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Address correspondence to Sally Hall Dykgraaf, RN, GradCertClinMan, ANU Medical School, 54 Mills Road, The Australian National University, Canberra ACT 2600, Australia.
The COVID-19 pandemic has highlighted the extreme vulnerability of older people and other individuals who reside in long-term care, creating an urgent need for evidence-based policy that can adequately protect these community members. This study aimed to provide synthesized evidence to support policy decision making.
Design
Rapid narrative review investigating strategies that have prevented or mitigated SARS-CoV-2 transmission in long-term care.
Setting and Participants
Residents and staff in care settings such as nursing homes and long-term care facilities.
Methods
PubMed/Medline, Cochrane Library, and Scopus were systematically searched, with studies describing potentially effective strategies included. Studies were excluded if they did not report empirical evidence (eg, commentaries and consensus guidelines). Study quality was appraised on the basis of study design; data were extracted from published reports and synthesized narratively using tabulated data extracts and summary tables.
Results
Searches yielded 713 articles; 80 papers describing 77 studies were included. Most studies were observational, with no randomized controlled trials identified. Intervention studies provided strong support for widespread surveillance, early identification and response, and rigorous infection prevention and control measures. Symptom- or temperature-based screening and single point-prevalence testing were found to be ineffective, and serial universal testing of residents and staff was considered crucial. Attention to ventilation and environmental management, digital health applications, and acute sector support were also considered beneficial although evidence for effectiveness was lacking. In observational studies, staff represented substantial transmission risk and workforce management strategies were important components of pandemic response. Higher-performing facilities with less crowding and higher nurse staffing ratios had reduced transmission rates. Outbreak investigations suggested that facility-level leadership, intersectoral collaboration, and policy that facilitated access to critical resources were all significant enablers of success.
Conclusions and Implications
High-quality evidence of effectiveness in protecting LTCFs from COVID-19 was limited at the time of this study, though it continues to emerge. Despite widespread COVID-19 vaccination programs in many countries, continuing prevention and mitigation measures may be required to protect vulnerable long-term care residents from COVID-19 and other infectious diseases. This rapid review summarizes current evidence regarding strategies that may be effective.
Around the world, residential care settings such as nursing homes and long-term care facilities (LTCFs) have seen repeated COVID-19 outbreaks and been a conspicuous source of COVID-19 morbidity and mortality.
Age is an independent, nonmodifiable risk factor for COVID-19–related morbidity; poor prognostic outcomes increase with advancing age, and mortality rates of up to 15% have been reported among people aged more than 80 years.
Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.
Predictors of transmission in long-term care settings include congregate living, personal care requirements that necessitate physical proximity, increased frailty or compromised health status among residents, and behavioral and cognitive challenges that complicate infection prevention and control (IPC) measures.
Although carers working in LTCFs may be adept at supporting older people with cognitive and physical impairment, they are often untrained in identifying and managing acutely unwell residents
The pronounced vulnerability of long-term care residents has been highlighted in many countries, as harrowing accounts of the impact of the pandemic on nursing homes and LTCFs emerge.
European Centre for Disease Prevention and Control Increase in fatal cases of COVID-19 among long-term care facility residents in the EU/EEA and the UK. 19 November 2020.
In the United Kingdom, 53.1% of 5126 LTCFs participating in a national survey reported COVID-19 cases. Protecting vulnerable individuals such as those living in long-term care is a crucial policy response in the pandemic context
Where policy makers urgently require knowledge on which to base decisions, the World Health Organization and others have advocated use of rapid review methodologies.
User survey finds rapid evidence reviews increased uptake of evidence by Veterans Health Administration leadership to inform fast-paced health-system decision-making.
This article describes the results of a rapid review of international literature, conducted to support federal policy decision making in Australia at the end of 2020. As part of Australia's public health response to COVID-19, policy makers had requested an urgent review of international strategies that had been successful in preventing or reducing COVID-19 transmission in long-term care settings.
A number of high-profile outbreaks had occurred in nursing homes during the first wave of COVID-19 in Australia,
Australian Broadcasting Corporation Coronavirus “nightmare” for aged care residents and their families trying to deal with isolation, old age and the virus.
These circumstances raised urgent policy questions about COVID-19 mitigation and containment measures known to be effective in long-term care and to assist in being better prepared for future outbreaks of infectious disease. Although several intercountry comparisons of aged care outcomes and multiple guidelines and recommendations were available, there was little synthesized evidence available regarding the effectiveness of specific strategies.
Many different terms are used to refer to long-term care across different sectors and countries,
and although these overlap to some degree, they are not directly interchangeable. However, for simplicity and consistency with the international literature, we use the nomenclature LTCF to encompass the range of settings and terminology used. This approach recognizes that long-term care is not exclusively for the very old and that the same risks and challenges apply to settings such as disability care with respect to COVID-19.
Methods
We conducted a structured search of PubMed/Medline, Cochrane Library and Scopus (Health & Medicine, Elsevier) to November 24, 2020, for English-language articles, using the search string [“aged care” OR “long term care” OR “social care” OR “residential care” OR “elder care” OR “nursing home” OR “care home”] AND [COVID OR SARS-CoV-2] AND [prevent∗ OR limit∗ OR control OR manage OR mitigate OR contain OR interrupt OR intervention]. We hand-searched reference lists of identified articles and other relevant articles on COVID-19 in aged care settings. We also looked for country-based strategic approaches documented in non–peer-reviewed literature, and their perceived success or otherwise; this included examining key websites such as the International Long-Term Care Policy Network.
Studies were included if they described interventions, associations, or investigations that provided potential evidence for effectiveness in preventing or reducing COVID-19 transmission within LTCFs. Consistent with other rapid review methodologies,
What are the best methodologies for rapid reviews of the research evidence for evidence-informed decision making in health policy and practice: A rapid review.
title and abstract screening was conducted by a single reviewer (S.H. or S.M.) with cross-validation of a random sample by a second reviewer (A.M., J.D., G.D., E.S.). Full-text screening and data abstraction were undertaken by a single reviewer for each paper (A.M., J.D., G.D., S.M., E.S., S.H.) using an agreed extraction template, with collective review if required. Given the rapid speed with which the review was undertaken, and significant constraints on the nature of the evidence base due to its timing relatively early in the pandemic, risk of bias was not examined in detail, with study quality assessed on the basis of study design and results stratified accordingly. Owing to study heterogeneity, data were synthesized narratively using tabulated data extracts and summary tables.
Results
The review identified 713 unique records, with 197 full-text articles assessed for eligibility after title and abstract screening (Figure 1). Eighty publications describing 77 studies were included: 4 were systematic reviews (Table 1)
Can Chinese medicine be used for prevention of corona virus disease 2019 (COVID-19)? A review of historical classics, research evidence and current prevention programs.
Using serologic testing to assess the effectiveness of outbreak control efforts, serial PCR testing, and cohorting of positive SARS-CoV-2 patients in a skilled nursing facility.
Widespread severe acute respiratory coronavirus (SARS-CoV-2) laboratory surveillance program to minimize asymptomatic transmission in high-risk inpatient and congregate living settings.
Preventing COVID-19 outbreaks in long-term care facilities through preemptive testing of residents and staff members - Fulton County, Georgia, March-May 2020.
; and 17 described epidemiologic investigations of COVID-19 outbreaks in LTCFs, reflecting on the effectiveness of strategies or lessons learned (Table 4).
Detection of SARS-CoV-2 among residents and staff members of an independent and assisted living community for older adults - Seattle, Washington, 2020.
Overall, the evidence base is immature, composed mainly of observational studies with no randomized or controlled trials, and few rigorous systematic reviews. As of this writing (November 2020), we found little evidence linking interventions or strategies to robust data on effectiveness. Included studies are outlined by study type in Table 1, Table 2, Table 3, Table 4, with study characteristics summarized in Table 5. Noting differences in nomenclature identified previously, facility types are collated according to the language used in the relevant article. We acknowledge that in some cases these “types” represent different terminology for similar or even identical organizations.
Examine epidemiology of COVID-19; containment interventions
Epidemiology, prognosis, containment interventions, role of HCW in transmission
High rates of infection, hospitalization, and mortality; high proportions of asymptomatic transmission among staff and residents. Risk of outbreak related to CMS Five-Star Quality Rating, resident characteristics, staffing levels, county-level transmission, LTCF size, degree of room occupancy, and for-profit status. Extensive IPC measures including universal testing and cohorting have proven effective in mitigating outbreaks.
Can Chinese medicine be used for prevention of corona virus disease 2019 (COVID-19)? A review of historical classics, research evidence and current prevention programs.
Historical records of Chinese medicine use in pandemics, human research evidence from SARS and H1N1 influenza, and current COVID-19 prevention programs in 23 Chinese provinces
Oral Chinese Herbal Medicine formulae, including decoction, granules, or patent medicine
Infection rate defined as laboratory-confirmed incidence of disease
Chinese herbal formula could be an alternative approach for prevention of COVID-19 in high-risk populations. Prospective, rigorous population studies are warranted to confirm potential preventative effects.
Current guidelines for IPC in long-term care facilities for people aged ≥60 y for COVID-19, MERS, or SARS
Rapid review of guidelines
Establishing surveillance, monitoring, and evaluation of symptoms and illness among staff and residents; mandated PPE for staff, residents and/or visitors; social distancing and isolation of residents; cohorting of confirmed or suspected cases; disinfection of surfaces; hand hygiene; respiratory hygiene; mandatory sick leave for staff with symptoms or suspected cases.
Present current data regarding transmission of COVID-19 in LTCFs, identify shortcomings and possible solutions to enable better management of the pandemic and future epidemics
COVID-19 cases, deaths, and predictors of COVID-19 infection
High incidence of COVID-19 associated with high mortality among residents with the exception of countries with fewer fatalities in total. Increased risk for severe outcomes and death associated with older age, male sex, underlying comorbidities, and disability. Transmission risk associated with congregate setting, limited testing, staff shortages, staff working across multiple sites and while contagious, PPE shortages, and inadequate training.
CMS, Centers for Medicare & Medicaid Services; HCWs, health care workers; MERS, Middle East respiratory syndrome; SARS, severe acute respiratory syndrome.
Screening of 5869 nursing home staff and residents within a hospital catchment area in Catalonia, Spain; N = 69 facilities, N = 5869 persons
Test-based screening as containment measure
Positive or negative RT-PCR test for COVID-19 among symptomatic and asymptomatic residents and staff or nursing homes
High proportions of asymptomatic infection among residents and staff; importance of test-based screening rather than symptom-based approaches as part of prevention and control measures.
Case investigation observational, cohort, time series
79 residents, 34 health care personnel in a single nursing home
Assess American Testing Guidance - nasopharyngeal testing done for all residents and staff and repeat weekly until no new cases identified
Proportion of staff and residents testing positive at baseline and weekly after that; seroconversion tested for all at 6 wk
Supports validity of updated testing guidance, and implementation of IPC in residents and staff with positive testing or symptoms. Asymptomatic staff with repeated negative tests can develop antibodies
RT-PCR screening of institutionalized residents and workers in 306 care homes in Galicia, Spain; N = 25,386 individuals
Pooling strategy using RT-PCR
Prevalence of COVID-19; effectiveness of pooling strategy
Pooled testing of sample groups effective in rapidly detecting infected individuals in the context of low SARS-Cov-2 prevalence while preserving testing resources; once zero prevalence is achieved, successive rounds of pooling testing is useful for transmission control
Case study, spatiotemporal analysis describing digital tool for mapping COVID-19
Assisted living facilities and nursing homes across Israel
Heat maps to quantify and predict spread and allow for tailored intervention
Heat maps (warm/red for cases; cold/blue for noncases) to quantify COVID-19 cases; trajectory of cases per facility
Heat mapping dashboard with interactive heat maps enabled prevention and containment by allowing “at-a-glance” picture to direct efforts, link outbreaks, and tailor disease mitigation steps; allowed policy makers to plan for hospital admission vs in-facility care, optimizing patient allocation
Post-acute and long-term care skilled nursing facilities (SNFs), N = 120
Point-prevalence testing and 3-tiered cohorting as tool for mitigating an outbreak in SNFs
Incidence of COVID-19 in cohorts
Facility-wide point prevalence testing coupled with 3-tiered cohorting approach effective in halting spread of outbreak; separating exposed from unexposed negative-test individuals is crucial to stop horizontal transmission; separating residents into smaller rooms and increased staffing ratios on memory units may be potential strategies to decrease transmission when strict cohorting is not feasible
Using serologic testing to assess the effectiveness of outbreak control efforts, serial PCR testing, and cohorting of positive SARS-CoV-2 patients in a skilled nursing facility.
Observational, longitudinal cohort study over 30 d
169 nursing homes and 27 institutions for people with physical and mental disabilities n = 10,000 institutionalized individuals and n = 4000 health care workers
COVIDApp providing real-time communication with primary care teams
RT-PCR, symptom status, mortality rates, suspected cases in HCWs, number of isolated health care workers
Decreasing prevalence but could be explained by parallel infection control methods
Nursing home residents (n = 97) and staff (n = 147)
Single universal testing of suspected asymptomatic population
RT-PCR–proven infection status with SARS-CoV-2
High proportion of asymptomatic infections—need for widespread testing among residents and staff coupled with intensive IPC to prevent spread of COVID-19; social distancing proved challenged, particularly for residents with dementia
Hospitalization and mortality reduced; multicomponent strategy including rapid identification of patients needing escalated care, care coordination, transfers, goal clarification for care outcomes, daily facility needs assessment
7 state or local health departments that conducted facility-wide testing in 288 nursing homes
Comparison of statewide testing (n = 2, 195 nursing homes) and targeted testing (n = 5, 93 nursing homes) based on identified cases among residents or staff (n = 88) or high rates of community transmission (n = 5)
RT-PCR test results and association with cumulative incidence, adjusted for local epidemiology
Rapid facility-wide testing following case identification might facilitate control of transmission; strategies needed to optimize universal testing in the absence of reported cases
Widespread severe acute respiratory coronavirus (SARS-CoV-2) laboratory surveillance program to minimize asymptomatic transmission in high-risk inpatient and congregate living settings.
A Veterans health integrated medical campus including a tertiary care center (160 beds), skilled nursing facility (150 beds), residential rehabilitation center (151 beds), and temporary shelter units for 218 homeless individuals (N = 1781 patients and residents)
Widespread laboratory surveillance followed by implementation of IPC measures to prevent disease transmission
In-house RT-PCR tests with external validation, symptom status
Importance of asymptomatic testing and widespread surveillance, in parallel with IPC
Nursing homes in Ireland (n = 45 nursing homes, n = 2043 residents)
Point-prevalence testing of residents and staff
Incidence of COVID-19
High prevalence among residents and staff, a significant proportion of which were asymptomatic or presymptomatic, highlighting the importance of systematic mass testing to reduce risk of transmission and contain outbreaks in LTCFs
28-item Infection Control Competency Checklist; payment incentive; on-site and virtual visits by infection control consultants; infection control weekly webinars; continuous Q&A communication from staff to infection control experts; PPE, staffing, and testing resources
Primary outcomes were the average weekly rates of new infections, hospitalizations, and deaths in residents and staff
Decreasing weekly rates of infections, hospitalizations and mortality; adherence to infection control processes, particularly proper wearing of PPE and cohorting, was significantly associated with reductions in weekly infection and mortality rates, suggesting role for payment incentives to improve infection control procedures
4 long-term care facilities with COVID-19 outbreaks. N = 431 participants tested in initial outbreak responses; an additional 303 asymptomatic persons (147 HCWs, 48.5%) and 156 residents, 51.5%).
Mass testing in each facility following sustained transmission (≥1 new resident case ≥14 d after first case OR absence of epidemiologic link between HCW and resident case(s)
RT-PCR; symptom assessment
High proportion of asymptomatic infections, symptom-based screening alone insufficient; need for parallel IPC and policies supporting HCW to stay at home when exposed or unwell
Observational cohort study, cross-sectional design over a 3-wk period
37 care homes in London (17 nursing homes, 13 residential homes, 1 mixed residential and nursing home, 6 extra care housing facilities; N = 2455; 1034 residents (42.1%) and 1421 staff (57.9%)
Point-prevalence testing
Nasopharyngeal testing with RT-PCR
High proportions of asymptomatic infection in staff and residents with underdetection of symptoms by care home staff, suggesting universal testing with rapid reporting of results would assist identification and facilitate prompt IPC action; analysis by facility type indicated some protection may be conferred by individual tenancy arrangements (ie, separate kitchen facilities, not sharing equipment, and a smaller number of carers)
Cohort 1: 1301 residents in 134 facilities for Veterans in nursing homes; cohort 2: 3368 residents spread across 282 facilities in a private national chain of community NHs
Temperature testing and correlation with test-confirmed SARS-CoV-2 infection.
Sensitivity, specificity, and Youden index with different temperature cutoffs for SARS-CoV-2 PCR results
A lower threshold of 37.2°C improves sensitivity for identifying SARS-CoV-2 compared to standard test, triggering thresholds of 38.0°C; however, temperature is a poor independent diagnostic tool and should be used as part of a screening tool coupled with other signs and symptoms of infection
Descriptive evaluation of mitigation measures implemented in 101 facilities
101 assisted living facilities in Ohio; N = 1794 residents, 74% female, mean age 88 ± 11 y
Comprehensive preparedness and suppression plan implemented by a home-based primary care group
Targeted testing for individuals with fever and lower respiratory tract symptoms, or with potential exposure to a confirmed or suspected case (n = 35); hospitalizations (n = 3); mortality (n = 1)
Components included a secure, cloud-based web application for case or exposure triage and reporting; isolation and IPC training and procedures adapted from US CDC; mobile-enabled screening app to prevent employees from attending work when ill
Retrospective cohort study (pooled outbreak investigations, n = 3)
Long-term care facilities, n = 3, all with an infected staff index case from an external source
Public health responses—testing, home quarantine, contact tracing, cohort quarantine
1 confirmed outbreak of 24 subsequent cases and 2 facilities with no further transmission
Early detection was the most important outbreak control method used in LTCFs; also recommended staff monitoring and management strategies, including individual distributed deployment
Long-term care facilities in regional France, N = 124
Compare application of recommended mitigation and infection control measures
Facility contamination with COVID-19 (1 or more residents or caregivers with RT-PCR confirmed infection)
Greater prevalence of COVID-19 in private facilities linked to better use of testing capability in those centers; staff compartmentalization within areas the main factor associated with COVID-19 infection in both public and private facilities
7325 residents in 134 community living centers for veterans
Temperature screening for COVID-19 detection
SARS-CoV-2 test (RT-PCR); temperature changes in daily clinical screening program before and after universal testing
Single temperature screening unlikely to detect COVID-19–positive residents; repeated measurement against a patient-derived baseline can increase sensitivity; current 38°C fever threshold for screening should be reconsidered
Cohort study; outbreak investigation and response across multiple facilities
2773 residents of 26 skilled nursing facilities in the Detroit area
Repeat mass testing to inform IPC practices, with onsite IPC support for facilities
SARS-CoV-2 test (RT-PCR, nasopharyngeal swab)
Repeated point-prevalence surveys in SNFs can identify asymptomatic cases, inform cohorting and IPC practices, and guide prioritization of health department resources
Preventing COVID-19 outbreaks in long-term care facilities through preemptive testing of residents and staff members - Fulton County, Georgia, March-May 2020.
N = 5671; 2868 residents and 2803 staff in 28 long-term care facilities (15 with cases and 13 without)
Mass screening of residents and staff with support from the National Guard
SARS-CoV-2 test (RT-PCR, nasopharyngeal swab)
Significantly higher prevalence in facilities with known infection (28.9%) compared with those screened as a preventive measure (1.6%), P < .001; proactive testing of residents and staff members might prevent large outbreaks in LTCFs through early identification and timely IPC response
Examine characteristics of nursing homes with documented COVID-19 cases
Facilities with COVID-19 cases, number of cases
Background factors affecting community transmission seem especially influential in whether an outbreak occurs; other factors may be more influential around internal spread
Nursing homes in Ontario, Canada, N = 600 nursing homes, N = 78,000 residents
Develop reproducible index of nursing home crowding and determine whether crowding was associated with COVID-19 cases and mortality in the first months of the pandemic
Cumulative incidence of COVID-19 cases confirmed by validated nucleic acid amplification assay, and mortality per 100 residents; the introduction of COVID-19 into a home (≥1 resident case) as a negative tracer outcome
Crowding associated with an increased incidence of infection and mortality and highly crowded LTCFs more likely to experience larger and deadlier outbreaks; no difference in probability of introduction of COVID-19 into a facility according to level of crowding; need for interventions targeting crowding including reducing room occupancy to reduce risk of transmission; reinforcement of other IPC measures also essential
Cross-sectional study using linked facility-level data
123 nursing homes in West Virginia
Examine associations between CMS star (quality) ratings and COVID-19 outbreaks in nursing homes
Outbreak vs no outbreak
Odds of a COVID-19 outbreak in 1-star–rated nursing homes were approximately 7 times higher than 2-3-star–rated and 17 times higher than 4-5-star–rated facilities; lower-rated homes might struggle to implement effective IPC and require assistance
New York State nursing homes with confirmed COVID-19 deaths, N = 355
Assess relation between COVID-19 mortality rate risk factors
Percentage of COVID-19 deaths, access to PPE and COVID-19 infection rates
Presence of labor unions in LTCFs associated with lower COVID-19 infection and mortality, and greater access to PPE (N95 respirators and eye shields), suggesting unions improve safety and health standards for workers and improved patient outcomes; unionization may play an important role in mitigating and preventing outbreaks in this setting
Understand risk factors associated with COVID-19 death in long-term care
Mortality rates
Documented infection in facility staff is a strong identifiable risk factor for mortality in residents, with temporality suggesting residents are infected by staff and not vice versa
Retrospective population-based cohort study from a national survey
Workers in long-term care facilities (N = 552)
Quantify risk for severe COVID-19 illness among workers at LTCFs
Demographic features; supply of PPEs; comorbidities
Working in LTCFs associated with an increased risk of severe illness from COVID-19 (50% of staff affected). Black, female, low-income employees and those with lower educational attainment highly vulnerable to infection; access to adequate PPE crucial along with testing and paid sick leave
Cross-sectional study using linked facility-level data
13,167 nursing homes reporting COVID-19 data
Explore role of staffing in COVID-19 cases and deaths using national data
Outbreak occurrence (any cases) and outbreak size (no. of cases)
Among facilities with at least 1 case, higher nurse aide hours and total nursing hours are associated with lower probability of an outbreak and with fewer deaths.
Cross-sectional study using linked facility-level data
1091 licensed Medicare/Medicaid certified nursing homes in California: 819 with no reported COIVD-19 cases; 272 with 1 or more COVID-19 cases
Comparative analysis of the association between nurse staffing and COVID-19 infection
Facilities with COVID-19 cases, number of cases
Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID19 infections; establishing minimum staffing standards at the federal and state levels could prevent this in the future
Cross-sectional study using linked facility-level data
1223 California skilled nursing facilities with reported quality metrics and longitudinal data on COVID-19 cases
Examine the relationship between nursing home reported quality and COVID-19 cases and deaths; other independent variables included nursing home ownership, size, years of operation, and patient race composition
COVID-19 resident cases and deaths
Nursing homes with 5-star ratings were less likely to have COVID-19 cases and deaths after adjusting for nursing home size and patient race proportion
Cross-sectional analysis of laboratory data from mass testing campaign
2074/2500 long-term care facilities, with N = 280,427 people tested, including 142,100 residents (51%) and 138,327 staff (49%)
Ascertain infection rate among symptomatic vs asymptomatic residents and staff of LTCFs
COVID-19-–positive test rates for residents and staff; symptomatic vs asymptomatic positive tests
In LTCFs, asymptomatic carriers represent an important driver of transmission; to limit the spread of SARS-CoV-2 in closed residential facilities; extensive IPC measures should be widely applied while the epidemic is ongoing
254 staff in 6 London care homes reporting a suspected outbreak (≥2 suspected cases) of COVID-19
Assess occupational risk factors for SARS-CoV-2 infection among staff in care homes experiencing a COVID-19 outbreak
COVID-19 positive vs negative; symptomatic vs asymptomatic at time of testing; working in a single care home vs across different care homes; regular contact with residents vs no contact with residents
Working across different care homes significantly increases the risk of COVID-19 infection. Infection control measures should be extended for all contact, including those between staff, while on care home premises
Determine association of nursing home registered nurse (RN) staffing, overall quality of care, and concentration of Medicaid or racial and ethnic minority residents with COVID-19 cases and mortality, using multivariable 2-part models
Confirmed COVID-19 cases and deaths among residents
Nursing homes with higher RN staffing and quality ratings have the potential to better control the spread of the novel coronavirus and reduce deaths; Nursing homes caring predominantly for Medicaid or racial and ethnic minority residents tend to have more confirmed cases
Observational study using secondary analysis of data from a rapid antibody screening test for detection of SARS-CoV-2
1005 employees of 22 older care homes in Stockholm, Sweden, were analyzed.
Ascertain the time point for a safe return to the workplace after COVID-19 infection.
Positive vs negative SARS-CoV-2 antibody tests; symptom status at time of testing
Results suggest that antibody testing of employees in older care homes is valuable for surveillance of disease development and a crucial screening tool
LTCFs (n = 5126) providing care to residents with dementia or aged ≥65 y
Identify factors associated with SARS-CoV-2 infection and outbreaks among LTCF staff and residents
Outbreaks, defined as at least 1 case of COVID-19 in a resident or staff member
Reduced transmission associated with adequate sick pay, minimal use of agency staff, increased staff-to-bed ratio, and staff cohorting with residents; increased transmission associated with a higher number of new admissions and poor compliance with isolation procedures
An academic long-term care facility (398 residents tested for SARS-CoV-2)
Describe clinical characteristics and risk factors associated with COVID-19 in long-stay nursing home residents
COVID-19 infection rates, and mortality rates
COVID-19 prevalence in many LTCFs associated with high asymptomatic transmission; significant predictors of infection include male sex, non-white, bowel incontinence, dementia, and staff residence in communities with high burden of disease; frailty was a risk factor for death with mortality increasing with frailty; need for strategies to identify and mitigate spread of COVID-19 including early, universal testing of residents and staff, and alternative housing for health care workers to reduce community exposure and potential introduction into LTCFs
Retrospective cohort study using administrative data set
Long-term care facilities in Ontario, N = 623
Examine association between for-profit status and risk of COVID-19 outbreaks
Outbreaks in the home (at least 1 resident case), extent of outbreak, number of resident deaths
Risk of an outbreak related to community transmission plus facility size (no. of beds) and older design standards; for-profit homes have larger outbreaks with more deaths than nonprofit and municipal (government) homes, mediated by older design standards and chain ownership; long-standing issues in financing, operation, and regulation of LTC homes exposed
Confirmed cases of COVID-19 in Bologna based on community testing criteria (epidemiologic link to another case or relevant symptoms)
Describe sociodemographic and transmission profile of COVID-19 after introduction of a stay at home order
New confirmed cases of COVID-19 before and after specified date
In this study, visits to facilities already restricted prior to the decree; residential care facilities unlikely to be protected by such measures if transmission has already occurred; highlights vulnerability rather than strategy
Retrospective cohort study; predictive model using machine learning algorithm
1146 nursing homes
Assess risk of COVID-19 outbreaks in nursing homes, associated risk factors, and possible vectors of infection using a machine-learning approach (model) trained on nursing home COVID-19 outcome data
Predictors of COVID-19 infection, sensitivity and specificity of model
Increased risk associated with county infection rate and population density, number of separate units in LTCF, health deficiencies, facility density of residents and staff; non-Hispanic white ethnicity a protective factor; possible primary vectors of infection included introduction from the outside community through presymptomatic and asymptomatic individuals and intrafacility transmission through close staff contact with residents.
Retrospective cohort study using linked data sets; 2-stage regression with multilevel modeling
US nursing homes, n = 13,709
Determine association between facility characteristics, geographic variables, and confirmed cases in nursing homes
Cumulative cases (rate)
Increased risk associated with: LPN staffing level; county transmission rate; no. of fines in 2020; unemployment rate; ethnicity; population density; household size, and per capita income; reduced risk associated with total staff
Identify county and facility factors associated with SARS-CoV-2 outbreaks in skilled nursing facilities
Any cases, number of confirmed cases, facility-level case fatality rate, case positive rate in facilities with universal testing
Outbreak risk (probability and severity) associated with facility size and community transmission; no evidence of relationship with SNF quality or staffing indices; larger size = more staff, visitors, and opportunities for transmission
CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare & Medicaid Services; LPN, licensed practical nurse; RN, registered nurse.
Outbreak investigation Retrospective cohort, environmental study
112 residents and 123 staff in a single Dutch nursing home
Outbreak response, including widespread surgical mask use
Differential transmission rates between staff and resident cohorts within a single facility, environmental contamination
COVID-19 detected in ventilation system, which recirculated unfiltered inside air as opposed to no transmission in cohorts with outside ventilation systems
Outbreak investigation Understand circumstances and identify lessons
Outbreak in a 102-bed RACF; 37 resident and 34 staff cases, with 19 deaths
Outbreak response
Identified issues relating to emergency response, leadership and management, communication, staffing, IPC, medical and clinical care, and family experience
Determine incidence, describe cases, and reflect on lessons learned about COVID-19 in nursing homes
Incidence of infection and death; comparison for excess death
High mortality among residents but no increased overall deaths relative to previous year; daily surveillance of staff and residents, ability to test quickly, universal PPE, physical distancing, and restricting visitors proved effective
Description of pandemic preparedness and lessons learnt
Ontario and British Columbia Long-term care home, including those for aged care
Outbreak analysis
Differential risk in residents in long-term care acquiring SARS-CoV-2
More deaths among residents in Ontario than in British Columbia (BC), which showed better preparedness: greater coordination between LTC, public health, and hospitals; greater funding of LTC; more care hours; lower room occupancy; more nonprofit facility ownership; more comprehensive inspection by regional health authorities. BC response also faster with public health support, staffing, and infection control measures BC leadership more decisive, coordinated, and consistent in overall communication and response
Outbreak in a skilled nursing facility with 129 cases; 81 residents, 34 staff, 14 visitors, 23 deaths
Outbreak response
Limitations in effective IPC and staff working across multiple facilities contributed to inter- and intrafacility spread Facilities should actively monitor to ensure early recognition of potential cases, exclude potentially infected staff and visitors, and implement appropriate IPC measures
Three Michigan nursing homes, 365 beds, total 29 cases; 11 hospitalized; 6 deaths; 23 of 606 (3.8%) NH staff tested positive
Outbreak response
Symptom-based screening alone inadequate for case detection; Measures deemed effective in containing spread: universal testing; cohorting of infected residents in a confined unit with dedicated staffing; communication of testing results to residents, families, and staff; PPE plus staff training; environmental cleaning; limiting staff interaction with residents; and virtual specialist visits Collaboration between LTCFs, public health and local hospitals enabled rapid response, which likely contributed to outbreak control
Description of outbreak response linked to international evidence
Retirement community
Multicomponent response
Apparent effectiveness of containment measures including serial universal testing, symptom based screening, cohorting of infected residents, cluster care scheduling, PPE use and educating staff and residents Rapid adoption of strategies prevented widespread infection
Outbreak in US Veteran nursing facility; 25 out of 80 (31%) residents tested positive; 5 asymptomatic; 9 hospitalized; 6 deaths
Outbreak response
Transmission increased by shared rooms, group activities, communal dining, shared resources (including dialysis unit). Outbreak contained by assignment of dedicated clinical team, universal testing of residents and staff, cohorting cases, and restricting staff movement. Test-based strategy to remove precautions unhelpful as person can test positive for up to 5 weeks.
Detection of SARS-CoV-2 among residents and staff members of an independent and assisted living community for older adults - Seattle, Washington, 2020.
Outbreak investigation in retrospective cohort study
Independent assisted living facility with 80 residents and 62 staff members following identification of 2 COVID-19–positive cases
Social distancing and other preventive measures; universal testing
Residents tested twice, 7 d apart, all staff tested once initially, plus symptom questionnaire
Apparent effectiveness of routine, but stringent, measures; symptom-based screening ineffective—high proportion of asymptomatic and presymptomatic residents and high levels of symptom reporting in COVID-negative individuals Measures: residents isolated in rooms, no communal meals or activities, visitors excluded, staff screened and excluded if symptomatic, enhanced hygiene and environmental cleaning
87 residents and 92 staff in a single nursing home in Western France
Mass testing
Symptoms, clinical history, and SARS-CoV-2 status (RT-PCR)
Pauci-symptomatic expression of COVID-19 in older residents together with the high prevalence of asymptomatic forms in caregivers, justifies conducting mass screening in nursing homes, possibly prioritizing residents with suggestive combinations of clinical signs Initial contamination likely from nonprofessional visitors encourages isolation measures in nursing homes
To determine sources and chains of COVID-19 transmission, testing of symptomatic residents and health care workers (HCWs) for SARS-CoV-2–positive whole genome sequencing
COVID-19 cases, sequence types including from the LTCF and outside community
Outbreak linked to widespread regional circulation; whole genome sequencing useful for revealing transmission patterns Introduction of SARS-CoV-2 infections rapidly contained through implementation of extensive IPC measures including a visitor ban, halting new admissions and group activities, testing residents and staff, prohibiting symptomatic staff from working, social distancing and isolation of residents, cohorting, PPE use, and environmental cleaning
Most articles, especially those detailing epidemiologic investigations, describe multifaceted infectious disease responses to manage risk or potential outbreaks in LTCFs (Supplementary Material 1). Owing to their retrospective, observational nature, high-quality evidence of effectiveness was limited. Approaches generally included some combination of IPC practices, public health surveillance and mitigation measures, and administrative or policy support functions. A number of studies concluded that early and proactive identification, followed by isolation of infected individuals, was the most important outbreak control method used.
Preventing COVID-19 outbreaks in long-term care facilities through preemptive testing of residents and staff members - Fulton County, Georgia, March-May 2020.
A survey of French LTCFs identified heterogeneity in implementation of IPC guidance, finding fewer COVID-19 occurrences among public LTCFs and those with compartmentalized staffing zones and better self-reported quality of implementation.
Lessons gleaned from outbreak investigations included the need for proactive and decisive leadership at both facility and jurisdictional level; active and ongoing communication; sustainable, collaborative responses; contingency plans for surge capacity in both staff and equipment supplies such as personal protective equipment (PPE); experienced IPC guidance to counter deficiencies in IPC competence and confidence among aged care workers; and balancing IPC with quality of life for residents.
Using serologic testing to assess the effectiveness of outbreak control efforts, serial PCR testing, and cohorting of positive SARS-CoV-2 patients in a skilled nursing facility.
Widespread severe acute respiratory coronavirus (SARS-CoV-2) laboratory surveillance program to minimize asymptomatic transmission in high-risk inpatient and congregate living settings.
Preventing COVID-19 outbreaks in long-term care facilities through preemptive testing of residents and staff members - Fulton County, Georgia, March-May 2020.
Detection of SARS-CoV-2 among residents and staff members of an independent and assisted living community for older adults - Seattle, Washington, 2020.
Preventing COVID-19 outbreaks in long-term care facilities through preemptive testing of residents and staff members - Fulton County, Georgia, March-May 2020.
One study demonstrated the effectiveness of a pooling strategy for detecting COVID-19 in LTCFs with low prevalence and recommended serial pooled-testing once zero prevalence was achieved.
Mass testing using nasopharyngeal swab with reverse transcription polymerase chain reaction was considered superior to symptom screening for case identification in light of high proportions of asymptomatic or presymptomatic infections among residents and staff (≤40%),
Detection of SARS-CoV-2 among residents and staff members of an independent and assisted living community for older adults - Seattle, Washington, 2020.
Mass testing identified greater COVID-19 prevalence when conducted in response to known infection (responsive testing) than without indication (passive testing); with possible merit in “passive” testing as a preventive measure with “responsive” testing to support containment strategies.
Such graduated approaches were suggested when testing availability was compromised, maintaining low symptom thresholds and incorporating atypical symptom profiles.
In a cohort of 17 French LTCFs (only 1 with positive cases), staff voluntarily self-confined with residents for more than 7 days, 24 hours per day, during March and April 2020. These facilities reported lower COVID-19 mortality among residents, and lower COVID-19 infections among residents and staff, than 9513 nursing homes in a national survey.
Five studies from the United States, Spain, and Israel outlined technology-based applications that supported IPC activities. Although none provided strong evidence, the authors attributed observed successes to these strategies. These included a multidisciplinary, telehealth-centered, collaborative outbreak response with rapid care escalation and daily needs rounds
; and a digital mapping and monitoring tool with interactive heat maps that followed and predicted outbreak trajectories, improving risk assessment and targeting of IPC.
Restricting visitors has been a widely utilized strategy to prevent introduction of SARS-CoV-2 into LTCFs (see Table 5). In recognition of the importance of social and family connection, visitors were allowed re-entry to Dutch nursing homes under strict trial conditions that included reduced visit frequency, duration, and volume; hand hygiene; temperature and symptom screening; physical distancing; and visitor mask use for patients with cognitive or behavioral challenges.
Facilities were also required to have adequate PPE, staffing, and access to local testing. No new infections were reported during the trial period, with reported value for residents.
Similarly, in Germany and Hong Kong, relaxation of visitor bans to nursing homes did not result in additional infections, providing anecdotal support for safety provided adequate IPC measures are in place.
A Dutch facility reported high prevalence of COVID-19 among residents and staff who lived or worked in one of seven wards, despite standardized, facility-wide, IPC measures, including staff use of surgical masks during all patient contacts. The ward positive for COVID-19 was the only one with a previously installed, automated, carbon dioxide–controlled energy-efficient ventilation system.
SARS-CoV-2 was subsequently identified on some ventilation system filters during environmental testing as part of outbreak investigation, suggesting that recirculated unfiltered air may have resulted in airborne transmission of COVID-19. Additionally, nursing homes with open plan designs were more susceptible to SARS-CoV-2 than those designed with separate bedrooms most likely owing to the virus's ability to travel long distances in poorly ventilated spaces.
Seven articles (United States, Canada, Germany) described collaboration models with hospitals, public health organizations, primary care, or academic institutions, focused on providing IPC support, augmented testing capability, staff education, and collaborative management.
Although evidence for effectiveness was limited, strategies included multidisciplinary acute care “strike teams” to disseminate IPC education and support
; and leveraging established collaborations with acute care and public health officials to enable rapid universal testing and implementation of IPC measures.
Studies using system-level data across multiple facilities suggested that although the strongest predictors of cases occurring in LTCFs were community transmission rates, facility size, or new admissions,
nurse staffing models impacted on transmission and outbreak size. Higher nurse staffing levels (both hours per patient and nurse qualifications) were associated with fewer cases, and facilities with nurse shortages were more susceptible to COVID-19 outbreaks.
A Canadian study assessed the association of crowding with COVID-19 cases and mortality (using a nursing home crowding index) among a cohort of 618 nursing homes.
Crowded facilities were more susceptible to COVID-19 outbreaks compared to those with single-occupancy rooms; with larger and more frequent outbreaks, and COVID-19 incidence and mortality double that of facilities with low crowding.
Staff management
LTCF staff were a major source of transmission risk, with high prevalence rates even among asymptomatic employees.
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