Are drug users at a higher risk of SARS-Cov-2 infection and severe COVID-19 outcomes?
As of 6 November 2020, ECDC reported 235 648 deaths (~46 per 100 000 inhabitants) linked to the SARS-Cov-2 virus, for a total of more than 8.5 million confirmed cases in EU/EEA and UK (ECDC). Are drug users at a higher risk of SARS-Cov-2 infection? Given the transmission mode of this respiratory virus, some common exposures among drug users can be considered as risk factors. They include – among others - social gathering in closed settings, sharing of drugs and paraphernalia, and poor access to soap, hand sanitiser and masks for marginalised populations. A seroprevalence study conducted in Czechia during the first wave of the pandemic (April 2020) among 4255 clients from drug services showed a prevalence of SARS-Cov-2 antibodies of 0.26% in this population. SARS-Cov-2 seroprevalence studies conducted in France, Spain and Switzerland at the end of the first wave (May-June), showed that between 4% and 10% of the general population had already been infected. While the Czech study was done early on, it might nevertheless suggest that the risk of getting COVID-19 was not higher among drug users than in the general population.
Prevalence of drug use is high in prison settings and there are concerns that people in prison might be disproportionally affected by COVID-19. Preliminary data from the French prison of Villeneuve les Maguelone showed that by mid-May 2020, among inmates (the prison has a capacity of 570), 24 people were tested, 2 were positive for COVID-19, and a further 67 high-risk contacts had to quarantine. As France is facing its second pandemic wave in October 2020, the prison guarantees the continuity of OST and support for patients with somatic and psychiatric disorders.
Are drug users at a higher risk of severe COVID-19 outcomes? Early observational studies have shown a strong and consistent association between underlying medical conditions (including cardiovascular diseases and lung diseases) and severe COVID-19 outcomes (leading to hospitalisation, ICU, deaths). Given the high prevalence of these underlying chronic conditions among high-risk drug users, they can be considered at high risk of developing severe outcomes when infected with Sars-Cov-2. A study of electronic health records in the United States in June 2020 showed that people with a recent diagnosis of substance use disorder (opioid, cocaine or cannabis) were at increased risk of COVID-19 and at increased risk of experiencing severe outcomes such as hospitalisation and death.
How is the pandemic affecting harm reduction services working on HIV, hepatitis and STIs?
Besides the direct impact COVID-19 is having on drug users, the pandemic is disrupting the functioning of essential drugs services that play a central role in the prevention and treatment of other infectious diseases such as HIV, viral hepatitis and sexually transmitted infections (STIs). In Germany, the RKI conducted a survey among 41 harm reduction services doing testing and counselling for drug users. The results showed that the 2020 spring lockdown led to an increase in the demand for needle exchange, but the limited number of clients and shortened duration of stay in facilities led reduced contact with clients, while testing services and counselling were discontinued. A second survey round will be conducted in December 2020.
The German survey, as well as a study from the civil society Correlation network and an ECDC report on medically and socially vulnerable populations during the pandemic, outlined the challenges faced by European harm reduction services and drug users during the pandemic, but also point to the capacity of drug services to innovate and provide flexible solutions to maintain service continuity. Examples include new outreach services, home delivery of OST, the use of telemedicine and the extension of prescription lengths for patients. Similarly, in Israel, HIV prevention among PWID was adapted during the lockdown to prevent the re-occurrence of the 2012-13 outbreak. NSP staff were declared essential staff, NSP services were moved outdoors to comply with COVID-19 regulations, OST was given for longer periods, and telemedicine encouraged. WHO Europe is currently assessing the disruptions to HIV services in Eastern Europe and Central Asia. As Europe is facing its second COVID-19 epidemic wave, the Euro-TEST initiative is conducting an assessment of the impact of the pandemic on testing for HIV, viral hepatitis and sexually transmitted infections in the WHO European Region.