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Abstract
Objectives The global COVID-19 pandemic produced large-scale health and economic complications. Older people and those with comorbidities are particularly vulnerable to this virus, with nursing homes and long term care facilities (LTCF) experiencing significant morbidity and mortality associated with COVID-19 outbreaks. The aim of this rapid systematic review was to investigate measures implemented in LTCF to reduce transmission of COVID-19 and their effect on morbidity and mortality of residents, staff and visitors.
Setting Long-term care facilities.
Participants Residents, staff and visitors of facilities.
Primary and secondary outcome measures Databases (PubMed, EMBASE, CINAHL, Cochrane Databases and repositories and MedRXiv prepublished database) were systematically searched from inception to 27 July 2020 to identify studies reporting assessment of interventions to reduce transmission of COVID-19 in nursing homes among residents, staff or visitors. Outcome measures include facility characteristics, morbidity data, case fatalities and transmission rates. Due to study quality and heterogeneity, no meta-analysis was conducted.
Results The search yielded 1414 articles, with 38 studies included. Reported interventions include mass testing, use of personal protective equipment, symptom screening, visitor restrictions, hand hygiene and droplet/contact precautions, and resident cohorting. Prevalence rates ranged from 1.2% to 85.4% in residents and 0.6% to 62.6% in staff. Mortality rates ranged from 5.3% to 55.3% in residents.
Conclusions Novel evidence in this review details the impact of facility size, availability of staff and practices of operating between multiple facilities, and for-profit status of facilities as factors contributing to the size and number of COVID-19 outbreaks. No causative relationships can be determined; however, this review provides evidence of interventions that reduce transmission of COVID-19 in LTCF.
PROSPERO registration number CRD42020191569.
- COVID-19
- public health
- geriatric medicine
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
Evidence from 38 studies identifies the measures taken to reduce transmission of COVID-19 in long-term care facilities.
No limitations were placed on study type, and all languages were eligible for inclusion.
Study quality was formally examined using the Mixed Methods Assessment Tool.
Due to the heterogeneity of included studies, meta-analysis was not able to be performed.
Introduction
SARS-CoV-2 is a novel virus, first identified in China in 2019, resulting in the current global pandemic in 2020.1 The ensuing disease associated with infection from SARS-CoV-2, termed COVID-19, has produced large-scale public health and worldwide economic effects.2
The virus spreads between people through close contact and droplet transmission (coughs and sneezes). While most infected people will experience mild influenza‐like symptoms, others may become seriously ill and die.3 At-risk groups include older people and those with underlying medical conditions, while men appear to have more susceptibility than women. Symptom severity varies; several individuals remain asymptomatic. Others experience fever, cough, sore throat, general weakness and fatigue, while more severe respiratory illnesses and infections may result, which can be fatal.4 5 Deterioration in clinical presentations can occur rapidly, leading to poorer health outcomes. Anosmia and ageusia are reported in evidence from South Korea, China and Italy in patients with confirmed SARS-CoV-2 infection, in some cases in the absence of other symptoms.6
The WHO declared the COVID-19 outbreak constituted a Public Health Emergency of International Concern on 30 January 2020.5 Two primary goals of action were (1) to accelerate innovative research to help contain the spread and facilitate care for all affected and (2) to support research priorities globally the learning from the pandemic response for preparedness. Globally, up to 25 March 2021, there are 123 636 852 cases of COVID-19 (following the applied case definitions and testing strategies in the affected countries) including 2 721 891 deaths.7 Within Europe, over 25 220 376 cases are reported, with 592 929 deaths.7
Given the infection and mortality figures noted, preventing and limiting transmission of the SARS-CoV-2 virus is advocated. International and national evidence mandates physical distancing, regular hand hygiene and cough etiquette, and limiting touching eyes, nose or mouth; in addition to regular cleaning of surfaces.8
As noted, older people are an at-risk group for COVID-19, and throughout the pandemic, the impact on this population has resulted in increased mortality, specifically those living in long term care facilities (LTCF) where a high proportion of outbreaks with increased rates of morbidity and case fatality in residents are recorded.9 In several European Union/European Economic Area countries, LTCF deaths among residents, associated with COVID-19, account for 37%–66% of all COVID-19-related fatalities.9 The specific rationale for their increased susceptibility is less clear. Comorbidities including cardiovascular disease and diabetes may increase the chances of fatal disease, but they alone do not explain why age is an independent risk factor.10 Molecular, biological and immunological changes inform emergent viable hypotheses.10 The United Nations (UN) (2020) acknowledge that COVID-19 exposes the inequalities in society and the failures expressed in the 2030 Agenda for Sustainable Development. The UN report the disproportionate fatality rates in those aged over 80 years as five times the global average11 and suggest a need for a more inclusive, equitable and age-friendly society, anchored in human rights (p16).12
The aim of this rapid review of the literature was to assess the extent to which measures implemented in LTCF reduced transmission of COVID-19 (SARS-CoV-2) among residents, staff and visitors, and the effect of these measures on morbidity and mortality outcomes.
Methods
The protocol is registered on PROSPERO13 and reporting follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.14 Ethical approval was not required for this systematic review.
Search strategy
Search strategies comprised search terms both for keywords and controlled-vocabulary search terms MESH and EMTREE (see online supplemental table 1 for full search terms). EMBASE (via OVID), PubMed (via OVID), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database and Repository and MedRXiv prepublished databases were searched. No time limits were imposed, and databases were searched up to 27 July 2020. Reference lists of included evidence were checked for further articles.
Supplemental material
Eligibility criteria
All study designs (experimental, observational and qualitative) are included, and no exclusions are placed on language. Included studies report an assessment of measures to reduce transmission of COVID-19 (including SARS or Middle Eastern Resipratory Virus (MERS)) in residents, employees or visitors of LTCF. To provide as comprehensive a review of the evidence we included any intervention implemented to reduce the transmission of COVID-19 in LTCF, including facility measures, social distancing, use of personal protective equipment (PPE) and hand hygiene.
A broad definition of LTCF was adopted for this review noting European Centre for Disease Prevention and Control (ECDC) guidance8 including institutions such as nursing homes, skilled nursing facilities, retirement homes, assisted-living facilities, residential care homes or other facilities providing care in a congregated setting for older aged adults.
Primary outcome measures
Primary outcome measures are morbidity data, case fatality rates and reductions in reported transmission rates.
Secondary outcomes
Secondary outcomes reported are facility characteristics associated with COVID-19 transmission.
Selection of studies and data extraction
Two authors developed search strings (DS and KF); all database searches were completed by one author (DS) (online supplemental table 1). Following de-duplication, references were uploaded into Covidence management platform (LM), and two authors independently screened all titles and abstracts (LM and KF). Full texts of all potentially eligible studies were independently reviewed by two authors (LM and KF). Disagreements were resolved by discussion with a third author (CCK). Data from included studies were independently extracted in duplicate (LM and KF). A data extraction form was developed and modified from documents used previously by authors (KF and CCK). Extracted data included study characteristics (title, lead author, year of publication, country, study setting, study design), description of the intervention, number and characteristics of participants, outcomes, duration of follow-up, sources of funding, peer review status. Study design (required for review of quality) was independently assessed by two authors (LM and KF), with disagreements resolved by a third author (CCK).
Assessment of quality
Two review authors (LM and EL) independently assessed the quality of included studies using Mixed Methods Assessment Tool (MMAT),15 with disagreements resolved by a third author (KF) and discussed with the lead author (CCK) (online supplemental table 2). The MMAT is used widely and considered a valid indicator of methodological quality using instruments for non-randomised and descriptive studies.
Supplemental material
Data synthesis
Meta-analysis was not possible due to heterogeneity in study designs, participants, outcomes and nature of the interventions and no attempt was made to transform statistical data. The Synthesis without meta-analysis (SWiM) criteria16 guide a narrative summary, with data presented in tabular format and subgroup reporting of population groups.
Patient and public involvement
No patients were involved in this study.
Results
We identified 1414 articles and 131 full-text articles were selected for review. After an evaluation against our inclusion criteria, 38 studies (40 papers) are included in this systematic review (figure 1).
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart.
Study characteristics
Geographically we report evidence from 11 countries; the majority (20 studies) are from USA17–36 and UK.37–41 We report evidence from Canada,42–44 France,45 46 Hong Kong,47 48 Belgium,49 Germany,50 Ireland,51 Japan,52 Korea53 and Spain54 (table 1).
Characteristics of studies including infection control measures
Infection control measures
Twenty studies report the nature of LTCFs related to outbreaks and transmission of COVID-19 infection (table 2).17 24 29 30 32 34 36–40 42–44 46–48 51–53 Thirty studies (table 318–30 33–35 38–44 46–51 54); report evidence of measures to reduce transmission of COVID-19 in long-term residential care facilities for residents, 25 studies (table 418–23 25 27–31 33 35 39 40 43–49 51 54); report evidence for employee outcomes, and two studies report evidence for visitors (table 5).29 48
COVID-19 outcomes related to the nature of long-term care facilities
Resident-specific outcomes of strategies implemented in nursing homes
Staff-specific outcomes of strategies to reduce transmission
Visitor-specific outcomes following the implementation of strategies
A variety of infection control measures are described (tables 1 and 3–5) including: mass testing/point-prevalence testing (22 studies18 20–23 26–31 33–35 39 40 45 46 49–51 54), use of PPE (10 studies18 19 21 26 29 30 33 46 48 50), screening of residents, staff or visitors for symptoms (8 studies19–21 24 26 28 30 33), restrictions on visitor entry (10 studies19–21 26 28 30 33 46 50 54), hand hygiene and contact and droplet precautions (6 studies20 24 26 33 46 47) and cohorting/isolation of residents (11 studies20 21 23 26 29 30 33 34 46 48 50). Thirteen studies examined characteristics of LTCF and their association with COVID-19 infection and risk.17 25 32 36–38 40–44 52 53
Morbidity and mortality
Morbidity and mortality results from included studies are presented for residents (table 3), staff (table 4) and visitors (table 5). Prevalence of COVID-19 infection was reported in 29 studies, including prevalence in residents (27 studies18–30 33–35 39 40 42 44 46–51 54) and staff (22 studies18 20–23 25 27–31 33 35 39 40 45–49 51 54), with two studies reporting absolute case numbers in visitors.29 48 Prevalence rates ranged from 3.8% in a sample of 2074 LTCF49 and 1.2% in the third point-prevalence survey at a single facility21 to 85.4% in a single facility that implemented a telemedicine service to limit transmission.25 Staff prevalence ranged from 0.6% in a point-prevalence survey in a single facility21 to 62.6% in a group of nine LTCF.22 One study reported 16 COVID-19 positive visitor cases,29 while a study that examined SARS infection following an outbreak in a Hong Kong facility reported three positive visitor cases.48
The symptom status (symptomatic/presymptomatic/asymptomatic, typical/atypical symptoms) of participants was reported in 16 studies, with resident and staff symptom status reported in 1518–20 22 23 26–28 30 33 34 46 49 51 54 and 13 studies,20–23 27 28 30 33 45 46 49 51 54 respectively. No studies reported symptom status of visitors. The proportion of COVID-19 positive residents presenting with symptoms ranged from 26.3%20 27 to 59.8% (a sample of both residents and healthcare workers).28 Asymptomatic cases in residents were reported in 13 studies,18 20 22 23 26–28 30 33 46 49 51 54 with proportions of COVID-19 positive residents presenting with no symptoms varying from 2.4%46 to 75.3%.49 Among COVID-19 positive staff, the proportion of symptomatic cases ranged from 6.4%27 to 100%,33 and asymptomatic cases ranged from 23.6%51 to 100%.21 23
Mortality results were reported in 22 studies, including information on mortality of residents (22 studies18–20 23–25 28–30 34 35 38–44 46 48 50 51), staff (4 studies29 35 46 48) and visitors (2 studies29 48). Mortality rates in COVID-19 positive residents ranged from 5.3%20 to 55.3%.39 One study reported a 66.7% death rate in residents who tested positive for the SARS virus.48 A study examining the mortality risk in Ontario LTCF reported a death rate of 0.1% across all residents.43 Across the three studies which presented mortality results in COVID-19 positive staff, mortality rates were 0%.29 35 46 One study presenting mortality rates in a nursing home following a SARS outbreak reported one death of a member of staff.48 Mortality rates reported in visitors in two studies was 0%48 and 6.2%,29 respectively.
Characteristics of LTCFs on COVID-19 transmission
Numerous facility-specific characteristics were linked with risk of COVID-19 cases (table 2). These include size of LTCF17 38 39 52; staffing levels and/or use of agency care staff29 32 37 39 40 44 51; part of larger chain of organisations and/or for profit status17 32 36 43 44 51; and related staffing, crowding, or availability of single rooms.24 30 40 42 44 46–48
Quality review
The quality ratings of included studies are presented in online supplemental table 2. Overall quality of evidence in this review is considered low based on MMAT assessment criteria.
Discussion
Evidence in this review indicates the impact of COVID-19 on LTCF, demonstrating the vulnerability of this setting in 11 countries. A novel outcome highlights the characteristics of LTCF associated with COVID-19 outbreaks, in addition to reporting the prevalence rates of COVID-19 and associated mortality and morbidity for residents, staff and visitors. A variety of measures were implemented in LTCF, of which many were instigated locally by facility managers, and others through agile public health policy. Due to the rapid nature of introducing public health measures though, the evidence base does not facilitate an evaluation of the effects of these measures individually. Mass testing of residents with or without staff testing was the primary measure used to reduce transmission of COVID-19. This provides objective evidence of infection rates in facilities, and enables application of subsequent measures, including isolation of residents who are infected with re-designation of specific staff to care for them. Repeated point-prevalence testing allows facilities to grasp the spread of the virus along with the impact of their mitigation strategies.
Further measures implemented in facilities echoed public health recommendations to the broader community to limit the spread of the virus. These included guidance on hand hygiene, contact and droplet precautions, and restricting staff, including agency workers, to working in only one facility.55 Restricting visitor access to facilities was implemented generally to reduce the likelihood of introducing COVID-19 into LTCF, assessing body temperature and symptom screening of staff and visitors on entry.
The prevalence of COVID-19 infection varied throughout included studies, with no distinct pattern emerging between prevention strategies and infection prevalence. Similarly, the mortality rate varied widely among studies and prevention measures. However, patterns emerged regarding associations between facility characteristics and the risk of a COVID-19 outbreak and spread. Sepulveda et al report the disproportionately higher risk of contracting COVID-19 for residents of LTCF, calculating a 12-country average mortality rate of 2772 per 100 000 LTCF residents compared with 122 per 100 000 for community dwelling older persons.56 This represented an average 24.2-fold higher rate of death (range 14.2 (Germany) to 73.7 (Canada)). Higher LTCF mortality rates in Canada (78.4% compared with the Organisation for Economic Co-operation and Development (OECD) 12 country average of 43.7%) are explained by poorer services in care facilities and includes limited staffing and funding.56
Evidence identified the facility size/number of beds was significantly associated with the probability of having a COVID-19 case, and the resulting size of an outbreak. For example, in a sample of 30 US nursing homes, the probability of having a COVID-19 case was increased in medium and large facilities compared with small facilities,17 while in 121 UK homes reporting an outbreak, facilities with ≥70 beds had 80% greater infection rates than facilities with <35 beds.39 A sample of 623 Canadian nursing homes demonstrated facilities with a high crowding index had more infections and deaths than those with a low crowding index. Simulations conducted suggested nearly 20% of infections and deaths may have been averted by converting all four-bed rooms into two-bed rooms.42 Similarly, facilities with a greater number of employees, staff who work in multiple facilities and an increased number of infected staff, were also more likely to experience a COVID-19 outbreak.37 40 51 However, facilities where staff receive sick leave were shown to be less likely to have positive cases.40 Reduced availability of PPE predicted the spread and increase in case number in facilities,37 while for-profit status of facilities was commonly identified as increasing the odds of case outbreaks relative to non-profit status.17 32 36 43 44
Rapid development of COVID-19 vaccines was recognised in early March 2020.57 Lurie et al note previous success in the development of H1N1 vaccination, and similarly the challenges for SARS, Ebola and Zika vaccines.57 The speed of developments is acknowledged, and Public Health England report that at the end of February 2021 up to 5900 deaths were averted in people aged 80 years and older, with over 200 deaths prevented in those aged 7–79 years.58 Montano advises that an accelerated pace of vaccine developments may not lead to total eradication of the virus, citing smallpox as the only virus that has been eliminated worldwide.59 Given this, the transmission reduction measures highlighted in the present review are of crucial importance for the continued management of COVID-19 in LTCF.
Quality review
The quality of evidence in this review is technically low, primarily reported from observational studies, expert opinion, reporting of outbreaks and describing the process and management (online supplemental table 2). Factors associated with lower quality of evidence include the reliance on self-reporting of symptoms, recall bias, use of datasets which may be incomplete and use of convenience sampling. However, confirmation of COVID-19 in the majority of studies was via laboratory testing. We did not remove any study following our review of quality and the evidence is consistent with real-time reporting of data to learn from outbreaks. Papers included from MEDRXIV pre publishing repository are acknowledged; however, as papers were subsequently published in peer review journals we reviewed accordingly. The Institute of Medicine60 advocates for early detection of epidemics, effective communication to the public and promotion of research and development for strategic planning.
Limitations in the review process
A key strength of this review is that it addresses a knowledge gap and has collated evidence from a broad methodological base to report the measures to reduce transmission of COVID-19 in LTCF and reports characteristics of facilities.
Due to the heterogeneity of included studies, meta-analysis was not performed, while the descriptive nature of studies prevents identification of a causative relationship between measures and outcomes. We acknowledge that while a summary of facility characteristics and COVID-19 outcomes are presented, insufficient evidence is available to statistically evaluate and summarise the relationship between individual measures to prevent COVID-19 transmission and thus further research studies are required to elucidate this. Despite this, the systematic approach to this review has identified the scope of interventions implemented in LTCF to reduce COVID-19 transmission.
Publication bias was minimised with inclusion of prepublished evidence, follow-up contacts with authors for early reporting and through the inclusion of observational study designs. Most studies reported are in English, we translated papers from German and Spanish as part of the assessment and review. Outbreak reports include convenience samples or smaller cohorts of residents in LTCF with limited data reported in brief reports and letters. However, real-time reporting of outbreaks provides immediate evidence and shared understanding advocated by the Institute of Medicine.60
Evidence in this review builds on publications from Salcher-Konrad et al,61 a report from WHO,62 and an Irish Expert Panel review,55 furthermore, data on the role of facilities in the transmission of COVID-19 are presented.
Conclusion
This novel, rapid review summarises the evidence base to date identifying specific factors for consideration as part of preparedness plans to reduce transmission of COVID-19 outbreaks in LTCF. Future research should incorporate methodologically robust study designs with longer follow-up to assess the impact on reducing transmission.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @katef224, @doclach5195
KF and LM contributed equally.
Contributors CCK, KF and LM designed the study; KF and DS developed the search strategy; DS conducted the literature search; KF and LM screened titles and full texts to select studies, and extracted data; LM, EL, KF and CCK conducted quality ratings; KF, LM, DS, EL, EC, CCK interpreted and synthesised data; KF, LM, DS, EL, EC, CCK were involved in writing. All authors have approved the final version of the manuscript. CCK acts as the guarantor for this work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests CCK was a member of an expert panel investigating COVID-19 in nursing homes in Ireland.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.