COVID‐19 vaccination among socially vulnerable people who use drugs

Abstract

The coronavirus SARS-Cov-2 infection (COVID-19) has emerged as a global emergency in early 2020, with fast world-wide dissemination. Respiratory droplets and direct contact in the asymptomatic and symptomatic phases transmit the virus, making agglomerations unadvisable, which encouraged different levels of city and country lockdowns and social distancing measures world-wide. Open-air drug scenes can potentially raise an additional challenge to COVID 19 mitigation, as they concentrate a significant amount of people in poor sanitary conditions, probably contributing to the spread of the virus. In the United States, people who use drugs have been disproportionately affected by the COVID-19 pandemic—not only are they at increased risk for severe disease and death due to COVID-19 [1], but there are also data showing that overdose deaths have increased during the pandemic [2]. Furthermore, people who use drugs are over-represented among those facing housing instability and homelessness, domestic and sexual violence and incarceration—social conditions that increase the harm posed by COVID-19 [3]. In Brazil, the 'Cracolândia', in the central region of São Paulo, is the oldest and most densely populated open-air drug scene in the country, with approximately 500 residents and more than 2000 regular visitors [4]. Other Brazilian cities have similar 'Cracolândias', rendering them a national problem [5]. They are characterized by agglomerations of people in high vulnerability situations where simple protective measures, such as the use of face masks and social distancing to decrease virus transmission, are not respected, creating a scenario with great potential for the spread of the COVID-19 [5, 6]. The United Kingdom was the first country in the world to approve the vaccination of the population against COVID-19, in December 2020. After that, several countries approved the use of vaccines and started vaccination campaigns. In Brazil, vaccination against COVID-19 started on 17 January 2021. However, the national immunization plan runs somewhat slowly, and thus far only covers the so-called priority groups, such as health professionals, Quilombolas, 1 Indigenous people and institutionalized people aged 60 years or over as well as general-population older adults aged 85 years and older. People who use drugs were not included in the initial priority groups and may face barriers to vaccination, especially those who live in an open-air drug use scene such as 'Cracolândia'. People living in such conditions and using drugs are potential victims and disseminators of the disease. As such, an immunization plan must be developed specifically for this population, considering the specific barriers faced by this population [7]. The first step is to develop effective strategies to deal with this population's mistrust of health professionals [7]. People who use drugs continue to suffer stigma from both the general population and health professionals [8]. Therefore, it is naive to believe that people who use drugs will unquestionably and willingly stay in line to receive vaccines [7, 8]. Furthermore, there are numerous structural barriers to vaccination for people living in open-air drug scenes, including inadequate access to transport and technology, which limit their ability to reach vaccine delivery sites and make it difficult to track people and administer vaccines. A follow-up for vaccine second doses will probably be even harder to achieve. Also, unstable housing and the need to seek food emphasize the problem of competing priorities of higher-order needs. A strategy that could be implemented to provide vaccination effectively for that population is to create vaccination points inside their own areas, facilitating this population's access to this resource. Another option is that local and state governments consider providing resources and services, including hotel accommodations, food or food vouchers, telephones, chargers and the services of case managers and social workers at vaccination sites [6]. Such services would greatly increase the likelihood of completing the vaccine series and could even be a motivation for the first contact with the addiction treatment system. This could improve long-term outcomes, including sustained recovery, overdose reduction and housing status [6]. Moreover, creating links with health teams that work directly in this territory, such as the outreach teams, could reduce the mistrust of the population towards health professionals and encourage adherence to the vaccine. None.

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