Risk factors for outbreaks of SARS-CoV-2 infection at retirement homes in Ontario, Canada: a population-level cohort study

Roxby A.C., Greninger A.L., Hatfield K.M., Lynch J.B., Dellit T.H., James A., Taylor J., Page L.C., Kimball A., Arons M., Munanga A., Stone N., Jernigan J.A., Reddy S.C., Lewis J., et. al.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused epidemic spread of coronavirus disease 2019 (COVID-19) in the Seattle, Washington, metropolitan area, with morbidity and mortality concentrated among residents of skilled nursing facilities. The prevalence of COVID-19 among older adults in independent/assisted living is not understood.To conduct surveillance for SARS-CoV-2 and describe symptoms of COVID-19 among residents and staff of an independent/assisted living community.In March 2020, public health surveillance of staff and residents was conducted on site at an assisted and independent living residence for older adults in Seattle, Washington, after exposure to 2 residents who were hospitalized with COVID-19.Surveillance for SARS-CoV-2 infection in a congregate setting implementing social isolation and infection prevention protocols.SARS-CoV-2 real-time polymerase chain reaction was performed on nasopharyngeal swabs from residents and staff; a symptom questionnaire was completed assessing fever, cough, and other symptoms for the preceding 14 days. Residents were retested for SARS-CoV-2 7 days after initial screening.Testing was performed on 80 residents; 62 were women (77%), with mean age of 86 (range, 69-102) years. SARS-CoV-2 was detected in 3 of 80 residents (3.8%); none felt ill, 1 male resident reported resolved cough and 1 loose stool during the preceding 14 days. Virus was also detected in 2 of 62 staff (3.2%); both were symptomatic. One week later, resident SARS-CoV-2 testing was repeated and 1 new infection detected (asymptomatic). All residents remained in isolation and were clinically stable 14 days after the second test.Detection of SARS-CoV-2 in asymptomatic residents highlights challenges in protecting older adults living in congregate settings. In this study, symptom screening failed to identify residents with infections and all 4 residents with SARS-CoV-2 remained asymptomatic after 14 days. Although 1 asymptomatic infection was found on retesting, a widespread facility outbreak was avoided. Compared with skilled nursing settings, in assisted/independent living communities, early surveillance to identify asymptomatic persons among residents and staff, in combination with adherence to recommended preventive strategies, may reduce viral spread.

Stall N.M., Jones A., Brown K.A., Rochon P.A., Costa A.P.

BACKGROUND: Long-term care (LTC) homes have been the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada to date. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than nonprofit homes. METHODS: We conducted a retrospective cohort study of all LTC homes in Ontario, Canada, from Mar. 29 to May 20, 2020, using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between profit status of LTC homes (for-profit, nonprofit or municipal) and COVID-19 outbreaks in LTC homes, the extent of COVID-19 outbreaks (number of residents infected), and deaths of residents from COVID-19. RESULTS: The analysis included all 623 Ontario LTC homes, comprising 75 676 residents; 360 LTC homes (57.7%) were for profit, 162 (26.0%) were nonprofit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) outbreaks of COVID-19 in LTC homes, involving 5218 residents and resulting in 1452 deaths, with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak were associated with the incidence of COVID-19 in the public health unit region surrounding an LTC home (adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.19–3.05), the number of residents (adjusted OR 1.38, 95% CI 1.18–1.61), and older design standards of the home (adjusted OR 1.55, 95% CI 1.01–2.38), but not profit status. For-profit status was associated with both the extent of an outbreak in an LTC home (adjusted risk ratio [RR] 1.96, 95% CI 1.26–3.05) and the number of resident deaths (adjusted RR 1.78, 95% CI 1.03–3.07), compared with nonprofit homes. These associations were mediated by a higher prevalence of older design standards in for-profit LTC homes and chain ownership. INTERPRETATION: For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths, but not the likelihood of outbreaks. Differences between for-profit and nonprofit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy.

McMichael T.M., Currie D.W., Clark S., Pogosjans S., Kay M., Schwartz N.G., Lewis J., Baer A., Kawakami V., Lukoff M.D., Ferro J., Brostrom-Smith C., Rea T.D., Sayre M.R., Riedo F.X., et. al.

Abstract Background Long-term care facilities are high-risk settings for severe outcomes from outbreaks of Covid-19, owing to both the advanced age and frequent chronic underlying health conditions of the residents and the movement of health care personnel among facilities in a region. Methods After identification on February 28, 2020, of a confirmed case of Covid-19 in a skilled nursing facility in King County, Washington, Public Health–Seattle and King County, aided by the Centers for Disease Control and Prevention, launched a case investigation, contact tracing, quarantine of exposed persons, isolation of confirmed and suspected cases, and on-site enhancement of infection prevention and control. Results As of March 18, a total of 167 confirmed cases of Covid-19 affecting 101 residents, 50 health care personnel, and 16 visitors were found to be epidemiologically linked to the facility. Most cases among residents included respiratory illness consistent with Covid-19; however, in 7 residents no symptoms were documented. Hospitalization rates for facility residents, visitors, and staff were 54.5%, 50.0%, and 6.0%, respectively. The case fatality rate for residents was 33.7% (34 of 101). As of March 18, a total of 30 long-term care facilities with at least one confirmed case of Covid-19 had been identified in King County. Conclusions In the context of rapidly escalating Covid-19 outbreaks, proactive steps by long-term care facilities to identify and exclude potentially infected staff and visitors, actively monitor for potentially infected patients, and implement appropriate infection prevention and control measures are needed to prevent the introduction of Covid-19.

Roblin B., Deber R., Kuluski K., Silver M.P.

RÉSUMÉLa demande croissante de lits en établissements publics subventionnés de soins de longue durée (ÉPSLD) occasionne de longues listes d’attentes en Ontario. Ces temps d’attente doivent être absorbés par les autres types d’hébergements, incluant les résidences non subventionnées (RNS). Cette étude compare les ÉPSLD et les RNS en termes de services fournis, de régimes de financement et des implications de ces sources de financement pour les personnes âgées. Des données descriptives pour les ÉPSLD et les RNS ont été collectées à partir de sources publiques et privées afin de représenter l’offre de services, leur disponibilité, leurs coûts et les sources de financement de ces types d’hébergement. Les services offerts par les ÉPSLD et les RNS se chevauchent en partie, particulièrement dans les niveaux de soins les plus élevés. Bien que les secteurs public et privé facturent des frais d’hébergement aux résidents, la plus grande partie des coûts en ÉPSLD sont couverts par des fonds publics, tandis que les résidents en RNS assument personnellement ces frais, en règle générale. Compte tenu des listes d’attente des ÉPSLD, plusieurs personnes âgées doivent se tourner vers d’autres établissements de soins, tels que les RNS. Plusieurs politiques alternatives existantes pourraient être considérées en vue d’améliorer l’équité dans l’accès aux soins en résidence pour les personnes âgées.

Benchimol E.I., Smeeth L., Guttmann A., Harron K., Moher D., Petersen I., Sørensen H.T., von Elm E., Langan S.M.

Routinely collected health data, obtained for administrative and clinical purposes without specific a priori research goals, are increasingly used for research. The rapid evolution and availability of these data have revealed issues not addressed by existing reporting guidelines, such as Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The REporting of studies Conducted using Observational Routinely collected health Data (RECORD) statement was created to fill these gaps. RECORD was created as an extension to the STROBE statement to address reporting items specific to observational studies using routinely collected health data. RECORD consists of a checklist of 13 items related to the title, abstract, introduction, methods, results, and discussion section of articles, and other information required for inclusion in such research reports. This document contains the checklist and explanatory and elaboration information to enhance the use of the checklist. Examples of good reporting for each RECORD checklist item are also included herein. This document, as well as the accompanying website and message board (http://www.record-statement.org), will enhance the implementation and understanding of RECORD. Through implementation of RECORD, authors, journals editors, and peer reviewers can encourage transparency of research reporting.

von Elm E., Altman D.G., Egger M., Pocock S.J., Gøtzsche P.C., Vandenbroucke J.P.

Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalizability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed "Explanation and Elaboration" document is published separately and is freely available on the web sites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.

Savage R.D., Huynh T., Hahn‐Goldberg S., Matai L., Boblitz A., Altaf A., Bronskill S.E., Brown K.A., Feng P., Lewis‐Fung S.E., Sheth M.S., Yu C., Recknagel J., Rochon P.A.

AbstractBackgroundNaturally occurring retirement communities (NORCs) are geographical areas that have naturally become home to a large concentration of older adults. This density means that NORCs have the potential to become a pillar for aging in place strategies, but at present, there is limited data on residents and their health needs. Our objective was to describe and compare the health and healthcare use of older adults living in high‐rise NORC buildings to those in all other housing types in the community.MethodsWe conducted a population‐based descriptive study of community‐dwelling older adults aged ≥65 years by linking a provincial NORC registry in Ontario, Canada with health administrative records. Individuals were classified as NORC residents if their residential postal code on January 1, 2020 matched the NORC registry. Sociodemographic, clinical, and healthcare use characteristics were compared by NORC status using standardized differences (STD) and stratified by rurality, and further by age and sex in urban settings.ResultsOverall, 219,995 (7.7%) of 2,869,706 older adults were NORC residents. Compared to community‐dwelling older adults, NORC residents were older (mean 77.4 vs 74.6 years; STD 0.34), and more were female (61.8% vs 52.2%; STD 0.19) and had low income (16.0% vs 9.3%; STD 0.11). NORC residents also had more active chronic conditions (mean 1.9 vs 1.5; STD 0.27), medications (mean 3.4 vs 2.8; STD 0.21), home care use (15.3% vs 9.8%; STD 0.17), and primary care visits (mean 9.7 vs 7.6 visits in prior 2 years; STD 0.22). Findings were robust across rurality, age, and sex.ConclusionsOur findings suggest that NORC residents have greater health needs than other older adults living in the community and underscore NORCs as important targets for equity‐focused strategies to support aging in place.

Katz A., Li T., James L., Buhariwala P., Osei-Twum J., Siegel J., O’Campo P.

Abstract Background An October, 2021 review of Public Health Ontario's COVID-19 guidance for congregate settings such as shelters and long-term care homes demonstrated that this guidance did not include references to ventilation or filtration. In April 2022, an interdisciplinary team with expertise in indoor air quality (IAQ), engineering, epidemiology, community programming and knowledge translation launched a virtual ventilation and filtration consultation program for community spaces in Toronto, Ontario. The program gives people working in community spaces direct access to IAQ experts through 25-min online appointments. The program aims to help reduce the risk of COVID-19 transmission in community spaces, and was designed to help compensate for gaps in public health guidance and action. Methods Representatives from participating organizations (n. 27) received a link to an online survey via email in April 2023. Survey questions explored the impacts of the program on topics such as: purchase and use of portable air filters; maintenance and use of bathroom fans; and, maintenance and modification of HVAC systems. Survey participation was anonymous, and no demographic information was collected from participants. Results Representatives from 11 organizations completed the survey (40%). Of those who responded, nine (82%) made changes as a result of the program, with eight (73%) making two or more changes such as purchasing portable air filters and increasing routine maintenance of HVAC systems. Conclusions When presented with brief access to expert support and tailored plain language guidance, people working in community spaces increased their use of ventilation and filtration strategies for COVID-19 infection prevention and control.

Dam D., Chen M., Rees E.E., Cheng B., Sukkarieh L., McGill E., Tehami Y., Bellos A., Edwin J., Patterson K.

Abstract Background The severity of COVID-19 outbreaks is disproportionate across settings (e.g., long-term care facilities (LTCF), schools) across Canada. Few studies have examined factors associated with outbreak severity to inform prevention and response. Our study objective was to assess how outbreak severity, as measured using outbreak intensity and defined as number of outbreak-associated cases divided by outbreak duration, differed by setting and factors known to influence SARS-CoV-2 transmission. Methods We described outbreak intensity trends in 2021 using data from the Canadian COVID-19 Outbreak Surveillance System from seven provinces/territories, representing 93% of the Canadian population. A negative binomial fixed-effects model was used to assess for associations between the outcome, outbreak intensity, and characteristics of outbreaks: setting type, median age of cases, number at risk, and vaccination coverage of at least 1 dose. Also included were variables previously reported to influence SARS-CoV-2 transmission: stringency of non-pharmaceutical interventions (NPI) and the predominant SARS-CoV-2 variant detected by surveillance. Results The longest outbreaks occurred in LTCF (mean = 25.4 days) and correctional facilities (mean = 20.6 days) which also reported the largest outbreaks (mean = 29.6 cases per outbreak). Model results indicated that outbreak intensity was highest in correctional facilities. Relative to correctional facilities (referent), the second highest adjusted intensity ratio was in childcare centres (intensity ratio = 0.58 [95% CI: 0.51–0.66]), followed by LTCF (0.56 [95% CI: 0.51–0.66]). Schools had the lowest adjusted intensity ratio (0.46 [95% CI: 0.40–0.53]) despite having the highest proportion of outbreaks (37.5%). An increase in outbreak intensity was associated with increases in median age, the number at risk, and stringency of NPI. Greater vaccination coverage with at least 1 dose was associated with reduced outbreak intensity. Conclusion Descriptive and multivariable model results indicated that in Canada during 2021, outbreak intensity was greatest in closed congregate living facilities: correctional facilities and LTCF. Findings from this study support the importance of vaccination in reducing outbreak intensity when vaccines are effective against infection with circulating variants, which is especially important for closed congregate living facilities where NPIs are more challenging to implement.

Hogan D.B., Maxwell C.J., Dampf H., McGrail K., Estabrooks C.A., Poss J.W., Bakal J.A., Hoben M.

Assisted living (AL) is a significant and growing congregate care option for vulnerable older adults designed to reduce the use of nursing homes (NHs). However, work on excess mortality in congregate care during the COVID-19 pandemic has primarily focused on NHs with only a few US studies examining AL. The objective of this study was to assess excess mortality among AL and NH residents with and without dementia or significant cognitive impairment in Alberta, Canada, during the first 2 years of the COVID-19 pandemic, relative to the 3 years before.

Fahim C., Hassan A.T., Quinn de Launay K., Takaoka A., Togo E., Strifler L., Bach V., Paul N., Mrazovac A., Firman J., Gruppuso V., Boyd J.M., Straus S.

ABSTRACTCOVID-19 presented a crisis for long-term care homes (LTCHs) and retirement homes (RHs). This study explored the pandemic-related challenges LTCHs and RHs faced and the strategies they used to mitigate them. Ninety-one key informant interviews were conducted with LTCH and RH leadership across 47 homes (33 LTCHs, 14 RHs) in Ontario, Canada from February 2021 to July 2022. Findings confirmed evidence for three main challenges. First, leaders were challenged to implement infection prevention and control protocols and measures. Second, they needed supports to facilitate COVID-19 vaccine access and to promote vaccine confidence. Third, LTCH/RH staff experienced significant well-being challenges in the face of COVID-19 pressures. Findings also reveal a plethora of strategies implemented by homes, with ranging reports of perceived success. Homes’ needs evolved rapidly as the COVID-19 pandemic progressed. The use of a co-creation, responsive and tailored approach to address evolving barriers and meaningfully support homes during emergencies is recommended.Key pointsCOVID-19 challenges in homes persisted over one year into the pandemicWe describe the IPAC, vaccine and wellness challenges faced by LTCH and RHWe used these data to design a congregate care home support program to navigate COVID-19 challenges

D'Ascanio A.M., Hewlett D., Davda K., Montecalvo M.A.

Context: Assisted living facility (ALF) residents are especially vulnerable to SARS-CoV-2 infection due to the age and comorbidities of the resident population and the social nature of these facilities. Objective: To collate all New York State Department of Health guidance and regulations to control transmission of SARS-CoV-2 infection within ALFs from March 2020 through December 2022 and to include US Food and Drug Administration COVID-19 testing and vaccine authorizations. Design: A narrative chronological review of all New York State Department of Health guidance. Results: Documents and associated guidance and regulations are divided into 4 sections: (1) lockdown until COVID-19 vaccine emergency use authorization; (2) COVID-19 vaccine authorization until phased reopening; (3) phased reopening, vaccination requirements, and booster vaccination; (4) the period of the bivalent booster. Conclusion: Controlling the spread of SARS-CoV-2 within ALFs required a multifactorial approach that included stringent infection control measures, testing, and vaccination and careful attention to the social structure and support systems within ALFs. The SARS-CoV-2 pandemic highlighted the complexity of controlling spread of an easily transmissible respiratory pathogen in assisted living communities and the need to structure infection control programs within the diverse ALFs that provide care for our aging population.

Leis J.A., Chan C.K., Tan C., Callahan J., Serapion V., Pascual B., Lee W., O’Brien J., Thomas N.R., Candon H., Crittenden M., Kiss A., Chan A.K., Ofner M., Powis J.E.

Abstract Background: Older adults residing in congregate living settings (CLS) such as nursing homes and independent living facilities remain at increased risk of morbidity and mortality from coronavirus disease 2019. We performed a prospective multicenter study of consecutive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) exposures to identify predictors of transmission in this setting. Methods: Consecutive resident SARS-CoV-2 exposures across 17 CLS were prospectively characterized from 1 September 2022 to 1 March 2023, including factors related to environment, source, and exposed resident. Room size, humidity, and ventilation were measured in locations where exposures occurred. Predictors were incorporated in a generalized estimating equation model adjusting for the correlation within CLS. Results: Among 670 consecutive exposures to SARS-CoV-2 across 17 CLS, transmission occurred among 328 (49.0%). Increased risk was associated with nursing homes (odds ratio (OR) = 90.8; 95% CI, 7.8–1047.4), Jack and Jill rooms (OR = 2.2; 95% CI, 1.3–3.6), from source who was pre-symptomatic (OR = 11.2; 95% CI, 4.1–30.9), symptomatic (OR = 6.5; 95% CI, 1.4–29.9), or rapid antigen test positive (OR = 35.6; 95% CI, 5.6–225.6), and in the presence of secondary exposure (OR = 6.3; 95% CI, 1.6–24.0). Exposure in dining room was associated with reduced risk (OR = 0.02; 95% CI, 0.005–0.08) as was medium room size (OR = 0.3; 95% CI, 0.2–0.6). Recent vaccination of exposed resident (OR = 0.5; 95% CI, 0.3–1.0) and increased ventilation of room (OR = 0.9; 95% CI, 0.8–1.0) were marginally associated with reduced risk. Conclusion: Prospective assessment of SARS-CoV-2 exposures in CLS suggests that source characteristics and location of exposure are most predictive of resident transmission. These findings can inform risk assessment and further opportunities to prevent transmission in CLS.

Janssens H., Heytens S., Meyers E., Devleesschauwer B., Cools P., Geens T.

In a previous study in Belgian nursing homes (NH) during the first wave of the COVID-19 pandemic, we found a SARS-CoV-2 seroprevalence of 17% with a large variability (0–45%) between NH. The current exploratory study aimed to identify nursing home-specific risk factors for high SARS-CoV-2 seroprevalence. Between October 19th, 2020 and November 13th, 2020, during the second COVID-19 wave in Belgium, capillary blood was collected on dried blood spots from 60 residents and staff in each of the 20 participating NH in Flanders and Brussels. The presence of SARS-CoV-2-specific IgG antibodies was assessed by ELISA. Risk factors were evaluated using a questionnaire, filled in by the director or manager of the NH. Assessed risk factors comprised community-related factors, resident-related factors, management and performance features as well as building-related aspects. The relation between risk factors and seroprevalence was assessed by applying random forest modelling, generalized linear models and Bayesian linear regression. The present analyses showed that the prevalence of residents with dementia, the scarcity of personal protective equipment (surgical masks, FFP2 masks, glasses and face shields), and inadequate PCR test capacity were related to a higher seroprevalence. Generally, our study put forward that the various aspects of infection prevention in NH require more attention and investment. This exploratory study suggests that the ratio of residents with dementia, the availability of test capacity and personal protective equipment may have played a role in the SARS-CoV-2 seroprevalence of NH, after the first wave. It underscores the importance of the availability of PPE and education in infection prevention. Moreover, investments may also yield benefits in the prevention of other respiratory infections (such as influenza).

Manis D.R., Katz P., Lane N.E., Rochon P.A., Sinha S.K., Andel R., Heckman G.A., Kirkwood D., Costa A.P.

Objective We investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities. Design Repeated cross-sectional study. Setting and Participants Linked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019. Methods Counts and proportions were calculated to describe the sociodemographic characteristics and clinical comorbidities. Relative changes and trend tests were calculated to quantify the longitudinal changes in the characteristics of residents of assisted living facilities between 2013 and 2019. A Sankey plot was graphed to display transitions between different care settings (ie, hospital admission, nursing home admission, died, or remained in the assisted living facility) each year from 2013 to 2019. Results There was a 34% relative increase in the resident population size of assisted living facilities (56,9752019 vs 42,6002013). These older adults had a mean age of 87 years, and women accounted for nearly two-thirds of the population across all years. The 5 clinical comorbidities that had the highest relative increases were renal disease (24.3%), other mental health conditions (16.8%), cardiac arrhythmias (9.6%), diabetes (8.5%), and cancer (6.9%). Nearly 20% of the original cohort from 2013 remained in an assisted living facility at the end of 2019, and approximately 10% of that cohort transitioned to a nursing home in any year from 2013 to 2019. Conclusions and Implications Residents of assisted living facilities are an important older adult population that has progressively increased in clinical complexity within less than a decade. Clinicians and policy makers should advocate for the implementation of on-site medical care that is aligned with the needs of these older adults.

Hoben M., Hogan D.B., Poss J.W., Gruneir A., McGrail K., Griffith L.E., Chamberlain S.A., Estabrooks C.A., Maxwell C.J.

AbstractBackgroundWhile assisted living (AL) and nursing home (NHs) residents in share vulnerabilities, AL provides fewer staffing resources and services. Research has largely neglected AL, especially during the COVID‐19 pandemic. Our study compared trends of practice‐sensitive, risk‐adjusted quality indicators between AL and NHs, and changes in these trends after the start of the pandemic.MethodsThis repeated cross‐sectional study used population‐based resident data in Alberta, Canada. Using Resident Assessment Instrument data (01/2017–12/2021), we created quarterly cohorts, using each resident's latest assessment in each quarter. We applied validated inclusion/exclusion criteria and risk‐adjustments to create nine quality indicators and their 95% confidence intervals (CIs): potentially inappropriate antipsychotic use, pain, depressive symptoms, total dependency in late‐loss activities of daily living, physical restraint use, pressure ulcers, delirium, weight loss, urinary tract infections. Run charts compared quality indicators between AL and NHs over time and segmented regressions assessed whether these trends changed after the start of the pandemic.ResultsQuarterly samples included 2015–2710 AL residents and 12,881–13,807 NH residents. Antipsychotic use (21%–26%), pain (20%–24%), and depressive symptoms (17%–25%) were most common in AL. In NHs, they were physical dependency (33%–36%), depressive symptoms (26%–32%), and antipsychotic use (17%–22%). Antipsychotic use and pain were consistently higher in AL. Depressive symptoms, physical dependency, physical restraint use, delirium, weight loss were consistently lower in AL. The most notable segmented regression findings were an increase in antipsychotic use during the pandemic in both settings (AL: change in slope = 0.6% [95% CI: 0.1%–1.0%], p = 0.0140; NHs: change in slope = 0.4% [95% CI: 0.3%–0.5%], p < 0.0001), and an increase in physical dependency in AL only (change in slope = 0.5% [95% CI: 0.1%–0.8%], p = 0.0222).ConclusionsQIs differed significantly between AL and NHs before and during the pandemic. Any changes implemented to address deficiencies in either setting need to account for these differences and require monitoring to assess their impact.

España P.P., Bilbao-Gonzalez A., Larrea N., Castillo-Sintes I., García-Gutiérrez S., Portuondo J., Villanueva A., Uranga A., Legarreta M.J., Gascon M., Quintana J.M.

There is insufficient evidence regarding the magnitude and durability of the protection conferred by the combined effect of natural immunity after SARS-CoV-2 infection and vaccine-induced immunity among nursing home residents (NHRs), a frail and vulnerable population.1Morciano M. Stokes J. Kontopantelis E. et al.Excess mortality for care home residents during the first 23 weeks of the COVID-19 pandemic in England: a national cohort study.BMC Med. 2021; 19: 71Crossref PubMed Scopus (48) Google Scholar,2Costa A.P. Manis D.R. Jones A. et al.Risk factors for outbreaks of SARS-CoV-2 infection at retirement homes in Ontario, Canada: a population-level cohort study.CMAJ (Can Med Assoc J). 2021; 193: E672-E680Crossref PubMed Scopus (9) Google Scholar In this study, we investigated the effectiveness of licensed mRNA COVID-19 vaccines in preventing COVID-19 infections in NHRs taking into account the presence of previous SARS-CoV-2 infection. This is a retrospective study of a cohort of patients living in nursing homes in our area based on data from the electronic database and health records of our public health service. Only patients aged >60 years were included. We monitored nonvaccinated participants from the beginning of the vaccination campaign until the first dose of vaccine plus 14 days, or death, or the end of the study (January 31, 2022). Those with 1 dose were then switched to “1 vaccine dose” status. We monitored participants with 1 dose from the day they received the first dose plus 14 days until the date of the second dose of vaccine, or death or the end of the study, and those who received a second dose were switched to the “2 vaccine doses” status. We monitored participants with 2 doses from the day they received the second dose until the date of the third dose, or death or the end of the study, and those with a third dose were switched to “3 vaccine doses” status. Finally, participants with 3 doses were monitored from the day they received the third dose until death or the end of the study. We thus treated exposure as time-varying, and a single participant can be included in all 4 statuses (unvaccinated, 1-dose, 2-dose, and 3-dose). Outcome of this study was being positive SARS-CoV-2 infection laboratory-confirmed by a positive result on the reverse transcriptase–polymerase chain reaction assay or a positive antigen test between March 1, 2020, and January 31, 2022. From March 1, 2020, to July 31, 2020, positive IgM or IgG antibody tests performed because of patients displaying symptoms of the disease or having had contact with a positive case were also included in the sample. All positives from each patient were collected if the difference between the date of one positive and the next was ≥120 days. Prior to the vaccination period, the incidence of COVID-19 infection was of 11.44 per 10,000 person-days. Table 1 shows COVID-19 infection according to vaccination status and previous COVID-19 infection for unvaccinated, first, second, and third dose among NHRs. The COVID-19 infection rate per 10,000 person-days for unvaccinated individuals was 11.29, falling after receipt of 1 vaccination dose (9.03) and even more sharply following the second dose (2.19), although it rose again at the time of the third dose (17.73), which also coincided with the appearance of the Omicron variant. The adjusted HR for COVID-19 infection in the 2-dose status compared to the nonvaccinated status was HR = 0.42 (P = .0006). With regard to the effect of prior COVID-19 infection on new infection, the infection rate was much lower for NHRs who had previously had COVID-19. This result was reflected in all adjusted HRs (P < .0001) in all vaccination statuses.Table 1Number and Incidence Rates for COVID-19 According to First, Second, and Third Vaccination Dose Status Among Nursing Home ResidentsStatusPopulationCasesExposure Person-DaysExposure Days (Mean)Rate per 10,000 Person-DaysAdjusted Hazard Ratio (95% CI)∗Adjusted for sex, age, and comorbidities.P Value∗Adjusted for sex, age, and comorbidities.Unvaccinated17,475809716,78741.0211.29Ref.— No previous COVID-1913,014758558,11742.8913.58Ref.— Previous COVID-19446151158,67035.573.210.21 (0.16-0.28)

Leung M.H., Kung K.H., Yau I.S., Fung Y.Y., Mohammad K.N., Lau C.C., Au K.W., Chuang S.K.

Background: COVID-19 outbreaks in residential care homes for the elderly (RCHEs) and for persons with disability (RCHDs) have caused significant morbidity and mortality during 5th epidemic in Hong Kong. This article reviewed COVID-19 outbreaks situation and estimated the effectiveness of receiving at least two-dose of COVID-19 vaccine in preventing severe outcomes. Methods: To estimate attack rates and vaccination coverage, documentation on COVID-19 infection and their vaccination records of residential care homes (RCH) residents reported between December 31, 2021 and May 31, 2022 were reviewed, and infected cases were follow-up for 4 weeks for severe outcomes or death. Correlation between vaccination coverage against attack rate by types of homes was examined. Infected RCH residents with available information were included in the analysis of vaccine effectiveness against severe outcomes and death. Results: COVID-19 vaccination coverage was low in RCHDs (median 0.46, IQR: 0.24–0.76) and very low in RCHEs (median 0.08, IQR: 0.00–0.19). Higher attack rates were recorded among RCHE residents (median 0.84, IQR: 0.64–0.93) and higher case fatality rate (CFR: 28.1%) than in RCHDs (median 0.58, IQR: 0.31–0.84; CFR: 3.9%). The attack rate decreased when vaccination coverage increased for both RCHEs (ρ = −0.131, p < 0.001) and RCHDs (ρ = −0.333, p < 0.001). Comparing with infected residents who were unvaccinated/vaccinated with one-dose, receiving at least two-dose was estimated to be effective in reducing severe outcomes in 31% and 36% of infected RCHE and RCHD residents respectively; with greater reduction in mortality among RCHD than RCHE residents (54% and 38%, respectively). Vaccine effectiveness of two-dose of BNT162b2 against severe outcomes and death are higher than that of CoronaVac. Conclusion: Increasing COVID-19 vaccination could have significant impact on reducing the risk of COVID-19 outbreaks in RCHs. At least two-dose of COVID-19 vaccine is still effective in reducing severe outcomes and death among infected residents in RCHs during Omicron epidemic.

Ernst C., Pires-Afonso Y., Bejko D., Huberty C., Dentzer T.G., Wienecke-Baldacchino A., Hugoson E., Alvarez D., Weydert M., Vergison A., Mossong J.

In spring 2021, a long-term care facility (LTCF) of 154 residents in Luxembourg experienced a large severe, acute respiratory-syndrome coronavirus 2 (SARS-CoV-2) outbreak a few days after a vaccination campaign. We conducted an outbreak investigation and a serosurvey two months after the outbreak, compared attack rates (AR) among residents and staff, and calculated hospitalization and case-fatality rates (CFR). Whole genome sequencing (WGS) was performed to detect variants in available samples and results were compared to genomes published on GISAID. Eighty-four (55%) residents and forty-five (26%) staff members tested positive for SARS-CoV-2; eighteen (21%) residents and one (2.2%) staff member were hospitalized, and twenty-three (CFR: 27%) residents died. Twenty-seven (21% of cases) experienced a reinfection. Sequencing identified seventy-seven cases (97% of sequenced cases) with B.1.1.420 and two cases among staff with B.1.351. The outbreak strain B.1.1.420 formed a separate cluster from cases from other European countries. Convalescent and vaccinated residents had higher anti-SARS-CoV-2 IgG antibody concentrations than vaccinated residents without infection (98% vs. 52%, respectively, with >120 RU/mL, p < 0.001). We documented an extensive outbreak of SARS-CoV-2 in an LTCF due to the presence of a specific variant leading to high CFR. Infection in vaccinated residents increased antibody responses. A single vaccine dose was insufficient to mitigate the outbreak.

Kühl A., Hering C., Herrmann W.J., Gangnus A., Kohl R., Steinhagen-Thiessen E., Kuhlmey A., Gellert P.

Abstract Background Though evidence on the detrimental impact of the COVID-19 pandemic in nursing homes is vast, research focusing on general practitioners’ (GP) care during the pandemic in nursing homes is still scarce. Methods A retrospective online survey among 1,010 nursing home managers in Germany was conducted during the first wave of the COVID-19 pandemic between November 2020 and February 2021. Associations between perceived deficits in GP care (routine and acute visits) and both general and COVID-19-related characteristics of nursing homes were analysed using multiple logistic regression analyses. Results The majority of nursing home managers reported no deficits in GP care (routine visits, 84.3%; acute visits, 92.9%). Logistic regression analyses revealed that deficits in GP care (routine visits) were significantly associated with visiting restrictions for GPs and nursing home size. Small nursing homes (1–50 residents) were significantly more likely to report deficits in GP care (routine visits) compared to medium (51–100 residents) and large nursing homes (> 100 residents). Further, deficits in GP care (acute visits) were significantly associated with dementia as a focus of care and the burden of insufficient testing for SARS-CoV-2 among residents. Moreover, visiting restrictions for GPs were significantly associated with dementia as the focus of care and the COVID-19 incidence at the federal state level. Finally, COVID-19 cases in nursing homes were significantly associated with size of nursing homes, COVID-19-incidence on the federal state level and the burden of insufficient testing capacities for SARS-CoV-2 among residents. Conclusion We found structural factors associated with GP care deficits during the pandemic. New concepts for GP care should be implemented in pandemic preparedness plans to ensure high quality, consistent, and reliable GP care as well as effective infection prevention measures in nursing homes.

Manis D.R., Bronskill S.E., Rochon P.A., Sinha S.K., Boscart V., Tanuseputro P., Poss J.W., Rahim A., Tarride J., Abelson J., Costa A.P.

In this study, we (1) identify the terms used to describe the assisted living sector and the legislation governing operation in all Canadian provinces and territories; (2) identify the cost estimates associated with residency in these homes; and (3) quantify the growth of the sector.Environmental scan.Internet searches of Canadian provincial and territorial government websites and professional associations were conducted in 2021 to retrieve publicly accessible sources related to the assisted living sector.We synthesized data that identified the terms used to describe the sector in all provinces and territories, the legislation governing operation, financing, median fees per month for care, and growth of the sector from 2012 to 2020. Counts and proportions were calculated for some extracted variables. All data were narratively synthesized.The terms used to describe the assisted living sector varied across Canada. The terms "assisted living," "retirement homes," and "supportive living" were prevalent. Ontario was the only province to regulate the sector through an independent, not-for-profit organization. Ontario, British Columbia, and Alberta had some of the highest median fees for room, board, and care per month (range: $1873 to $6726). The licensed assisted living sector in Ontario doubled in size (768 in 2020 vs 383 in 2012), and there was a threefold increase in the number of corporate-owned chain assisted living facilities (465 in 2020 vs 142 in 2012).The rapid growth of the assisted living sector that is primarily financed through out-of-pocket payments may indicate a rise in a two-tier system of housing and health care for older adults. Policymakers need better mechanisms, such as standardized reporting systems and assessments, to understand the needs of older adults who reside in assisted living facilities and inform the need for sector regulation and oversight.