ALREADY KNOWN ON THIS TOPIC
The consideration of unique social housing needs has largely been absent from the SARS-CoV-2 preparedness and response plans, particularly in tailoring strategies to improve access to testing and vaccine uptake among this vulnerable and high-risk population in Ontario.
WHAT THIS STUDY ADDS
In the Ontario social housing population, SARS-CoV-2 PCR testing rates were lower among 5–11 and 12–17 age groups, and higher among those aged 80 years and older, compared with the general population.
SARS-CoV-2 test positivity rates were higher in the social housing cohort than in the general population cohort among individuals aged 60–79 years (7.9% vs 5.3%, respectively) and those aged 80 years and older by as much as 4%.
Booster vaccines saw a smaller uptake among social housing residents, with only 36.7% having received a booster, compared with 52.4% in the general population.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Our study contributes critical insights for future pandemic preparedness and response to ensure better outcomes and equitable care for vulnerable populations like those residing in social housing.
Introduction
The SARS-CoV-2 virus, which sparked the global COVID-19 pandemic, has inflicted significant morbidity, mortality and socioeconomic challenges in Ontario, Canada.1 Vaccination against SARS-CoV-2 emerged as an integral part of the public health strategy to reduce infection and mortality rates. In Ontario, the COVID-19 vaccination programme began on 14 December 2020.2 As of March 2024, individuals, aged 6 months and older, are eligible for Health Canada authorised COVID-19 vaccines.3 Bivalent COVID-19 vaccines, introduced on 12 September 2022, are recommended as booster doses at a 6-month interval for individuals aged 5 years and older.3 Booster doses are important in maintaining and strengthening immune protection against the virus, helping to prevent the severity of infections, hospitalisations and contagion among close contacts.4 5 Throughout the pandemic, PCR testing for SARS-CoV-2 also expanded and, by January 2022, rapid antigen tests were publicly funded and widely available.6 Despite testing efforts and 86% of Canadians having received at least one vaccine dose, COVID-19 infection rates remained high.7 8 This is particularly concerning in vulnerable communities where access to vaccinations and testing remains low.7,10 There is limited information on testing for SARS-CoV-2 and vaccine coverage among the vulnerable population of social housing residents, whereas such data have been well documented in the general population and for some high-risk groups.11,14
In Ontario, there are approximately 260 000 social housing units that provide financially supported accommodations (eg, government-funded subsidies and rent-geared-to-income housing) for almost one-third of the province’s low-income renters.15 16 Social housing is also referred to as public or project housing in the USA and council housing in the UK.17 18 We have previously provided a detailed description of the Ontario social housing population elsewhere.19 20 Social housing complexes are notable for housing a significant number of low-income individuals in small spaces at high density, making them potential hotspots for the next COVID-19 outbreak.21 While this arrangement offers opportunities for health interventions or strategies to mitigate health issues, it also presents opportunities for the spread of infectious illnesses such as COVID-19.21 Moreover, this population is not simply another ‘low-income population’. To qualify for social housing, residents must demonstrate an income below the low-income threshold and have specific social needs aligned with municipal priority areas, such as a history of vulnerability or homelessness.22 23 Given the growing population of social housing residents, an epidemiological examination as a ‘clustered group’ is warranted.
The objectives of this study were to describe the distribution of PCR testing, test positivity and vaccination rates of SARS-CoV-2 in the social housing population compared with the general population in Ontario, Canada.
Methods
Study design
We conducted a retrospective population-based cohort study that used administrative health data from Ontario, Canada between 1 January 2020 and 31 December 2021. Ontario administrative healthcare data are securely held in a linked, coded form and analysed at the not-for-profit research institute, ICES (www.ices.on.ca).
Population and cohort definition
We studied two cohorts of individuals aged 5 years and older who were alive on 1 January 2020: those residing in Ontario social housing buildings, defined by their unique postal codes and those who were not. The lower age threshold of 5 years was chosen since only individuals aged 5 years and older were eligible for COVID-19 vaccination during the study period. Street addresses of social housing buildings were obtained from the 47 Ontario regional social housing authorities, either from their websites or directly from a representative of the authority. Postal codes were then obtained from Canada Post. Google Maps (https://www.google.com/maps/) was used to visually validate whether each social housing building shared its postal code with adjacent residential or commercial buildings. The social housing cohort was limited to 2667 postal codes in which at least 50% of the units were social housing.
Data sources and outcomes
SARS-CoV-2 PCR test results were captured in the Ontario Laboratories Information System. COVID-19 vaccination events were captured in the provincial COVaxON database. Demographic, place of residence and vital status information were obtained from the Ontario Health Insurance Plan Registered Persons Database. These databases are linked at the individual level and analysed at ICES in an anonymous, coded form under section 45 of Ontario’s Personal Health Information Protection Act.
The three outcomes of interest were (1) SARS-CoV-2 PCR testing, measured as the percentage (%) of individuals who had at least one PCR test; (2) SARS-CoV-2 PCR test positivity, measured as the number of people with at least one positive test and (3) vaccination rate, which included the number of individuals who had one dose (considered partially vaccinated), two doses (considered fully vaccinated) or three doses of the COVID-19 vaccine (considered boosted), comparing residents of social housing to the general population in Ontario. The last date of the study period was 31 December 2021.
Statistical analysis
Descriptive statistics (percentages) were used to summarise the characteristics of both populations studied. All comparisons were unadjusted, stratified by sex and age and evaluated using standardised differences; differences greater than 10% (0.1) were considered important.24 All statistical analyses were performed by using SPSS V.28.1.25
Results
Between 1 January 2020 and 31 December 2021, we identified 363 819 social housing residents and 14 181 709 non-social housing residents from the general population in Ontario, Canada. In the social housing cohort, there were 1 57 019 males (42.3%) and 2 06 800 females (56.7%), while in the general population cohort, there were 7 022 640 males (49.5%) and 7 159 069 females (50.5%).
The age distribution of the social housing and general population cohorts is provided in table 1. In the social housing population, the proportion of individuals aged 80 years or older was higher compared with the general population (7.3% vs 4.0%, respectively), while the proportion of individuals aged 40–59 years was lower (23.5% vs 28.9%, respectively). This trend was consistent across both males and females. The age distribution was similar for the remaining age groups.
Table 1. Age and sex distribution in the social housing cohort versus the general population, 2020–2021.
| Age group | Social housing (%) | General population (%) | Standardised mean difference* |
|---|---|---|---|
| Overall | n=363 819 | n=14 181 709 | SD |
| 5–11 | 9.7% | 8.1% | 0.06 |
| 12–17 | 8.4% | 6.9% | 0.06 |
| 18–39 | 29.2% | 31.5% | 0.05 |
| 40–59 | 23.5% | 28.9% | 0.12* |
| 60–79 | 21.9% | 20.6% | 0.03 |
| ≥80 | 7.3% | 4.0% | 0.14* |
| Male | n=157 019 (42.3%) | n=7 022 640 (49.5%) | SD |
| 5–11 | 11.5% | 8.4% | 0.10 |
| 12–17 | 9.9% | 7.2% | 0.10 |
| 18–39 | 30.8% | 32.0% | 0.03 |
| 40–59 | 22.6% | 28.9% | 0.14* |
| 60–79 | 20.1% | 20.0% | 0.00 |
| ≥80 | 5.1% | 3.5% | 0.08 |
| Female | n=206 800 (56.7%) | n=7 159 069 (50.5%) | SD |
| 5–11 | 8.4% | 7.8% | 0.02 |
| 12–17 | 7.3% | 6.7% | 0.02 |
| 18–39 | 28.0% | 30.9% | 0.06 |
| 40–59 | 24.2% | 29.0% | 0.11* |
| 60–79 | 23.2% | 21.1% | 0.05 |
| ≥80 | 8.9% | 4.6% | 0.17* |
StandardizedStandardised mean difference of >0.1 (10%) was considered to be meaningful.
SD, standardised mean difference.
SAR-CoV-2 PCR testing
The percentage of individuals who received at least one SARS-CoV-2 PCR test was lower among the 5–11 and 12–17 age groups in the social housing cohort compared with the general population cohort (46.7% vs 51.6% and 42.1% vs 48.3%, respectively). However, social housing residents aged 80 years and older had a testing percentage of 56.1%, which was relatively higher compared with the percentage of 48.3% in the general population (see table 2). These findings were consistent across both males and females.
Table 2. Percentage of social housing residents versus the general population receiving at least one SARS-CoV-2 PCR test by age and sex, 2020–2021.
| Age group | Social housing (%) | General population (%) | Standardised mean difference* |
|---|---|---|---|
| Overall | n=363 819 | n=14 181 709 | SD |
| 5–11 | 46.7% | 51.6% | 0.10 |
| 12–17 | 42.1% | 48.3% | 0.12* |
| 18–39 | 54.0% | 55.5% | 0.03 |
| 40–59 | 49.7% | 49.5% | 0.00 |
| 60–79 | 46.9% | 42.9% | 0.08 |
| ≥80 | 56.1% | 48.3% | 0.16* |
| All ages | 46.9% | 47.3% | 0.01 |
| Male | n=157 019 (42.3%) | n=7 022 640 (49.5%) | SD |
| 5–11 | 47.4% | 52.3% | 0.10 |
| 12–17 | 39.9% | 46.6% | 0.14* |
| 18–39 | 47.8% | 51.1% | 0.07 |
| 40–59 | 45.2% | 46.2% | 0.02 |
| 60–79 | 47.3% | 43.2% | 0.08 |
| ≥80 | 57.9% | 49.2% | 0.18* |
| All ages | 43.6% | 45.0% | 0.03 |
| Female | n=206 800 (56.7%) | n=7 159 069 (50.5%) | SD |
| 5–11 | 46.0% | 51.0% | 0.10 |
| 12–17 | 44.2% | 50.1% | 0.12* |
| 18–39 | 59.1% | 59.9% | 0.02 |
| 40–59 | 52.8% | 52.7% | 0.00 |
| 60–79 | 46.7% | 42.7% | 0.08 |
| ≥80 | 55.3% | 47.6% | 0.15* |
| All ages | 52.3% | 49.5% | 0.06 |
StandardizedStandardised mean difference of >0.1 (10%) was considered to be meaningful.
SD, standardised mean difference.
SAR-CoV-2 test positivity
Overall, COVID-19 test positivity rates were higher in the social housing cohort compared with the general population cohort among those aged 60–79 years (7.9% vs 5.3%, respectively) and 80 years and older (12.0% vs 7.9%, respectively). Among males aged 60–79 years, 8.8% of individuals in the social housing cohort and 5.6% in the general population cohort tested positive for COVID-19 (see table 3). Similarly, among females aged 60–79 years, 7.3% in the social housing cohort and 5.0% in the general population cohort had at least one positive COVID-19 test. Among males aged 80 years and older, 12.9% and 8.1% of individuals in the social housing and general population cohorts, respectively, tested positive for COVID-19.
Table 3. SARS-CoV-2 test positivity in social housing residents versus the general population by age and sex, 2020–2021.
| Age group | Social housing (%) | General population (%) | Standardised mean difference* |
|---|---|---|---|
| Overall | n=363 819 | n=14 181 709 | SD |
| 5–11 | 6.9% | 6.7% | 0.01 |
| 12–17 | 8.6% | 8.2% | 0.01 |
| 18–39 | 13.3% | 11.4% | 0.06 |
| 40–59 | 11.0% | 9.1% | 0.06 |
| 60–79 | 7.9% | 5.3% | 0.10 |
| ≥80 | 12.0% | 7.9% | 0.14* |
| All ages | 10.4% | 8.3% | 0.07 |
| Male | n=157 019 (42.3%) | n=7 022 640 (49.5%) | SD |
| 5–11 | 6.9% | 6.8% | 0.00 |
| 12–17 | 7.8% | 7.6% | 0.01 |
| 18–39 | 11.3% | 10.0% | 0.04 |
| 40–59 | 9.3% | 8.3% | 0.04 |
| 60–79 | 8.8% | 5.6% | 0.12* |
| ≥80 | 12.9% | 8.1% | 0.16* |
| All ages | 9.9% | 7.7% | 0.08 |
| Female | n=206 800 (56.7%) | n=7 159 069 (50.5%) | SD |
| 5–11 | 7.0% | 6.5% | 0.02 |
| 12–17 | 9.4% | 8.7% | 0.02 |
| 18–39 | 14.9% | 12.8% | 0.06 |
| 40–59 | 12.2% | 10.0% | 0.07 |
| 60–79 | 7.3% | 5.0% | 0.10 |
| ≥80 | 11.6% | 7.8% | 0.13* |
| All ages | 11.1% | 8.9% | 0.07 |
StandardizedStandardised mean difference of >0.1 (10%) was considered to be meaningful.
SD, standardised mean difference.
SAR-CoV-2 vaccination coverage
As of December 2021, 34.3% of social housing residents aged 5 years or older were fully vaccinated, compared with 29.6% of the general population cohort (see table 4 and online supplemental table 1). Within the 18–79 age group, a greater percentage of social housing residents were partially or fully vaccinated compared with the general population. However, among individuals aged 5–11 years, only 29.5% in the social housing cohort were fully vaccinated, whereas 47.9% in the general population cohort were fully vaccinated. Regarding booster vaccines, 36.7% of social housing residents had received a booster, in contrast to 52.4% of the general population being boosted. Among the 5–11 age group, booster vaccine uptake was the lowest, with only 1.9% of social housing residents receiving a booster, compared with 7.4% in the general population. The highest percentages of individuals with a booster dose were found in the 60–79 age group (64.6% in social housing vs 76.5% in the general population) and those aged 80 and older (64.6% in social housing vs 71.2% in the general population). In both the 60–79 and 80 and older age groups, a higher percentage of individuals are considered boosted than fully vaccinated. Overall, social housing residents had a lower percentage of individuals considered boosted compared with the general population across all age groups.
Table 4. SARS-CoV-2 vaccination coverage in social housing residents versus the general population by age, 2020–2021.
| Age group | Dose | Social housingn=363 819 | General populationn=13 394 303 | SD* |
|---|---|---|---|---|
| 5–11 | Partially vaccinated | 10.7% | 8.9% | 0.06 |
| Fully vaccinated | 29.5% | 47.9% | 0.38* | |
| Boosted | 1.9% | 7.4% | 0.26* | |
| 12–17 | Partially vaccinated | 4.7% | 1.8% | 0.16* |
| Fully vaccinated | 58.8% | 53.8% | 0.10 | |
| Boosted | 11.8% | 30.9% | 0.48* | |
| 18–39 | Partially vaccinated | 4.0% | 2.0% | 0.12* |
| Fully vaccinated | 45.7% | 37.0% | 0.18* | |
| Boosted | 23.5% | 43.4% | 0.43* | |
| 40–59 | Partially vaccinated | 2.4% | 1.2% | 0.09 |
| Fully vaccinated | 35.8% | 25.9% | 0.22* | |
| Boosted | 42.2% | 60.1% | 0.36* | |
| 60–79 | Partially vaccinated | 1.7% | 0.9% | 0.07 |
| Fully vaccinated | 17.5% | 11.9% | 0.16* | |
| Boosted | 64.6% | 76.5% | 0.26* | |
| ≥80 | Partially vaccinated | 2.2% | 1.6% | 0.04 |
| Fully vaccinated | 12.2% | 9.6% | 0.08 | |
| Boosted | 64.6% | 71.2% | 0.14* | |
| All ages | Partially vaccinated | 3.7% | 2.1% | 0.10 |
| Fully vaccinated | 34.3% | 29.6% | 0.10 | |
| Boosted | 36.7% | 52.4% | 0.32* |
StandardizedStandardised mean difference of >0.1 (10%) was considered meaningful.
SD, standardised mean difference.
Discussion
Summary of the main results
To our knowledge, this is the first study of SARS-CoV-2 testing, test positivity and vaccination rates in social housing residents compared with the general population between 1 January 2020 and 31 December 2021. We found that that SARS-CoV-2 testing rates were slightly lower among younger social housing residents, whereas those aged 80 years and older, had higher testing rates compared with the general population. This may have been due to government policies prioritising testing for older adults, who are particularly vulnerable to severe outcomes from SARS-CoV-2.26 Another key finding was that SARS-CoV-2 positivity rates were up to 4% higher among older adults in social housing compared with the general population. This finding aligns with our expectations given testing rates and the densely populated living conditions in social housing buildings.21 Social housing living conditions include shared common spaces such as elevators and laundry facilities, which likely facilitated the spread of COVID-19 in these settings.27
Our study findings are also consistent with previous literature. A Swiss population-based study found that more SARS-CoV-2 tests were conducted in neighbourhoods with higher socioeconomic status compared with those with lower socioeconomic status.28 Furthermore, test positivity was lower in higher socioeconomic neighbourhoods than in lower socioeconomic neighbourhoods.28 Similarly, a population-based study in Ontario, Canada, found that individuals residing in low-income areas were less likely to be tested but had higher test-positivity rates for SARS-CoV-2 compared with those residing in high-income areas.29 In Ontario, there were delays in widespread testing, and early testing efforts primarily focused on symptomatic individuals with recent travel history or close contacts with confirmed cases.30,32 This may have contributed to barriers to accessing testing for social housing residents.
Furthermore, by December 2021, Canadian adults were encouraged to receive the primary vaccine series plus one booster dose.33 However, significantly fewer social housing residents had a COVID-19 vaccine booster compared with the general population. Although a large percentage of social housing residents were fully vaccinated, a relatively smaller proportion received a booster dose by the end of our study period. This may be attributed to a lack of understanding of the need and/or poor widespread accessibility.34 Additionally, previous research has shown that marginalised populations had a lower acceptance and uptake of COVID-19 vaccines. Populations particularly affected included racialised communities, individuals with low socioeconomic status and residents of rural areas.35,37 For example, in Southeastern Ontario, vaccine coverage rates were nearly 11% lower among individuals residing in low-income areas and 9% lower in rural areas compared with high-income and urban areas, respectively.38 The lower rates of acceptance and uptake of COVID-19 vaccines may have also impacted the uptake of booster doses among these populations.
Future directions
The notably lower uptake of COVID-19 booster vaccines in the social housing population may be attributed in part to poor health literacy or limited access to booster doses.34 This disparity holds important implications for policy and vaccine outreach programmes, especially as vaccination programmes may be needed to protect against new strains of SARS-COV-2. To address this issue, new or enhanced outreach strategies are required to increase the proportion of boosted individuals among social housing residents. A targeted approach could include partnering with housing organisations, primary care partners, and healthcare providers to establish or host free mobile testing and vaccine clinics in densely populated social housing buildings and neighbourhoods.39 These clinics could offer drive-thru, walk-in and home-visit options to improve accessibility. Another crucial strategy is to improve the communication, education and engagement efforts within this population. This is needed to raise awareness about the importance of testing and receiving booster vaccines and to address specific barriers such as improving health literacy skills.
Limitations
The results are based on data collected during the early stages of the vaccine rollout, up to 31 December 2021. Vaccination promotion efforts were still ongoing at the end of our study period, and the percentage of social housing residents who ultimately received a booster dose may have increased, possibly aligning more closely with rates in the general population after our study period. Additionally, our study focused on individuals who sought and underwent laboratory PCR testing for SARS-CoV-2 infection. Therefore, we cannot provide information on the prevalence of infection among those who remained asymptomatic or symptomatic individuals who did not seek testing, given the latter group may be more prevalent among social housing residents, who might face barriers to accessing PCR testing. A strength of this study is the use of administrative health data, which offers greater accuracy and reliability. The provincial COVaxON database was also rigorously monitored and maintained, reducing the potential for errors. This approach facilitated a more comprehensive and province-wide analysis.
Conclusions
Our study highlights higher test positivity rates among older adults and lower booster vaccine uptake among social housing residents, emphasising the importance of improving access to testing and vaccination services in this vulnerable population. To address these disparities, improved outreach strategies such as walk-in appointments, mobile clinics, health systems collaborations and improved communication efforts are needed. Our study contributes critical insights for future pandemic preparedness and response to ensure better outcomes and equitable care for vulnerable populations like those residing in social housing.
Supplementary material
Acknowledgements
This study was supported by the Ontario Health Data Platform (OHDP), a Province of Ontario initiative to support Ontario’s ongoing response to COVID-19 and its related impacts. The opinions, results and conclusions reported in this paper are those of the authors and are independent of the funding sources. No endorsement by the OHDP, its partners or the Province of Ontario is intended or should be inferred. This study was also supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health. This document used data adapted from the Statistics Canada Postal CodeOM Conversion File, which is based on data licensed from Canada Post Corporation and/or data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under licence from Canada Post Corporation and Statistics Canada. Parts of this material are based on data and/or information compiled and provided by the Ontario Ministry of Health, Ontario Health, and the Canadian Institute for Health Information. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.
The analyses, conclusions, opinions and statements expressed here are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. The funder had no role in the study design, data collection and analysis or preparation of the paper. All authors had full access to study data and can take responsibility for the integrity of the data and accuracy of the data analysis.
Footnotes
Funding: This study was funded by McMaster COVID-19 Research Fund/Ontario Health Data Platform OHDP (Ontario Health Data Base Funding). All authors confirm independence from the funder.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants. It was reviewed by the Hamilton Integrated Research Ethics Board (Project #11476-C). It was granted an exemption as all individual-level study data were held and analysed at ICES under section 45 of Ontario’s Personal Health Information Protection Act.
Data availability free text: The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (eg, healthcare organisations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet prespecified criteria for confidential access, available at www.ices.on.ca/DAS (email: das@ices.on.ca). The full dataset creation plan and underlying analytical code are available from the authors on request, understanding that the computer programs may rely on coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.
Data availability statement
Data are available on reasonable request.
References
- 1.Umakanthan S, Sahu P, Ranade AV, et al. Origin, transmission, diagnosis and management of coronavirus disease 2019 (COVID-19) Postgrad Med J. 2020;96:753–8. doi: 10.1136/postgradmedj-2020-138234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ontario Newsroom Ontario delivers first COVID-19 vaccine in the country. 2020. https://news.ontario.ca/en/statement/59635/ontario-delivers-first-covid-19-vaccine-in-the-country Available.
- 3.Ontario.ca COVID 19 vaccines. 2022. https://www.ontario.ca/page/covid-19vaccines Available.
- 4.Miyauchi S, Hiyama T, Nakano Y, et al. Real-World Effectiveness of a Booster Dose of the COVID-19 Vaccines among Japanese University Students. Vaccines (Basel) 2022;10:1283. doi: 10.3390/vaccines10081283. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Andrews N, Stowe J, Kirsebom F, et al. Effectiveness of COVID-19 booster vaccines against COVID-19-related symptoms, hospitalization and death in England. Nat Med. 2022;28:831–7. doi: 10.1038/s41591-022-01699-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ontario Newsroom Ontario expanding access to free rapid tests for general public. 2022. https://news.ontario.ca/en/release/1001575/ontario-expanding-access-to-free-rapid-tests-for-general-public Available.
- 7.Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020;20:533–4. doi: 10.1016/S1473-3099(20)30120-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.World Health Organization Data.who.int, WHO coronavirus (COVID-19) dashboard > cases [dashboard] https://data.who.int/dashboards/covid19/cases n.d. Available.
- 9.Bruxvoort KJ, Sy LS, Qian L, et al. Effectiveness of mRNA-1273 against delta, mu, and other emerging variants of SARS-CoV-2: test negative case-control study. BMJ. 2021;375:e068848. doi: 10.1136/bmj-2021-068848. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Iacobucci G. Covid-19: Fourth vaccine doses—who needs them and why? BMJ. 2022;376:30. doi: 10.1136/bmj.o30. [DOI] [PubMed] [Google Scholar]
- 11.Thiara S, Henry B, Patrick D, et al. British Columbia’s COVID-19 experience. BC Med J. 2020;62:277–9. [Google Scholar]
- 12.eHealth Ontario Ontario laboratories information system (OLIS) standard. https://ehealthontario.on.ca/en/standards/ontario-laboratories-information-system-standard n.d. Available.
- 13.Sundaram M, Nasreen S, Calzavara A, et al. Background rates of all-cause mortality, hospitalizations, and emergency department visits among nursing home residents in Ontario, Canada to inform COVID-19 vaccine safety assessments. Vaccine (Auckl) 2021;39:5265–70. doi: 10.1016/j.vaccine.2021.07.060. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Redditt V, Wright V, Rashid M, et al. Outbreak of SARS-CoV-2 infection at a large refugee shelter in Toronto, April 2020: a clinical and epidemiologic descriptive analysis. CMAJ Open. 2020;8:E819–24. doi: 10.9778/cmajo.20200165. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Turner S. Canadian Policy Research Networks; 2007. Sustaining ontario’s subsidized housing by supporting non-profit organizations. [Google Scholar]
- 16.Ontario Human Rights Commission VII. Social Housing. https://www.ohrc.on.ca/en/policy-human-rights-and-rental-housing/vii-social-housing n.d. Available.
- 17.Hud’s Public Housing Program HUD.gov / U.S. department of housing and urban development (HUD) 2021. https://www.hud.gov/topics/rental_assistance/phprog Available.
- 18.National Housing Federation About social housing. https://www.housing.org.uk/about-housing-associations/about-social-housing/ n.d. Available.
- 19.Agarwal G, Lee J, Keshavarz H, et al. Cardiometabolic risk factors in social housing residents: A multi-site cross-sectional survey in older adults from Ontario, Canada. PLoS ONE. 2024;19:e0301548. doi: 10.1371/journal.pone.0301548. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Agarwal G, Keshavarz H, Angeles R, et al. Department of Family Medicine, McMaster University; 2023. Chronic disease prevalence and preventive care among ontario social housing residents. [Manuscript under peer review] [Google Scholar]
- 21.Pirrie M, Agarwal G. Older adults living in social housing in Canada: the next COVID-19 hotspot? Can J Public Health. 2021;112:4–7. doi: 10.17269/s41997-020-00462-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Atkey J, Chau L, Falvo N, et al. The Municipal Role in Housing. Toronto: Institute on Municipal Finance and Governance; 2022. pp. 1–25. [Google Scholar]
- 23.Health Canada Priority strategies to optimize testing and screening for COVID-19 in Canada: report. 2021:1–31.
- 24.Austin PC. Using the Standardized Difference to Compare the Prevalence of a Binary Variable Between Two Groups in Observational Research. Commun Stat Simul Comput. 2009;38:1228–34. doi: 10.1080/03610910902859574. [DOI] [Google Scholar]
- 25.IBM Corp . IBM Corp; 2021. IBM SPSS Statistics for Windows (Version 28.0) [Computer Software] [Google Scholar]
- 26.Wong MK, Brooks DJ, Ikejezie J, et al. COVID-19 Mortality and Progress Toward Vaccinating Older Adults — World Health Organization, Worldwide, 2020–2022. MMWR Morb Mortal Wkly Rep. 2023;72:113–8. doi: 10.15585/mmwr.mm7205a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Dzerounian J, Pirrie M, AlShenaiber L, et al. Health knowledge and self-efficacy to make health behaviour changes: a survey of older adults living in Ontario social housing. BMC Geriatr. 2022;22:473. doi: 10.1186/s12877-022-03116-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Riou J, Panczak R, Althaus CL, et al. Socioeconomic position and the COVID-19 care cascade from testing to mortality in Switzerland: a population-based analysis. Lancet Public Health. 2021;6:e683–91. doi: 10.1016/S2468-2667(21)00160-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Antonova L, Somayaji C, Cameron J, et al. Comparison of socio-economic determinants of COVID-19 testing and positivity in Canada: A multi-provincial analysis. PLoS One. 2023;18:e0289292. doi: 10.1371/journal.pone.0289292. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Public Health Ontario; 2020. The story of covid-19 testing in ontario.https://www.publichealthontario.ca/en/About/News/2020/Story-Covid-19-Testing-Ontario Available. [Google Scholar]
- 31.Detsky AS, Bogoch II. COVID-19 in Canada: Experience and Response. JAMA. 2020;324:743–4. doi: 10.1001/jama.2020.14033. [DOI] [PubMed] [Google Scholar]
- 32.Yu A, Prasad S, Akande A, et al. COVID-19 in Canada: A self-assessment and review of preparedness and response. J Glob Health. 2020;10:0203104. doi: 10.7189/jogh.10.0203104. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Ontario Newsroom; 2021. Ontario accelerating booster eligibility to adults aged 50+https://news.ontario.ca/en/release/1001269/ontario-accelerating-booster-eligibility-to-adults-aged-50 Available. [Google Scholar]
- 34.Fenta ET, Tiruneh MG, Delie AM, et al. Health literacy and COVID-19 vaccine acceptance worldwide: A systematic review. SAGE Open Med. 2023;11:20503121231197869. doi: 10.1177/20503121231197869. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Crawshaw J, Konnyu K, Castillo G, et al. Factors Affecting COVID-19 Vaccination Acceptance and Uptake among the General Public: A Living Behavioural Science Evidence Synthesis. Ottawa: Ottawa Hospital Research Institute; 2021. [Google Scholar]
- 36.MacDonald NE, Comeau J, Dubé È, et al. Royal society of Canada COVID-19 report: Enhancing COVID-19 vaccine acceptance in Canada. Facets (Ott) 2021;6:1184–246. doi: 10.1139/facets-2021-0037. [DOI] [Google Scholar]
- 37.Public Health Agency of Canada . Emerging Evidence on COVID-19 Evergreen Rapid Review on COVID-19 Vaccine Attitudes and Uptake in Canada- Update 10. Ottawa, Ontario: Government of Canada; 2021. [Google Scholar]
- 38.Carter MA, Biro S, Maier A, et al. COVID-19 Vaccine Uptake in Southeastern Ontario, Canada: Monitoring and Addressing Health Inequities. J Public Health Manag Pract. 2022;28:615–23. doi: 10.1097/PHH.0000000000001565. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Embrett M, Sim SM, Caldwell HAT, et al. Barriers to and strategies to address COVID-19 testing hesitancy: a rapid scoping review. BMC Public Health. 2022;22:750. doi: 10.1186/s12889022-13127-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Data Availability Statement
Data are available on reasonable request.