COVID-19 Burden in Long-Term Care Facilities in the Omicron Era: Public Health Action Not Yet Redundant.

Since the beginning of the pandemic, public health authorities have provided support to long-term care facilities (LTCFs) for the implementation of risk mitigation measures. Nevertheless, the necessity of these measures has been doubted, especially after vaccines and antiviral treatment became available. Here, we present the burden of COVID-19 infection in LTCFs during the first 9 months of 2022 across Greece. We tested the possible association of LTCF characteristics and public health response with the occurrence of clusters (two or more linked cases in LTCFs) with facilities recording one case as reference. After excluding LTCFs with sporadic cases, we tested the effect of the abovementioned variables on attack rate (cases/total number of persons in the LTCF). The disease burden in LTCFs was high and substantially varied among facilities, with hospitalization and case fatality rates ranging from 2 to 80% (median 14%, IQR 27%) and from 1 to 50% (median 5%, IQR 7%), respectively. The probability of transmission inside the facility increased when notification of public health authorities was delayed (p-Value < 0.001) after adjusting for vaccination status and phase of the pandemic. Results showed that active support from public health authorities is still important in reducing the burden in LTCFs.

Assessment of COVID-19 outbreaks in long-term care facilities.

BACKGROUND: The B.1.167.2 (Delta) variant quickly became the predominant circulating SARS-CoV-2 strain in the USA during summer 2021. Missouri identified a high number of outbreaks in long-term care facilities (LTCFs) across the state with low vaccination rates among LTCF staff members and poor adherence to mitigation measures within local communities. AIM: To describe COVID-19 outbreaks that occurred in Missouri LTCFs impacting staff and residents during the surge of the Delta variant. METHODS: Outbreaks of COVID-19 in 178 LTCFs were identified by the Missouri Department of Health and Senior Services. Case data from LTCFs with the highest burden of disease were analysed to assess disease transmission, vaccination status, and outcomes among residents and staff. Additional investigational measures included onsite visits to facilities with recent COVID-19 outbreaks in communities with substantial transmission to assess mitigation measures. FINDINGS: During April 22nd to July 29th, 2021, 159 COVID-19 cases among 72 staff members and 87 residents were identified in 10 LTCFs. More than 74.7% of resident cases were vaccinated compared to 23.6% of staff cases. Vaccinated residents had a lower proportion of hospitalizations and deaths reported compared to unvaccinated residents. Data analysis and contact-tracing efforts from a sample of the facilities suggest that staff members were likely a major factor in introducing SARS-CoV-2 virus into the facilities. Adherence to COVID-19 mitigation measures varied at the visited facilities. CONCLUSION: Data showed that vaccination rates varied between staff cases and resident cases in facilities with high-burden outbreaks. Differences were identified in mitigation practices in at least two facilities.

Differences in and Factors Related to Willingness to Provide Care to Patients with Suspected or Confirmed COVID-19 in Long-Term Care Facilities.

The coronavirus disease 2019 (COVID-19) pandemic has exerted tremendous effects on the residents of and caregivers at long-term care facilities (LTCF). The combination of a vulnerable, aged population, staffing shortages, and inadequate resources in LTCF will cause a great negative impact in these sectors. Addressing the caregiver's lack of interest in providing care for patients with COVID-19 is a great challenge for institutional managers. The primary objective of this study was to analyze the factors related to the willingness of personnel at LTCF to provide care to patients with COVID-19. This was a cross-sectional study in which personnel from 10 LTCF were recruited as participants through convenience sampling and completed structured questionnaires. A total of 500 questionnaires were distributed and 385 valid questionnaires were recovered, posting a response rate of 77%. A statistical analysis was performed using SPSS 22.0. The results of the survey revealed that only 30% of the participants were willing to provide care to patients with COVID-19; 23% more of the participants were willing to provide such care if their institutions provided sufficient PPE. Regarding other conditions, 31.5% and 76% of the participants expressed that they would be willing to provide such care if their compensation were increased and working hours were reduced. In the univariate analysis, the willingness of participants with different characteristics (job categories, years of holding a professional certificate, job location type, monthly income, experience with caring for patients with confirmed COVID-19, and completion of training related to communicable disease control) varied significantly (p < 0.05). Furthermore, in the logistic regression analysis, several demographic and professional characteristics (education level, job category, number of patients served daily, and monthly income) were significantly correlated with willingness to provide care to patients with COVID-19 (p < 0.05). On the basis of these findings, the LTCF should securitize the associated factors of care wiliness in personnel to eliminate the difference of the willingness to provide care to patients with suspected or confirmed COVID-19.

Model-based evaluation of policy impacts and the continued COVID-19 risk at long term care facilities.

The COVID-19 pandemic severely impacted long-term care facilities resulting in the death of approximately 8% of residents nationwide as of March 2021. As COVID-19 case rates declined and state and county restrictions were lifted in spring 2021, facility managers, local and state health agencies were challenged with defining their own policies moving forward to appropriately mitigate disease transmission. The continued emergence of variants of concern and variable vaccine uptake across facilities highlighted the need for a readily available tool that can be employed at the facility-level to determine best practices for mitigation and ensure resident and staff safety. To assist leadership in determining the impact of various infection surveillance and response strategies, we developed an agent-based model and an online dashboard interface that simulates COVID-19 infection within congregate care settings under various mitigation measures. This dashboard quantifies the continued risk for COVID-19 infections within a facility given a designated testing schedule and vaccine requirements. Key findings were that choice of COVID-19 diagnostic (ex. nasal swab qRT-PCR vs rapid antigen) and testing cadence has less impact on attack rate and staff workdays missed than does vaccination rates among staff and residents. Specifically, low vaccine uptake among staff at long-term care facilities puts staff and residents at risk of ongoing COVID-19 outbreaks. Here we present our model and dashboard as an exemplar of a tool for state public health officials and facility directors to gain insights from an infectious disease model that can directly inform policy decisions in the midst of a pandemic.

The Effects of the 2020 COVID-19 Lockdown on Mood, Behavior, and Social and Cognitive Functioning in Older Long-Term Care Residents.

OBJECTIVES: We aimed to explore the effects of the Dutch COVID-19 lockdown (March 20-May 25, 2020) on mood, behavior, and social and cognitive functioning of older residents of long-term care facilities (LTCFs) prospectively. DESIGN: Mixed methods: historically controlled longitudinal cohort study and focus groups. SETTING AND PARTICIPANTS: Residents of Dutch LTCFs. METHODS: Residents who were assessed during and prior to the lockdown were compared to residents of the same wards with 2 assessments prior to the lockdown. We used mixed models and generalized estimating equation analyses to explore differences in changes in mood, withdrawal and aggressive behavior, loneliness and conflict, and cognition and delirium. We also explored whether the effect of the lockdown differed for different subgroups. In 2 online focus groups, LTCF care professionals, ranging from care staff to physicians, reflected on their experiences of the effect of the lockdown and the cohort study results. RESULTS: The lockdown group of 298 residents was compared to the control group of 625 residents. Self-reported mood symptoms showed a slightly greater increase during the lockdown. During the first half of the lockdown, the level of conflict with other residents decreased whereas it increased in the control group. The subgroup with moderate-severe cognitive impairment showed a decrease in withdrawal during the lockdown, whereas the group with no-mild cognitive impairment showed a statistically nonsignificant relative increase. Professionals described great individual variation in the effects of the lockdown on residents. Facilities attempted to preserve the experienced positive effects, for example, by promoting tranquility in shared rooms and continuing to organize individualized ward-based activities. CONCLUSIONS AND IMPLICATIONS: We did not find clinically relevant negative effects of the lockdown on mood, behavior, and social and cognitive functioning in older residents of LTCFs at the group level. Possibly, staff mitigated the negative effects at the group level. Meanwhile, they learned lessons that they continue to apply to enhance resident well-being.

Pre-Hospital Administration of Remdesivir During a Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Outbreak in a Skilled Nursing Facility.

Completion of a 5-day course of remdesivir was associated with approximately 17-fold increased odds of survival among a sample of 54 nursing home residents with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during the course of an outbreak from October to December 2020. Remdesivir was well tolerated; administration was logistically feasible in a pre-hospital environment.

Effectiveness of mRNA COVID-19 vaccines in preventing SARS-CoV-2 infections and COVID-19 hospitalisations and deaths in elderly long-term care facility residents, Spain, weeks 53 2020 to 13 2021.

Residents in long-term care facilities (LTCF) experienced a large morbidity and mortality during the COVID-19 pandemic in Spain and were prioritised for early COVID-19 vaccination. We used the screening method and population-based data sources to obtain estimates of mRNA COVID-19 vaccine effectiveness for elderly LTCF residents. The estimates were 71% (95% CI: 56-82%), 88% (95% CI: 75-95%), and 97% (95% CI: 92-99%), against SARS-CoV-2 infections (symptomatic and asymptomatic), and COVID-19 hospitalisations and deaths, respectively.

Safety and Efficacy of Convalescent Plasma in Elderly COVID-19 Patients: The RESCUE Trial.

OBJECTIVE: To assess the safety and efficacy of convalescent plasma (CP) transfusion in elderly people with moderate to severe coronavirus disease 2019 (COVID-19) living in a long-term care facility (LTCF). PATIENTS AND METHODS: Twenty-two consecutive elderly patients with COVID-19 infection living in an LTCF in Lombardy, Italy, who were given CP during May 15 to July 31, 2020, were enrolled in a prospective cohort study. Their clinical, instrumental, and laboratory parameters were assessed following the CP treatment. The overall mortality rate in this group was compared with that recorded in other LTCFs in Lombardy during the 3-month period from March to May 2020. RESULTS: Of the 22 patients enrolled, 68.2% (n=15) received 1 CP unit, 27.3% (n=6) received 2 units, and 4.5% (n=1) received 3 units. Of the CP units transfused, 76.7% (23/30) had a neutralizing antibody titer of 1:160 or greater. No adverse reactions were recorded during or after CP administration. Improvements in clinical, functional, radiologic, and laboratory parameters during the 14 days after CP transfusion were observed in all 19 patients who survived. Viral clearance was achieved in all patients by the end of follow-up (median, 66 days; interquartile range, 48-80 days). The overall mortality rate was 13.6% (3/22), which compared favorably with that in the control group (38.3% [281/733]; P=.02) and corresponded to a 65% reduction in mortality risk. CONCLUSION: Early administration of CP with an adequate anti-severe acute respiratory syndrome coronavirus 2 antibody titer to elderly symptomatic patients with COVID-19 infection in an LTCF was safe and effective in eliminating the virus, restoring patients' immunity, and blocking the progression of COVID-19 infection, thereby improving patients' survival. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04569188.

Clinical Characteristics and Risk Factors for Death of Hospitalized Patients With COVID-19 in a Community Hospital: A Retrospective Cohort Study.

OBJECTIVE: To describe the clinical characteristics, outcomes, and risk factors for death of patients with coronavirus disease 2019 (COVID-19) in a community hospital setting. PATIENTS AND METHODS: This single-center retrospective cohort study included 313 adult patients with laboratory-confirmed COVID-19 admitted to a community hospital in Cook County, Illinois, from March 1, 2020, to May 25, 2020. Demographics, medical history, underlying comorbidities, symptoms, signs, laboratory findings, imaging studies, management, and progression to discharge or death data were collected and analyzed. RESULTS: Of 313 patients, the median age was 68 years (interquartile range, 59.0-78.5 years; range, 19-98 years), 182 (58.1%) were male, 119 (38%) were white, and 194 (62%) were admitted from a long-term care facility (LTCF). As of May 25, 2020, there were 212 (67.7%) survivors identified, whereas 101 (32.3%) nonsurvivors were identified. Multivariable Cox regression analysis showed increasing hazards of inpatient death associated with older age (hazard ratio [HR] 1.02; 95% CI, 1.01-1.04), LTCF residence (HR, 3.23; 95% CI, 1.68-6.20), and quick Sequential Organ Failure Assessment scores (HR, 2.59; 95% CI, 1.78-3.76). CONCLUSION: In this single-center retrospective cohort study of 313 adult patients hospitalized with COVID-19 illness in a community hospital in Cook County, Illinois, older patients, LTCF residents, and patients with high quick Sequential Organ Failure Assessment scores were found to have worse clinical outcomes and increased risk of death.

Clinical Presentation, Course, and Risk Factors Associated with Mortality in a Severe Outbreak of COVID-19 in Rhode Island, USA, April-June 2020.

Long-term care facilities (LTCFs) have had a disproportionally high mortality rate due to COVID-19. We describe a rapidly escalating COVID-19 outbreak among 116 LTCF residents in Rhode Island, USA. Overall, 111 (95.6%) residents tested positive and, of these, 48 (43.2%) died. The most common comorbidities were hypertension (84.7%) and cardiovascular disease (84.7%). A small percentage (9%) of residents were asymptomatic, while 33.3% of residents were pre-symptomatic, with progression to symptoms within a median of three days following the positive test. While typical symptoms of fever (80.2%) and cough (43.2%) were prevalent, shortness of breath (14.4%) was rarely found despite common hypoxemia (95.5%). The majority of patients demonstrated atypical symptoms with the most common being loss of appetite (61.3%), lethargy (42.3%), diarrhea (37.8%), and fatigue (32.4%). Many residents had increased agitation (38.7%) and anxiety (5.4%), potentially due to the restriction measures or the underlying mental illness. The fever curve was characterized by an intermittent low-grade fever, often the first presenting symptom. Mortality was associated with a disease course beginning with a loss of appetite and lethargy, as well as one more often involving fever greater than 38 °C, loss of appetite, altered mental status, diarrhea, and respiratory distress. Interestingly, no differences in age or comorbidities were noted between survivors and non-survivors. Taking demographic factors into account, treatment with anticoagulation was still associated with reduced mortality (adjusted OR 0.16; 95% C.I. 0.06-0.39; p < 0.001). Overall, the clinical features of the disease in this population can be subtle and the symptoms are commonly atypical. However, clinical decline among those who did not survive was often rapid with patients expiring within 10 days from disease detection. Further studies are needed to better explain the variability in clinical course of COVID-19 among LTCF residents, specifically the factors affecting mortality, the differences observed in symptom presentation, and rate of clinical decline.

COVID-19 in long-term care facilities in Frankfurt am Main, Germany: incidence, case reports, and lessons learned.

As of August 30, 2020, the World Health Organisation (WHO) reported 24,822,800 COVID-19 infections world wide. Severe disease and deaths occur especially in older people with chronic illnesses. Residents of nursing homes are considered to be the most vulnerable group. In this paper, the experiences with COVID-19 in nursing homes in Frankfurt will be presented and discussed. Materials and methods: Based on the data of the statutory reporting obligation, the reported COVID-19 cases are presented and incidences are calculated in different age groups and among residents of nursing homes. Outbreaks in various homes are described in detail based on the documentation from the public health department. Results: By August 28, 2020, 2,665 COVID-19 infections were reported in Frankfurt am Main (incidence 351/100,000 inhabitants), including 116 (4.3%) residents of nursing homes (2,416/100,000 residents). Almost half (39%) of all deaths in Frankfurt (n=69; incidence 9.1/100,000) were among nursing home residents (n=27; incidence 558/100,000 nursing home residents), with 22 of them in just one long-term care facility (LTCF). Compared to previous years, the mortality rate in nursing homes did not increase in the first half of 2020. In one home, 75% of residents tested positive for SARS-CoV-2 and 25% died; in two other homes, 6.7% and 14.1% of the residents became infected, and the mortality rate was 0.5% and 1%, resp. In the other 42 homes in the city (3,906 beds), the infection rate remained below 1% and the death rate was 0.1%. Discussion: In many countries, 30-70% of all deaths occur among nursing home residents, including Frankfurt (39%). An increase in overall mortality compared to previous years was not observed in Frankfurt as a whole or in the nursing homes in the city specifically. Due to the measures taken (monitoring of residents and staff, nursing care in protective clothing, prohibition or restriction of visits, physical distancing, isolation of infected people and quarantining of contact persons), only individual cases of COVID-19 illnesses occurred in nursing home residents in most homes and the outbreaks in the three homes could be stopped. We do not recommend regular nontargeted testing in nursing homes, but rather vigilance and the implementation of good hygiene as well as immediate targeted testing if COVID-19 is suspected in residents or staff. In order to mitigate the considerable negative effects of these measures on the residents, a good balance should be sought between infection prevention and the goal of ensuring self-determination and the residents' quality of life.