This is a summary, written by members of the CITF Secretariat, of:

Richard L, Nisenbaum R, Liu M, McGeer A, Mishra S, Gingras A-C, Gommerman JL, Sniderman R, Pedersen C, Spandier O, Jenkinson JIR, Baral S, Mejia-Lancheros C, Agarwal A, Jamal AJ, Ostrowski M, Dhalla I, Stewart S, Gabriel M, Brown M, Hester J, Hwang SW. Ku-gaa-gii pimitizi-win, the COVID-19 cohort study of people experiencing homelessness in Toronto, Canada: a study protocol. BMJ Open. 27 June 2022. doi:

The results and/or conclusions contained in the research do not necessarily reflect the views of all CITF members.

In a paper published in BMJ Open, Dr. Stephan Hwang (MAP Centre for Urban Health Solutions, St. Michael’s Hospital and University of Toronto) and colleagues developed a study protocol documenting the CITF-funded Ku-gaa-gii pimitizi-win study (formerly known as the COVENANT study), which aims to estimate the prevalence and incidence of COVID-19 infection among people experiencing homelessness in Canada. They will also examine individual and shelter level characteristics associated with COVID-19 infection and other related outcomes,  and develop a novel infection transmission model for people experiencing homelessness in urban settings.

Compared to the general population, people experiencing homelessness are not only at higher risk of COVID-19 infection due to shared living spaces and crowding, but also due to greater burden of physical and mental health conditions associated with complications following infection. Despite this, there are few longitudinal data collections aimed at evaluating the impact of COVID-19 on people experiencing homelessness.

To fill this gap, the Ku-gaa-gii pimitizi-win study recruited a total of 736 participants ages 16 and older by random sample from over 60 emergency shelter sites, physical distancing hotels (hotels temporarily commissioned as homeless shelters to better permit physical distancing during the pandemic) and one major urban encampment across Toronto between June and September 2021. Every 3 months over the course of a year, a follow-up interview will be conducted to collect information about current COVID-19 symptoms, COVID-19 infection history, vaccination history, housing history, and activities and behaviours related to COVID-19. At each interview blood and saliva samples will also be obtained to test for active SARS-CoV-2 infection and measure anti-SARS-CoV-2 antibodies indicating past infection or vaccination.

Key points:

  • The five broad objectives of the Ku-gaa-gii pimitizi-win study include:
    • determining the incidence and prevalence of COVID-19 infection among people experiencing homelessness over 12 months,
    • examining the association between housing history and individual and shelter-level characteristics with incident COVID-19 infection over 12 months,
    • investigating the association between individual and shelter-level characteristics and COVID-19 related adverse outcomes,
    • assessing vaccination uptake and the factors/reasons associated with vaccination, and
    • developing a novel COVID-19 transmission model describing infection transmission among people experiencing homelessness in urban settings.
  • Key variables in the study incorporate saliva and blood sample data to avoid limitations of self-reported infection and vaccination status data. In addition, results are cross-referenced against data from Ontario health administrative sources.
  • Individuals recruited represent only 10% of people experiencing homelessness in Toronto, so the sample in this study do not fully represent this population.
  • As anti-SARS-CoV-2 antibodies decline over time, this may have led to underestimation of SARS-CoV-2 prevalence in people experiencing homelessness.

The study data will yield answers to research questions in a series of research studies.