ABSTRACT
BackgroundNon-pharmaceutical interventions remain a primary means of suppressing COVID-19 until vaccination coverage is sufficient to achieve herd immunity. We used anonymized smartphone mobility measures in seven Canadian provinces to quantify the mobility level needed to suppress COVID-19 (mobility threshold), and the difference relative to current mobility levels (mobility gap). MethodsWe conducted a longitudinal study of weekly COVID-19 incidence from March 15, 2020 to January 16, 2021, among provinces with 20 COVID-19 cases in at least 10 weeks. The outcome was weekly growth rate defined as the ratio of current cases compared to the previous week. We examined the effects of average time spent outside the home (non-residential mobility) in the prior three weeks using a lognormal regression model accounting for province, season, and mean temperature. We calculated the COVID-19 mobility threshold and gap. ResultsAcross the 44-week study period, a total of 704,294 persons were infected with COVID-19. Non-residential mobility dropped rapidly in the spring and reached a median of 36% (IQR: 31,40) in April 2020. After adjustment, each 5% increase in non-residential mobility was associated with a 9% increase in the COVID-19 weekly growth rate (ratio=1.09, 95%CI: 1.07,1.12). The mobility gap increased through the fall months, which was associated with increasing case growth. InterpretationMobility strongly and consistently predicts weekly case growth, and low levels of mobility are needed to control COVID-19 through winter 2021. Mobility measures from anonymized smartphone data can be used to guide the provincial and regional implementation and loosening of physical distancing measures.
ABSTRACT
BackgroundThe epidemiology of COVID-19 in retirement homes (also known as assisted living facilities) is largely unknown. We examined the association between retirement home and community level characteristics and the risk of COVID-19 outbreaks in retirement homes during the first wave of the COVID-19 epidemic. MethodsWe conducted a population-based retrospective cohort study of licensed retirement homes in Ontario, Canada, from March 1st - September 24th, 2020. Our primary outcome was a COVID-19 outbreak ([≥]1 resident or staff confirmed case by validated nucleic acid amplification assay). We used time-dependent proportional hazards methods to model the associations between retirement home and community level characteristics and COVID-19 outbreaks. ResultsOur cohort included all 770 licensed retirement homes in Ontario, which housed 56,491 residents. There were 172 (22.3%) COVID-19 retirement home outbreaks involving 1,045 (1.9%) residents and 548 staff (1.5%). COVID-19 cases were distributed unevenly across retirement homes, with 1,593 (92.2%) resident and staff cases occurring in 77 (10%) of homes. The adjusted hazard of a COVID-19 outbreak in a retirement home was positively associated with homes that had a large resident capacity, homes that were co-located with a long-term care facility, large corporate owned chains, homes that offered many services onsite, increases in regional COVID-19 incidence, and a higher community-level ethnic concentration. InterpretationReadily identifiable retirement home-level characteristics are independently associated with COVID-19 outbreaks and may support risk identification. A higher ethnic concentration of the community surrounding a retirement home is associated COVID-19 outbreaks, with an uncertain mechanism.
ABSTRACT
In this population-based study of all Ontario nursing home residents, we found increased prescribing of psychotropic drugs at the onset of the COVID-19 pandemic that persisted through September 2020. Increases in prescribing were out of proportion to expected secular trends, and distinct from observed prescribing changes in other drugs during the pandemic. Our findings underscore the urgency of balancing infection prevention and control measures in nursing homes with the mental wellbeing of residents.
ABSTRACT
ObjectivePhysical distancing and stay-at-home measures implemented to slow transmission of novel coronavirus disease (COVID-19) may intensify feelings of loneliness in older adults, especially those living alone. Our aim was to characterize the extent of loneliness in a sample of older adults living in the community and assess characteristics associated with loneliness. DesignOnline cross-sectional survey between May 6 and May 19, 2020 SettingOntario, Canada ParticipantsConvenience sample of the members of a national retired educators organization. Primary outcome measuresSelf-reported loneliness, including differences between women and men. Results4879 respondents (71.0% women; 67.4% 65-79 years) reported that in the preceding week, 43.1% felt lonely at least some of the time, including 8.3% that felt lonely always or often. Women had increased odds of loneliness compared to men, whether living alone (adjusted Odds Ratio (aOR) 1.52 [95% Confidence Interval (CI) 1.13-2.04]) or with others (2.44 [95% CI 2.04-2.92]). Increasing age group decreased the odds of loneliness (aOR 0.69 [95% CI 0.59-0.81] 65-79 years and 0.50 [95% CI 0.39-0.65] 80+ years compared to <65 years). Living alone was associated with loneliness, with a greater association in men (aOR 4.26 [95% CI 3.15-5.76]) than women (aOR 2.65 [95% CI 2.26-3.11]). Other factors associated with loneliness included: fair or poor health (aOR 1.93 [95% CI 1.54-2.41]), being a caregiver (aOR 1.18 [95% CI 1.02-1.37]), receiving care (aOR 1.47 [95% CI 1.19-1.81]), high concern for the pandemic (aOR 1.55 [95% CI 1.31-1.84]), not experiencing positive effects of pandemic distancing measures (aOR 1.94 [95% CI 1.62-2.32]), and changes to daily routine (aOR 2.81 [95% CI 1.96-4.03]). ConclusionsWhile many older adults reported feeling lonely during COVID-19, several characteristics - such as being female and living alone - increased the odds of loneliness. These characteristics may help identify priorities for targeting interventions to reduce loneliness. Strengths and limitations of this studyO_LIThis survey study leveraged a strong community-based partnership to obtain timely data from a large sample of older Canadians on the impacts of COVID-19. C_LIO_LIThis study identified several characteristics that increased the odds of loneliness, which may help to identify priorities for targeted interventions to reduce loneliness. C_LIO_LIThe data were based on a convenience sample of retired, educational staff, who are not fully representative of the Canadian population. The perspectives of vulnerable groups who may be at greater risk for loneliness (e.g. those with severe mental health illness, low income, no home internet access, etc.) are likely underrepresented in this sample. C_LI
ABSTRACT
The risk of nursing home COVID-19 outbreaks is strongly associated with the rate of infection in the communities surrounding homes, yet the temporal relationship between rising rates of community COVID-19 infection and the risk threshold for subsequent nursing home COVID-19 outbreaks is not well defined. This population-based cohort study included all COVID-19 cases in Canadas most populous Province of Ontario between March 1-July 16, 2020. We evaluated the temporal relationship between trends in the number of active community COVID-19 cases and the number of nursing home outbreaks. We found that the average lag time between community cases and nursing home outbreaks was 23 days for Ontario overall, with substantial variability across geographic regions. We also determined thresholds of community incidence of COVID-19 associated with a 75% probability of observing a nursing home outbreak 5, 10 and 15 days into the future. For the province overall, when daily active COVID-19 community cases are 2.30 per 100,000 population, there is a 75% probability of a nursing home outbreak occurring five days later.
ABSTRACT
ObjectivesTo assess changes in the mobility of staff between long-term care homes in Ontario, Canada before and after enactment of public policy restricting staff from working at multiple homes. DesignPre-post observational study. Setting and Participants623 long-term cares homes in Ontario, Canada between March 2020 and June 2020. MethodsWe used anonymized mobile device location data to approximate connectivity between all 623 long-term care homes in Ontario during the 7 weeks before (March 1 - April 21) and after (April 22 - June 13) the policy restricting staff movement was implemented. We visualized connectivity between long-term care homes in Ontario using an undirected network and calculated the number of homes that had a connection with another long-term care home and the average number of connections per home in each period. We calculated the relative difference in these mobility metrics between the two time periods and compared within-home changes using McNemars test and the Wilcoxon rank-sum test. ResultsIn the period preceding restrictions, 266 (42.7%) long-term care homes had a connection with at least one other home, compared to 79 (12.7%) homes during the period after restrictions, a drop of 70.3% (p <0.001). The average number of connections in the before period was 3.90 compared to 0.77 in after period, a drop of 80.3% (p < 0.001). In both periods, mobility between long-term care homes was higher in homes located in larger communities, those with higher bed counts, and those part of a large chain. Conclusions and ImplicationsMobility between long-term care homes in Ontario fell sharply after an emergency order by the Ontario government limiting long-term care staff to a single home, though some mobility persisted. Reducing this residual mobility should be a focus of efforts to reduce risk within the long-term care sector during the COVID-19 pandemic.
ABSTRACT
Introduction - Worldwide, nursing home residents have experienced disproportionately high COVID-19 mortality due to the intersection of congregate living, multimorbidity, and advanced age. Among 12 OECD countries, Canada has had the highest proportion of COVID-19 deaths in nursing home residents (78%), raising concerns about a skewed pandemic response that averted much transmission and mortality in community-dwelling residents, but did not adequately protect those in nursing homes. To investigate this, we measured temporal variations in hospitalizations among community and nursing home-dwelling decedents with COVID-19 during the first and second waves of the pandemic. Methods - We conducted a population-based cohort study of residents of Ontario, Canada with COVID-19 who died between March 11, 2020 (first COVID-19 death in Ontario) and October 28, 2020. We examined hospitalization prior to death as a function of 4 factors: community (defined as all non-nursing home residents) vs. nursing home residence, age in years (<70, 70-79, 80-89, [≥]90), gender, and month of death (1st wave: March-April [peak], May, June-July 2020 [nadir], 2nd wave: August-October 2020). Results - A total of 3,114 people with confirmed COVID-19 died in Ontario from March to October, 2020 (Table 1), of whom 1,354 (43.5%) were hospitalized prior to death (median: 9 days before death, interquartile range: 4-19). Among nursing home decedents (N=2000), 22.4% were admitted to hospital prior to death, but this varied substantially from a low of 15.5% in March-April (peak of wave 1) to a high of 41.2% in June-July (nadir of wave 1). Among community-dwelling decedents (N=1,114), admission to acute care was higher (81.4%) and remained relatively stable throughout the first and second waves. Similar temporal trends for nursing home versus community decedents were apparent in age-stratified analyses (Figure 1). Women who died were less likely to have been hospitalized compared to men in both community (80% women vs 84% men) and nursing home (21% women vs 24% men) settings. Discussion - Only a minority of Ontario nursing home residents who died of COVID-19 were hospitalized prior to death, and that there were substantial temporal variations, with hospitalizations reaching their lowest point when overall COVID-19 incidence peaked in mid-April, 2020. While many nursing home residents had pre-pandemic advance directives precluding hospitalization, the low admission rate observed in March-April 2020 (15.5%) was inconsistent with both higher admission rates in subsequent months (>30%), and comparatively stable rates among community-dwelling adults. Our findings substantiate reports suggesting that hospitalizations for nursing home residents with COVID-19 were low during the peak of the pandemics first wave in Canada, which may have contributed to the particularly high concentration of COVID-19 mortality in Ontarios nursing homes.
ABSTRACT
ImportanceNursing home residents have been disproportionately impacted by the COVID-19 epidemic. Prevention recommendations have emphasized frequent testing of healthcare personnel and residents, but additional strategies are needed to protect nursing home residents. ObjectiveWe developed a reproducible index of nursing home crowding and determined whether crowding was associated with incidence of COVID-19 in the first months of the COVID-19 epidemic. Design, Setting, and ParticipantsPopulation-based retrospective cohort study of over 78,000 residents of 618 distinct nursing homes in Ontario, Canada from March 29 to May 20, 2020. ExposureThe nursing home crowding index equalled the average number of residents per bedroom and bathroom. OutcomesPrimary outcomes included the cumulative incidence of COVID-19 infection and mortality, per 100 residents; introduction of COVID-19 into a home ([≥]1 resident case) was a negative tracer. ResultsOf 623 homes in Ontario, we obtained complete information on 618 homes (99%) housing 78,607 residents. A total of 5,218 residents (6.6%) developed COVID-19 infection, and 1,452 (1.8%) died with COVID-19 infection as of May 20, 2020. COVID-19 infection was distributed unevenly across nursing homes: 4,496 (86%) of infections occurred in just 63 (10%) of homes. The crowding index ranged across homes from 1.3 (mainly single-occupancy rooms) to 4.0 (exclusively quadruple occupancy rooms); 308 (50%) homes had high crowding index ([≥]2). Incidence in high crowding index homes was 9.7%, versus 4.5% in low crowding index homes (p<0.001), while COVID-19 mortality was 2.7%, versus 1.3%. The likelihood of COVID-19 introduction did not differ (31.3% vs 30.2%, p=0.79). After adjustment for regional, nursing home, and resident covariates, the crowding index remained associated with increased risk of infection (RR=1.72, 95% Confidence Interval [CI]: 1.11-2.65) and mortality (RR=1.72, 95%CI: 1.03-2.86). Propensity score analysis yielded similar conclusions for infection (RR=2.06, 95%CI: 1.34-3.17) and mortality (RR=2.09, 95%CI: 1.30-3.38). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 988 (18.9%) infections of COVID-19 and 271 (18.7%) deaths. Conclusions and RelevanceCrowding was associated with higher incidence of COVID-19 infection and mortality. Reducing crowding in nursing homes could prevent future COVID-19 mortality.
ABSTRACT
BackgroundNursing homes have become the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada. Previous research demonstrates that for-profit nursing 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 non-profit homes. MethodsWe conducted a retrospective cohort study of all nursing homes in Ontario, Canada from March 29-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 nursing home profit status (for-profit, non-profit or municipal) and nursing home COVID-19 outbreaks, COVID-19 outbreak sizes, and COVID-19 resident deaths. ResultsThe analysis included all 623 Ontario nursing homes, of which 360 (57.7%) were for-profit, 162 (26.0%) were non-profit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) COVID-19 nursing home outbreaks involving 5218 residents (mean of 27.5 {+/-} 41.3 residents per home), resulting in 1452 deaths (mean of 7.6 {+/-} 12.7 residents per home) with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak was associated with the incidence of COVID-19 in the health region surrounding a nursing home (adjusted odds ratio [aOR], 1.94; 95% confidence interval [CI] 1.23-3.09) and number of beds (aOR, 1.40; 95% CI 1.20-1.63), but not profit status. For-profit status was associated with both the size of a nursing home outbreak (adjusted risk ratio [aRR], 1.96; 95% CI 1.26-3.05) and the number of resident deaths (aRR, 1.78; 95% CI 1.03-3.07), compared to non-profit homes. These associations were mediated by a higher prevalence of older nursing home design standards in for-profit homes. Interpretation: For-profit status is associated with the size of a COVID-19 nursing home outbreak and the number of resident deaths, but not the likelihood of outbreaks. Differences between for profit and non-profit homes are largely explained by older design standards, which should be a focus of infection control efforts and future policy.
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BackgroundSyndromic surveillance through web or phone-based polling has been used to track the course of infectious diseases worldwide. Our study objective was to describe the characteristics, symptoms, and self-reported testing rates of respondents in three different COVID-19 symptom surveys in Canada. MethodsData sources consisted of two distinct Canada-wide web-based surveys, and phone polling in Ontario. All three sources contained self-reported information on COVID-19 symptoms and testing. In addition to describing respondent characteristics, we examined symptom frequency and the testing rate among the symptomatic, as well as rates of symptoms and testing across respondent groups. ResultsWe found that 1.6% of respondents experienced a symptom on the day of their survey, 15% of Ontario households had a symptom in the previous week, and 44% of Canada-wide respondents had a symptom in the previous month over March-April 2020. Across the three surveys, SARS-CoV-2-testing was reported in 2-9% of symptomatic responses. Women, younger and middle-aged adults (versus older adults) and Indigenous/First nations/Inuit/Metis were more likely to report at least one symptom, and visible minorities were more likely to report the combination of fever with cough or shortness of breath. InterpretationThe low rate of testing among those reporting symptoms suggests significant opportunity to expand testing among community-dwelling residents of Canada. Syndromic surveillance data can supplement public health reports and provide much-needed context to gauge the adequacy of current SARS-CoV-2 testing rates.
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In this population-wide study in Ontario, Canada we report on all 194,372 unique residents who received testing for SARS-CoV-2 between January 23, 2020 and April 28, 2020. We found that while more women than men were tested for SARS-CoV-2, men had a higher rate of laboratory-confirmed COVID-19 infection, hospitalization, ICU admission and death. These findings were consistent even with age adjustment, suggesting that the observed differences in outcomes between women and men were not explained by age or systematic differences in testing by sex. Instead, they may be due to sex-based immunological or other gendered differences, such as higher rates of smoking leading to cardiovascular disease.
ABSTRACT
The COVID-19 Acute and Intense Resource Tool (CAIC-RT) is an interactive online tool capable of estimating the maximum daily number of incident COVID- 19 cases that a healthcare system could manage given age-based case distribution and severity.
