Substandard housing and the risk of COVID-19 infection and disease severity: A retrospective cohort study

In this study we examine associations between substandard housing and the risk of COVID-19 infection and severity during the first year of the pandemic by linking individual-level housing and clinical datasets. Residents of Chelsea, Massachusetts who were tested for COVID-19 at any Mass General Brigham testing site and who lived at a property that had received a city housing inspection were included (N = 2873). Chelsea is a densely populated city with a high prevalence of substandard housing. Inspected properties with housing code violations were considered substandard; inspected properties without violations were considered adequate. COVID-19 infection was defined as any positive PCR test, and severe disease defined as hospitalization with COVID-19. We used a propensity score design to match individuals on variables including age, race, sex, and income. In the severity model, we also matched on ten comorbidities. We estimated the risk of COVID-19 infection and severity associated with substandard housing using Cox Proportional Hazards models for lockdown, the first phase of reopening, and the full study period. In our sample, 32% (919/2873) of individuals tested positive for COVID-19 and 5.9% (135/2297) had severe disease. During lockdown, substandard housing was associated with a 48% increased risk of COVID-19 infection (95%CI 1.1-2.0, p = 0.006). Through Phase 1 reopening, substandard housing was associated with a 39% increased infection risk (95%CI 1.1-1.8, p = 0.020). The difference in risk attenuated over the full study period. There was no difference in severe disease risk between the two groups. The increased risk, observed only during lockdown and early reopening - when residents were most exposed to their housing - strengthens claims that substandard housing conveys higher infection risk. The results demonstrate the value of combining cross-sector datasets. Existing city housing data can be leveraged 1) to identify and prioritize high-risk areas for future pandemic response, and 2) for longer-term housing solutions.