COVID-19 in a Long-Term Care Facility - King County, Washington, February 27-March 9, 2020

Missing science: A scoping study of COVID-19 epidemiological data in the United States

Systematic approaches to epidemiologic data collection are critical for informing pandemic responses, providing information for the targeting and timing of mitigations, for judging the efficacy and efficiency of alternative response strategies, and for conducting real-world impact assessments. Here, we report on a scoping study to assess the completeness of epidemiological data available for COVID-19 pandemic management in the United States, enumerating authoritative US government estimates of parameters of infectious transmission, infection severity, and disease burden and characterizing the extent and scope of US public health affiliated epidemiological investigations published through November 2021. While we found authoritative estimates for most expected transmission and disease severity parameters, some were lacking, and others had significant uncertainties. Moreover, most transmission parameters were not validated domestically or re-assessed over the course of the pandemic. Publicly available disease surveillance measures did grow appreciably in scope and resolution over time; however, their resolution with regards to specific populations and exposure settings remained limited. We identified 283 published epidemiological reports authored by investigators affiliated with U.S. governmental public health entities. Most reported on descriptive studies. Published analytic studies did not appear to fully respond to knowledge gaps or to provide systematic evidence to support, evaluate or tailor community mitigation strategies. The existence of epidemiological data gaps 18 months after the declaration of the COVID-19 pandemic underscores the need for more timely standardization of data collection practices and for anticipatory research priorities and protocols for emerging infectious disease epidemics.

Cases of dental clinic visit by COVID-19 confirmed patients

Objectives

This study aims to review cases of dental visits by patients who had confirmed COVID‐19 infection in Seoul and Gyeonggi‐do. It analyses the patterns of infection transmission among dental healthcare professionals and dental clinic visitors.

Methods

This study obtained data from reports on disease trends and press releases published by the Korea Centers for Disease Control and Prevention (KCDC) on its COVID‐19 website.

Results

After examining cases of patients with a confirmed COVID‐19 infection, 24 people (10 in Seoul and 14 in Gyeonggi‐do) visited the dental office 1–13 days prior to their case confirmation; however, the spread of the virus in the dental office was not confirmed.

Conclusion

The WHO and KCDC guidelines must be followed to curb transmission of the SARS‐CoV‐2 virus among dental patients and professionals.

Workplaces Most Affected by COVID-19 Outbreaks in California, January 2020-August 2021

Objectives. To describe which industries have the highest burden of COVID-19 outbreaks in California. Methods. We assigned US census industry codes to COVID-19 outbreaks reported to the California Department of Public Health (CDPH) from January 1, 2020, to August 31, 2021, and determined numbers of outbreaks, numbers of outbreak-associated cases, and outbreak incidence levels by industry. We determined characteristics of outbreak-associated cases using individual case data linked to COVID-19 outbreaks. Results. Local health departments reported 19 893 COVID-19 outbreaks and 300 379 outbreak-associated cases to CDPH. The most outbreaks (47.8%) and outbreak-associated cases (54.8%) occurred in the health care and social assistance sector, where outbreak incidence levels were highest in skilled nursing facilities and residential care facilities (1306 and 544 outbreaks per 1000 establishments, respectively). High proportions of outbreaks also occurred in the retail trade (8.6%) and manufacturing (7.9%) sectors. Demographics of outbreak-associated cases varied across industries. Conclusions. Certain California industries, particularly in the health care, manufacturing, and retail sectors, have experienced a high burden of COVID-19 outbreaks during the pandemic. Public Health Implications. Tracking COVID-19 outbreaks by industry may help target prevention efforts, including workforce vaccination. (Am J Public Health. 2022;112(8):1180-1190. https://doi.org/10.2105/AJPH.2022.306862).

Characteristics and transmission dynamics of COVID-19 in healthcare workers in a tertiary teaching hospital

Coronavirus disease-19 (COVID-19) transmission significantly affected Healthcare workers (HCWs) worldwide. As a result, they have paid a heavy toll to the COVID-19 outbreak. However, the literature on its transmission routes and risk factors in HCWs is limited. The aim. The authors seek to characterize and know the transmission dynamics of COVID-19 infection in the HCWs of our hospital. Methods: A cross-sectional descriptive study was conducted by the authors. Staff records and virology testing results were used to identify SARS-CoV-2 positive HCWs and study the demographic characteristics and transmission dynamics over one and a half years. Data were analyzed using SPSS software version 23. Results: A total of 169 healthcare workers were positive for SARS-CoV-2. 6 doctors were positive from non-clinical branches, and 17 were positive from clinical branches. One health worker also died of cardio-pulmonary compromise. 88.2 % of healthcare workers got infected while managing patient’s positive for COVID-19. The most frequent clinical manifestation was myalgias in 90.53 % of health workers, followed by arthralgia in 86.98 %. The least common symptoms were loss of taste/smell followed by radiographic changes, and only 19 (11.24 %) presented with shortness of breath. 79.88 % have taken self-medication to relieve COVID symptoms. Maximum number of health workers got infected from July to September. Conclusions: Universal masking, reinforcement of hand hygiene, PPE kits with medical masks, appropriate infection control measures and testing of both clinical and non-clinical staff were essential measures for reducing transmission amongst HCWs

Reported Exposures Among In-Person Workers With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in 6 States, September 2020-June 2021

BACKGROUND

Surveillance systems lack detailed occupational exposure information from workers with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The National Institute for Occupational Safety and Health partnered with 6 states to collect information from adults diagnosed with SARS-CoV-2 infection who worked in person (outside the home) in non-healthcare settings during the 2 weeks prior to illness onset.

METHODS

The survey captured demographic, medical, and occupational characteristics and work- and non-work-related risk factors for SARS-CoV-2 infection. Reported close contact with a person known or suspected to have SARS-CoV-2 infection was categorized by setting as exposure at work, exposure outside of work only, or no known exposure/did not know. Frequencies and percentages of exposure types are compared by respondent characteristics and risk factors.

RESULTS

Of 1111 respondents, 19.4% reported exposure at work, 23.4% reported exposure outside of work only, and 57.2% reported no known exposure/did not know. Workers in protective service occupations (48.8%) and public administration industries (35.6%) reported exposure at work most often. More than one third (33.7%) of respondents who experienced close contact with ≥10 coworkers per day and 28.8% of respondents who experienced close contact with ≥10 customers/clients per day reported exposures at work.

CONCLUSIONS

Exposure to occupational SARS-CoV-2 was common among respondents. Examining differences in exposures among different worker groups can help identify populations with the greatest need for prevention interventions. The benefits of recording employment characteristics as standard demographic information will remain relevant as new and reemerging public health issues occur.

Relationship between dementia, COVID-19 risk, and adherence to COVID-19 mitigation behaviors among older adults in the United States

OBJECTIVES

To examine how dementia is associated with COVID-19 risk and adherence to COVID-19 mitigation behaviors, and whether mitigation behaviors mediate the relationship between dementia and COVID-19 risk.

METHODS/DESIGN

We analyzed 2019 and 2020 data from the National Health and Aging Trends Study, a national prospective cohort study of United States older adults age 65+. Outcomes were COVID-19 diagnosis and adherence to COVID-19 mitigation behaviors (handwashing, mask-wearing, and social distancing).

RESULTS

Among the 3257 older adults in this study, 485 (14.9%) had dementia in 2019 and 98 (3.1%) were COVID-19 positive in 2020. Dementia significantly increased the odds of COVID-19 by 129% (odds ratio [OR] = 2.29, 95% confidence interval [CI] 1.32-3.97), and remained elevated after adjusting for sociodemographics and health (OR = 1.67, 95% CI 0.90-3.11). Dementia significantly decreased the odds of handwashing by 72% (OR = 0.28, 95% CI 0.17-0.44), which remained lower after adjusting for sociodemographics and health (OR = 0.53, 95% CI 0.23-1.21). Dementia was not significantly associated with mask-wearing and social distancing. The relationship between dementia and COVID-19 was primarily mediated by functional impairment, income, and residential setting.

CONCLUSIONS

Dementia was associated with an increased COVID-19 risk and lower adherence to handwashing among U.S. older adults. Adherence to COVID-19 mitigation behaviors did not mediate COVID-19 risk by dementia status. For older adults with dementia, COVID-19 risk could be decreased by prioritizing health interventions.

SARS-CoV-2 and HIV co-infection; clinical features, diagnosis, and treatment strategies: A systematic review and meta-analysis

Background and aim

Coronavirus disease 2019 (COVID-19) in people living with human immunodeficiency virus (HIV) who has a compromised immune system can be associated with more significant risks for severe complications. To date, no comprehensive study has been performed to evaluate HIV in patients with COVID-19. In the present study, we assessed the status of patients co-infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and HIV as a systematic review and meta-analysis.

Methods

A systematic literature search strategy was conducted via reviewing original research articles published in Medline, Web of Science, and Embase databases in 2019 and 2020. Statistical analysis was performed using STATA software, version 14.0 (Stata Corporation, College Station, Texas, USA), to report the prevalence of HIV among patients with COVID-19. Case reports/case series were also evaluated as a systematic review.

Results

Sixty-three studies (53 case reports/case series and ten prevalence studies) were included in our study. A meta-analysis of prevalence studies showed that HIV infection among patients with COVID-19 was reported in 6 countries (Uganda, China, Iran, USA, Italy, and Spain) with an overall frequency of 1.2% [(95% CI) 0.8–1.7] among 14,424 COVID-19 patients. According to the case reports and case series, 111 patients with HIV have been reported among 113 patients with COVID-19 from 19 countries. Most of the cases were in the USA, China, Italy, and Spain.

Conclusion

The small number of SARS-CoV-2-HIV co-infected patients reported in the literature makes it difficult to draw precise conclusions. However, since people with HIV are more likely to develop more severe complications of COVID-19, targeted policies to address this raised risk in the current pandemic should be considered. Our findings highlight the importance of identifying underlying diseases, co-infections, co-morbidities, laboratory findings, and beneficial treatment strategies for HIV patients during the COVID-19 pandemic.

There and back again: the shape of telemedicine in U.S. nursing homes following COVID-19

Introduction

Telemedicine use in nursing homes (NHs) expanded during the COVID-19 pandemic. The objectives of this study were to characterize plans to continue telemedicine among newly adopting NHs and identify factors limiting its use after COVID-19.

Methods

Key informants from 9 Wisconsin NHs that adopted telemedicine during COVID-19 were recruited. Semi-structured interviews and surveys were employed to identify participant perceptions about the value of telemedicine, implementation challenges encountered, and plans and barriers to sustaining its delivery after COVID-19. Directed content analysis and a deductive thematic approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model was used during analyses. Quantitative and qualitative data were integrated to identify participant views on the value of telemedicine and the tools and work system enhancements needed to make telemedicine easier and more effective.

Results

All participating NHs indicated a preference to continue telemedicine after COVID-19. Urgent assessments of resident change-in-condition and cognitively based sub-specialty consultations were identified as the encounter types most amenable to telemedicine. Reductions in resident off-site encounters and minimization of resident therapy interruptions were identified as major benefits of telemedicine. Twelve work system enhancements needed to better sustain telemedicine were identified, including improvements to: 1) equipment/IT infrastructure; 2) scheduling; 3) information exchange; and 4) telemedicine facilitators.

Discussion

NHs that adopted telemedicine during COVID-19 wish to continue its use. However, interventions that enhance the integration of telemedicine into NH and off-site clinic work systems require changes to existing regulations and reimbursement models to sustain its utilization after COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03046-y.

Age, Multiple Chronic Conditions, and COVID-19: A Literature Review

BACKGROUND

Various patient demographic and clinical characteristics have been associated with poor outcomes for individuals with coronavirus disease 2019 (COVID-19). To describe the importance of age and chronic conditions in predicting COVID-19-related outcomes.

METHODS

Search strategies were conducted in PubMed/MEDLINE. Daily alerts were created.

RESULTS

A total of 28 studies met our inclusion criteria. Studies varied broadly in sample size (n = 21 to more than 17,000,000). Participants' mean age ranged from 48 years to 80 years, and the proportion of male participants ranged from 44% to 82%. The most prevalent underlying conditions in patients with COVID-19 were hypertension (range: 15%-69%), diabetes (8%-40%), cardiovascular disease (CVD) (4%-61%), chronic pulmonary disease (1%-33%), and chronic kidney disease (range 1%-48%). These conditions were each associated with an increased in-hospital case fatality rate (CFR) ranging from 1% to 56%. Overall, older adults have a substantially higher case fatality rate (CFR) as compared to younger individuals affected by COVID-19 (42% for those <65 vs 65% > 65 years). Only one study examined the association of chronic conditions and the risk of dying across different age groups; their findings suggested similar trends of increased risk in those < 65 years and those > 65 years as compared to those without these conditions.

CONCLUSIONS

There has been a traditional, single-condition approach to consideration of how chronic conditions and advancing age relate to COVID-19 outcomes. A more complete picture of the impact of burden of multimorbidity and advancing patient age is needed.

COVID-19 Seroprevalence in Emergency Department Healthcare Professionals Study (COV-ED): A Cross-sectional study

Introduction

ED health care professionals are at the frontline of evaluation and management of patients with acute, and often undifferentiated, illness. During the initial phase of the SARS-CoV-2 outbreak, there were concerns that ED health care professionals may have been at increased risk of exposure to SARS-CoV-2 due to difficulty in early identification of patients. This study assessed the seroprevalence of SARS-CoV-2 antibodies among ED health care professionals without confirmed history of COVID-19 infection at a quaternary academic medical center.

Methods

This study used a cross-sectional design. An ED health care professional was deemed eligible if they had worked at least 4 shifts in the adult emergency department from April 1, 2020, through May 31, 2020, were asymptomatic on the day of blood draw, and were not known to have had prior documented COVID-19 infection. The study period was December 17, 2020, to January 27, 2021. Eligible participants completed a questionnaire and had a blood sample drawn. Samples were run on the Roche Cobas Elecsys Anti-SARS-CoV-2 antibody assay.

Results

Of 103 health care professionals (16 attending physicians, 4 emergency residents, 16 advanced practice professionals, and 67 full-time emergency nurses), only 3 (2.9%; exact 95% CI, 0.6%-8.3%) were seropositive for SARS-CoV-2 antibodies.

Discussion

At this quaternary academic medical center, among those who volunteered to take an antibody test, there was a low seroprevalence of SARS-CoV-2 antibodies among ED clinicians who were asymptomatic at the time of blood draw and not known to have had prior COVID-19 infection.

Remote Infection Control Assessments of U.S. Nursing Homes During the COVID-19 Pandemic, April to June 2020

Background

Nursing homes (NHs) provide care in a congregate setting for residents at high risk of severe outcomes from SARS-CoV-2 infection. In spring 2020, NHs were implementing new guidance to minimize SARS-CoV-2 spread among residents and staff.

Objective

To assess whether telephone and video-based infection control assessment and response (TeleICAR) strategies could efficiently assess NH preparedness and help resolve gaps.

Design

We incorporated Centers for Disease Control and Prevention COVID-19 guidance for NH into an assessment tool covering 6 domains: visitor restrictions; health care personnel COVID-19 training; resident education, monitoring, screening, and cohorting; personal protective equipment supply; core infection prevention and control (IPC); and communication to public health. We performed TeleICAR consultations on behalf of health departments. Adherence to each element was documented and recommendations provided to the facility.

Setting and Participants

Health department–referred NHs that agreed to TeleICAR consultation.

Methods

We assessed overall numbers and proportions of NH that had not implemented each infection control element (gap) and proportion of NH that reported making ≥1 change in practice following the assessment.

Results

During April 13 to June 12, 2020, we completed TeleICAR consultations in 629 NHs across 19 states. Overall, 524 (83%) had ≥1 implementation gap identified; the median number of gaps was 2 (interquartile range: 1-4). The domains with the greatest number of facilities with gaps were core IPC practices (428/625; 68%) and COVID-19 education, monitoring, screening, and cohorting of residents (291/620; 47%).

Conclusions and Implications

TeleICAR was an alternative to onsite infection control assessments that enabled public health to efficiently reach NHs across the United States early in the COVID-19 pandemic. Assessments identified widespread gaps in core IPC practices that put residents and staff at risk of infection. TeleICAR is an important strategy that leverages infection control expertise and can be useful in future efforts to improve NH IPC.

Undiagnosed COVID-19 in households with a child with mitochondrial disease

Background

The impact of the COVID-19 pandemic on medically fragile populations, who are at higher risk of severe illness and sequelae, has not been well characterized. Viral infection is a major cause of morbidity in children with mitochondrial disease (MtD), and the COVID-19 pandemic represents an opportunity to study this vulnerable population.

Methods

A convenience sampling cross-sectional serology study was conducted (October 2020 to June 2021) in households (N = 20) containing a child with MtD (N = 22). Samples (N = 83) were collected in the home using a microsampling apparatus and shipped to investigators. Antibodies against SARS-CoV-2 nucleocapsid (IgG), spike protein (IgG, IgM, IgA), and receptor binding domain (IgG, IgM, IgA) were determined by enzyme linked immunosorbent assay.

Results

While only 4.8% of participants were clinically diagnosed for SARS-CoV-2 infection, 75.9% of study participants were seropositive for SARS-CoV-2 antibodies. Most samples were IgM positive for spike or RBD (70%), indicating that infection was recent. This translated to all 20 families showing evidence of infection in at least one household member. For the children with MtD, 91% had antibodies against SARS-CoV-2 and had not experienced any adverse outcomes at the time of assessment. For children with recent infections (IgM+ only), serologic data suggest household members as a source.

Conclusions

COVID-19 was highly prevalent and undiagnosed in households with a child with MtD through the 2020-2021 winter wave of the pandemic. In this first major wave, children with MtD tolerated SARS-CoV-2 infection well, potentially due to household adherence to CDC recommendations for risk mitigation.

The impact of organisational characteristics of staff and facility on infectious disease outbreaks in care homes: a systematic review

BACKGROUND

Infectious disease outbreaks are common in care homes, often with substantial impact on the rates of infection and mortality of the residents, who primarily are older people vulnerable to infections. There is growing evidence that organisational characteristics of staff and facility might play a role in infectious disease outbreaks however such evidence have not previously been systematically reviewed. Therefore, this systematic review aims to examine the impact of facility and staff characteristics on the risk of infectious disease outbreaks in care homes.

METHODS

Five databases (MEDLINE, EMBASE, ProQuest, Web of Science, CINAHL) were searched. Studies considered for inclusion were of any design reporting on an outbreak of any infectious disease in one or more care homes providing care for primarily older people with original data on: facility size, facility location (urban/rural), facility design, use of temporary hired staff, staff compartmentalizing, residence of staff, and/or nursing aides hours per resident. Retrieved studies were screened, assessed for quality using CASP, and analysed employing a narrative synthesis.

RESULTS

Sixteen studies (8 cohort studies, 6 cross-sectional studies, 2 case-control) were included from the search which generated 10,424 unique records. COVID-19 was the most commonly reported cause of outbreak (n = 11). The other studies focused on influenza, respiratory and gastrointestinal outbreaks. Most studies reported on the impact of facility size (n = 11) followed by facility design (n = 4), use of temporary hired staff (n = 3), facility location (n = 2), staff compartmentalizing (n = 2), nurse aides hours (n = 2) and residence of staff (n = 1). Findings suggest that urban location and larger facility size may be associated with greater risks of an infectious disease outbreak. Additionally, the risk of a larger outbreak seems lower in larger facilities. Whilst staff compartmentalizing may be associated with lower risk of an outbreak, staff residing in highly infected areas may be associated with greater risk of outbreak. The influence of facility design, use of temporary staff, and nurse aides hours remains unclear.

CONCLUSIONS

This systematic review suggests that larger facilities have greater risks of infectious disease outbreaks, yet the risk of a larger outbreak seems lower in larger facilities. Due to lack of robust findings the impact of facility and staff characteristics on infectious disease outbreaks remain largely unknown.

PROSPERO

CRD42020213585 .

Social Distancing and Isolation Strategies to Prevent and Control the Transmission of COVID-19 and Other Infectious Diseases in Care Homes for Older People: An International Review

Older people living in care homes are at high risk of poor health outcomes and mortality if they contract COVID-19 or other infectious diseases. Measures used to protect residents include social distancing and isolation, although implementation is challenging. This review aimed to assess the social distancing and isolation strategies used by care homes to prevent and control the transmission of COVID-19 and other infectious diseases. Seven electronic databases were searched: Medline, CINAHL, Embase, PsycINFO, HMIC, Social Care Online, and Web of Science Core Collection. Grey literature was searched using MedRxiv, PDQ-Evidence, NICE Evidence Search, LTCCovid19.org and TRIP. Extracted data were synthesised using narrative synthesis and tabulation. 103 papers were included (10 empirical studies, seven literature reviews, and 86 policy documents). Strategies used to prevent and control the transmission of COVID-19 and other infectious diseases included social distancing and isolation of residents and staff, zoning and cohorting of residents, restriction of resident movement/activities, restriction of visitors and restriction of staff working patterns. This review demonstrates a lack of empirical evidence and the limited nature of policy documentation around social distancing and isolation measures in care homes. Evaluative research on these interventions is needed urgently, focusing on the well-being of all residents, particularly those with hearing, vision or cognitive impairments.

Genomic Epidemiology and Transmission Dynamics of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Congregate Healthcare Facilities in Santa Clara County, California

BACKGROUND

Outbreaks of SARS-CoV-2 in long-term care facilities (LTCFs) cause significant morbidity and mortality. Mapping viral transmission within and between facilities by combining genomic sequencing with epidemiologic investigations enables targeting infection-control interventions.

METHODS

We conducted weekly surveillance of residents and staff in LTCFs in Santa Clara County, California, with ≥1 confirmed COVID-19 case between March and July 2020. Positive samples were referred for whole-genome sequencing. Epidemiological investigations and phylogenetic analyses of the largest outbreaks (>30 cases) were carried out in 6 LTCFs (Facilities A through F).

RESULTS

Among the 61 LTCFs in the county, 41 had ≥1 confirmed case during the study period, triggering weekly SARS-CoV-2 testing. The 6 largest outbreaks accounted for 60% of cases and 90% of deaths in LTCFs, although the bed capacity of these facilities represents only 11% of the LTCF beds in the county. Phylogenetic analysis of 196 whole-genome sequences recovered from those facilities showed that each outbreak was monophyletic, with staff and residents sharing a common viral lineage. Outbreak investigations revealed that infected staff members often worked at multiple facilities, and in 1 instance, a staff member infected while working in 1 facility was the likely index case in another.

CONCLUSIONS

We detected a pattern of rapid and sustained transmission after a single introduction of SARS-CoV-2 in 6 large LTCF outbreaks, with staff playing a key role in transmission within and between facilities. Infection control, testing, and occupational policies to reduce exposure and transmission risk for staff are essential components to keeping facility residents safe.

Analysis of a city-wide COVID-19 prevention strategy for aged-care facilities during third and fifth waves of COVID-19 in Kyoto City, Kyoto, Japan

BACKGROUND

During the third wave of the COVID-19 pandemic at the end of 2020, clusters occurred frequently in aged-care facilities (ACFs), which put pressure on the medical field in Japan. Based on this experience, Kyoto University and Kyoto City collaborated to promote a citywide COVID-19 prevention strategy to prevent the spread of COVID-19 within ACFs. The aim of this study was to clarify the effect of the prevention strategy among ACFs in Kyoto City during the third and fifth waves of the pandemic.

METHODS

During the study period, the following measures were adopted as the prevention strategy in all ACFs: (1) active polymerase chain reaction (PCR) mass testing and facility-wide testing when a single case was identified, (2) implementation of strategies to prevent transmission within a facility, and (3) vaccination program for ACFs.

RESULTS

Of the 1,144 facilities subjected to the mass testing, 71.0% participated in the whole program including active PCR testing. The remainder participated in the rest of the programs. The prevalence of ACF-related COVID-19 cases among total COVID-19 cases in Kyoto City decreased from 7.9% in the third wave to 4.1% in the fourth wave and 2.1% in the fifth wave. The incidence of clusters and proportion of severe elderly cases also decreased during the study period.

CONCLUSIONS

A city-wide multidisciplinary effort including PCR mass testing and a vaccination program in cooperation with a university and local administrative office successfully reduced the clusters and transmission in ACFs in Kyoto City, Japan.

Impact of the COVID-19 Pandemic on the Severity of Diabetic Ketoacidosis Presentations in a Tertiary Pediatric Emergency Department

More severe presentations of diabetic ketoacidosis (DKA) have been reported during the coronavirus disease 2019 (COVID-19) pandemic, possibly due to avoidance of healthcare settings or reduced access to care. To date, no studies have utilized statistical process control to relate temporal COVID-19 events with DKA severity. Our objectives were (1) to determine whether the severity of pediatric DKA presentations changed during COVID-19 and (2) to temporally relate changes in severity with regional pandemic events.

Methods

This study was a retrospective chart review of 175 patients younger than 18 years with DKA presenting to a pediatric emergency department in the United States between 5/1/2019 and 8/15/2020. As part of our ongoing clinical standard work in ED management of DKA, DKA severity measures, including presenting pH, the proportion of PICU admissions, and admission length of stay, were analyzed using statistical process control.

Results

During COVID-19, we found special cause variation with a downward shift in the mean pH on DKA presentation from 7.2 to 7.1 for all patients. The proportion of DKA patients requiring PICU admission increased from 34.2% to 54.6%. Changes temporally corresponded to the statewide bans on large events (3/11/2020), school closures (3/13/2020), and a reduction in our institution's emergency department volumes. Admission length of stay was unchanged.

Conclusions

Pediatric DKA presentations were more severe from March to June 2020, correlating with regional COVID-19 events. Future quality improvement interventions to reduce delayed presentations during COVID-19 surges or other natural disasters should target accessibility of care and public education regarding the importance of timely care for symptoms.

Surveillance of COVID-19 Vaccination in Nursing Homes, United States, December 2020-July 2021

Monitoring COVID-19 vaccination coverage among nursing home residents and staff is important to ensure high coverage rates and guide patient-safety policies. With the termination of the federal Pharmacy Partnership for Long-Term Care Program, another source of facility-based vaccination data is needed. We compared numbers of COVID-19 vaccinations administered to nursing home residents and staff reported by pharmacies participating in the temporary federal Pharmacy Partnership for Long-Term Care Program with the numbers of COVID-19 vaccinations reported by nursing homes participating in new COVID-19 vaccination modules of the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Pearson correlation coefficients comparing the number vaccinated between the 2 approaches were 0.89, 0.96, and 0.97 for residents and 0.74, 0.90, and 0.90 for staff, in the weeks ending January 3, 10, and 17, 2021, respectively. Based on subsequent NHSN reporting, vaccination coverage with ≥1 vaccine dose reached 73.7% for residents and 47.6% for staff the week ending January 31 and increased incrementally through July 2021. Continued monitoring of COVID-19 vaccination coverage is important as new nursing home residents are admitted, new staff are hired, and additional doses of vaccine are recommended.

Caring for a Relative With Dementia in Long-Term Care During COVID-19

OBJECTIVES

The COVID-19 pandemic created unique stressors for caregivers of persons with dementia living in long-term care (LTC) facilities. The purpose of this qualitative study was to identify the challenges associated with caring for a relative with dementia in LTC during the pandemic, as well as resources, strategies, and practices caregivers found helpful in coping with COVID-19.

DESIGN

This study was conducted within the context of an ongoing randomized controlled trial of a psychosocial intervention to support caregivers. Open-ended survey responses (n = 125) and semistructured interviews with a subset of the sample (n = 20) collected between June 2020 and June 2021 explored caregivers' experiences during COVID-19.

SETTING AND PARTICIPANTS

Participants included 125 family caregivers of persons with dementia living in residential LTC.

METHODS

Thematic analysis was used to identify themes capturing caregivers' experiences.

RESULTS

In addition to concerns about COVID-19 infection, participants reported key challenges such as the difficulty of maintaining contact with relatives because of visiting restrictions, lack of information about relatives' health and well-being, worries about overburdened LTC staff, impossibility of returning relatives home from the LTC facility, and fears about relatives dying alone. Participants also identified resources, strategies, and practices that they perceived as helpful, including effective infection prevention within the LTC facility, good communication with LTC staff, and creative strategies for connecting with their relatives.

CONCLUSIONS AND IMPLICATIONS

This qualitative analysis informs recommendations for practice within LTC facilities, as well as supports that may help caregivers manage stressful situations in the context of COVID-19. Vaccination and testing protocols should be implemented to maximize family caregivers' opportunities for in-person contact with relatives in LTC, as alternative visiting modalities were often unsatisfactory or unfeasible. Informing caregivers regularly about individual residents' needs and status is crucial. Supports for bereaved caregivers should address complicated grief and feelings of loss.

Using Non-Pharmaceutical Interventions and High Isolation of Asymptomatic Carriers to Contain the Spread of SARS-CoV-2 in Nursing Homes

More than 40% of the deaths recorded in the first wave of the SARS-CoV-2 pandemic were linked to nursing homes. Not only are the residents of long-term care facilities (LTCFs) typically older and more susceptible to endemic infections, the facilities' high degree of connection to wider communities makes them especially vulnerable to local COVID-19 outbreaks. In 2008, in the wake of the SARS-CoV-1 and MERS epidemics and anticipating an influenza pandemic, we created a stochastic compartmental model to evaluate the deployment of non-pharmaceutical interventions (NPIs) in LTCFs during influenza epidemics. In that model, the most effective NPI by far was a staff schedule consisting of 5-day duty periods with onsite residence, followed by an 4-to-5 day off-duty period with a 3-day quarantine period just prior to the return to work. Unlike influenza, COVID-19 appears to have significant rates of pre-symptomatic transmission. In this study, we modified our prior modeling framework to include new parameters and a set of NPIs to identify and control the degree of pre-symptomatic transmission. We found that infections, deaths, hospitalizations, and ICU utilization were projected to be high and largely irreducible, even with rigorous application of all defined NPIs, unless pre-symptomatic carriers can be identified and isolated at high rates. We found that increasingly rigorous application of NPIs is likely to significantly decrease the peak of infections; but even with complete isolation of symptomatic persons, and a 50% reduction in silent transmission, the attack rate is projected to be nearly 95%.

Assessment of Patient Perspectives and Barriers to Self-Infusion of Augmentation Therapy for Alpha-1 Antitrypsin Deficiency During the COVID-19 Pandemic

Introduction

Alpha-1 antitrypsin (AAT) deficiency is an autosomal co-dominant genetic condition that predisposes individuals to pulmonary and hepatic disease, and in severe cases is treated with augmentation by intravenous infusion. Our aim was to assess patient reluctance to transition to self-administered augmentation of alpha-1-antitrypsin, during the pandemic of SARS-CoV-2.

Methods

A phone questionnaire was administered to 22 patients with severe alpha-1-antitrypsin deficiency who were currently receiving AAT augmentation therapy. Inclusion criteria included patients \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 18 years old, diagnosed with AATD, and receiving intravenous AAT protein augmentation therapy. Information was gathered regarding demographics, perspectives on transitioning to self-administered treatment, and anxiety and depression prevalence. Results were collected anonymously using REDCap. Joint and marginal statistical analysis was done to quantify links between participants’ willingness to transition to self-infusion and correlations with sex, age, years of therapy, anxiety, and depression.

Results

Of 22 patients, 14 were male and eight were female. Ages ranged from 36 to 79 years, with an average of 62.5. Genotypes were ZZ (14), MZ (3), and SZ (2) among others. Average length of intravenous augmentation was 9.5 years. The majority, 16 participants, were aware self-infusion was an option. Eight participants were willing to consider transitioning to self-infusion if trained and educated. Eight patients reported that fear of COVID-19 transmission influenced their decision-making. Above-normal anxiety, and depression scores, were found in four, and six patients, respectively. Neither sex, age, years of treatment, anxiety, or depression were found to be associated with willingness to consider self-infusion therapy.

Conclusions

Although there are many reasons AATD patients may benefit from AAT self-infusion, including decreased exposure to SARS-CoV-2, the majority preferred home nurse-infused therapy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41030-022-00182-z.

The number of COVID-19 clusters in healthcare and elderly care facilities averted by vaccination of healthcare workers in Japan, February-June 2021

In Japan, a prioritized COVID-19 vaccination program using Pfizer/BioNTech messenger RNA (mRNA) vaccine among healthcare workers commenced on February 17, 2021. As vaccination coverage increases, clusters in healthcare and elderly care facilities including hospitals and nursing homes are expected to be reduced. The present study aimed to explicitly estimate the protective effect of vaccination in reducing cluster incidence in those facilities. A mathematical model was formulated using three pieces of information: (1) the incidence of clusters in facilities from October 26, 2020 to June 27, 2021; (2) the incidence of confirmed COVID-19 cases during the same period; and (3) vaccine doses among healthcare workers from February 17 to June 27, 2021, extracted from the national Vaccination System database. We found that the estimated proportion at risk in healthcare and elderly care facilities declined substantially as the vaccination coverage among healthcare workers increased; the greater risk reduction was observed in healthcare facilities, at 0.10 (95% confidence interval (CI): 0.04-0.16) times that in the pre-vaccination period, while that in elderly care facilities was 0.34 (95% CI: 0.24-0.43) times that in the earlier period. The averted numbers of clusters in healthcare facilities and elderly care facilities were estimated to be 247 (95% CI: 210-301) and 279 (95% CI: 218-354), respectively. Prioritized vaccination among healthcare workers had a marked impact on preventing the incidence of clusters in facilities.

Comparing the Clinical Characteristics and Mortality of Residential and Non-Residential Older People with COVID-19: Retrospective Observational Study

Nursing homes have accounted for a significant part of SARS-CoV-2 mortality, causing great social alarm. Using data collected from electronic medical records of 1,319,839 institutionalised and non-institutionalised persons ≥ 65 years, the present study investigated the epidemiology and differential characteristics between these two population groups. Our results showed that the form of presentation of the epidemic outbreak, as well as some risk factors, are different among the elderly institutionalised population with respect to those who are not. In addition to a twenty-fold increase in the rate of adjusted mortality among institutionalised individuals, the peak incidence was delayed by approximately three weeks. Having dementia was shown to be a risk factor for death, and, unlike the non-institutionalised group, neither obesity nor age were shown to be significantly associated with the risk of death among the institutionalised. These differential characteristics should be able to guide the actions to be taken by the health administration in the event of a similar infectious situation among institutionalised elderly people.

Environmental contamination with SARS-CoV-2 in nursing homes

BACKGROUND

SARS-CoV-2 outbreaks in nursing homes (NHs) have been devastating and have led to the creation of coronavirus disease 2019 (COVID-19) units within NHs to care for affected patients. Frequency and persistence of SARS-CoV-2 environmental contamination in these units have not been studied.

METHODS

A prospective cohort study was conducted between October 2020 and January 2021 in four Michigan NHs. Swabs from high-touch surfaces in COVID-19-infected patient rooms were obtained at enrollment and follow-up. Demographic and clinical data were collected from clinical records. Primary outcome of interest was the probability of SARS-CoV-2 RNA detection from specific environmental surfaces in COVID-19 patient rooms. We used multivariable logistic regression to assess patient risk factors for SARS-CoV-2 contamination. Pairwise Phi coefficients were calculated to measure correlation of site-specific environmental detection upon enrollment and during follow-up.

RESULTS

One hundred and four patients with COVID-19 were enrolled (61.5% >80 years; 67.3% female; 89.4% non-Hispanic White; 51% short stay) and followed up for 241 visits. The study population had significant disabilities in activities of daily living (ADL; 81.7% dependent in four or more ADLs) and comorbidities, including dementia (55.8%), diabetes (40.4%), and heart failure (32.7%). Over the 3-month study period, 2087 swab specimens were collected (1896 COVID-19 patient rooms, 191 common areas). SARS-CoV-2 positivity was 28.4% (538/1896 swabs) on patient room surfaces and 3.7% (7/191 swabs) on common area surfaces. Nearly 90% (93/104) of patients had SARS-CoV-2 contamination in their room at least once. Environmental contamination upon enrollment correlated with contamination of the same site during follow-up. Functional independence increased the odds of proximate contamination.

CONCLUSIONS

Environmental detection of viral RNA from surfaces in the rooms of COVID-19 patients is nearly universal and persistent; more investigation is needed to determine the implications of this for infectiousness. Patients with greater independence are more likely than fully dependent patients to contaminate their immediate environment.

Characterization of COVID-19 outbreaks in three nursing homes during the first wave in Berlin, Germany

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) belongs to the coronavirus family and is characterized by its high transmission competence. Elderly COVID-19 patients are at significantly higher risk of severe course of disease and death. Therefore, outbreaks in nursing homes are particularly challenging for facility managers and health authorities. Here, we report three outbreaks of COVID-19 related to nursing homes (NH01.a, NH02 and NH03) with almost 1000 affected individuals during the first COVID-19 wave in Berlin, Germany. The occurrence of cases and the measures taken were analyzed retrospectively. In all three outbreaks, the index persons were nursing home employees or volunteers. Measures taken were quarantine of contacts, close-meshed tests, separation of the affected housing unit, suspension of admission, ban on visiting, and equipping staff with personal protective equipment, of which there was a shortage in Germany at the beginning of the pandemic. A court-ordered quarantine became necessary for three residents of NH01.a due to cognitive disabilities. In total, 61 persons were tested positive for SARS-CoV-2 in NH01.a, ten persons in NH02, and sixteen persons in NH03. Seventeen patients (27.9%) of NH01.a and three patients (18.8%) of NH03 were referred to hospital. Of all confirmed cases, thirteen (21.3%) related to NH01.a and four (25.0%) related to NH03 died as a result of the infection. Besides one 82 year old volunteer, all deceased persons were residents aged between 66 and 98. Our results emphasize the importance of a previously developed containment and cluster strategy for nursing homes. Due to the particular vulnerability of the residents, immediate action, close cooperation and communication between the facility management, residents, visitors and the health authorities are essential in the case of confirmed COVID-19 cases in healthcare facilities.

Modelling the effect of Covid-19 mortality on the economy of Nigeria

Objectives

This paper is aimed at modelling the effect of COVID-19 mortality per population (CMP), a proxy for COVID-19 on the Gross Domestics Product (GDP) per capita per COVID-19 cases (RGDPC), a proxy for the economic wellbeing of a nation.

Methods

Nine models divided into three groups (Gaussian polynomial, other non-linear, and Gamma generalized polynomial models) were fitted for RGDPC data on CMP, collected from 1st June to 31st December 2020.

Results

The result showed that the gamma cubic model was selected as the best model out of the 9 competing models to predict the economic wellbeing of Nigeria. Predictions were made for the whole day in the year 2021.

Conclusion

It is therefore concluded that there is a non-linear relationship between COVID-19 mortality and the economic wellbeing of Nigerians. Thus, COVID-19 mortality has an adverse effect on the wellbeing of Nigerians. The economic wellbeing of Nigerians can be improved if COVID-19 mortality is stopped.

Early Adoption of Longitudinal Surveillance for SARS-CoV-2 among Staff in Long-Term Care Facilities: Prevalence, Virologic and Sequence Analysis

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in 2019 and has become a major global pathogen in an astonishingly short period of time. The emergence of SARS-CoV-2 has been notable due to its impacts on residents in long-term care facilities (LTCFs). LTCF residents tend to possess several risk factors for severe outcomes of SARS-CoV-2 infection, including advanced age and the presence of comorbidities. Indeed, residents of LTCFs represent approximately 40% of SARS-CoV-2 deaths in the United States. Few studies have focused on the prevalence and transmission dynamics of SARS-CoV-2 among LTCF staff during the early months of the pandemic, prior to mandated surveillance testing. To assess the prevalence and incidence of SARS-CoV-2 among LTCF staff, characterize the extent of asymptomatic infections, and investigate the genomic epidemiology of the virus within these settings, we sampled staff for 8 to 11 weeks at six LTCFs with nasopharyngeal swabs from March through June of 2020. We determined the presence and levels of viral RNA and infectious virus and sequenced 54 nearly complete genomes. Our data revealed that over 50% of infections were asymptomatic/mildly symptomatic and that there was a strongly significant relationship between viral RNA (vRNA) and infectious virus, prolonged infections, and persistent vRNA (4+ weeks) in a subset of individuals, and declining incidence over time. Our data suggest that asymptomatic SARS-CoV-2-infected LTCF staff contributed to virus persistence and transmission within the workplace during the early pandemic period. Genetic epidemiology data generated from samples collected during this period support that SARS-CoV-2 was commonly spread between staff within an LTCF and that multiple-introduction events were less common.

IMPORTANCE Our work comprises unique data on the characteristics of SARS-CoV-2 dynamics among staff working at LTCFs in the early months of the SARS-CoV-2 pandemic prior to mandated staff surveillance testing. During this time period, LTCF residents were largely sheltering-in-place. Given that staff were able to leave and return daily and could therefore be a continued source of imported or exported infection, we performed weekly SARS-CoV-2 PCR on nasal swab samples collected from this population. There are limited data from the early months of the pandemic comprising longitudinal surveillance of staff at LTCFs. Our data reveal the surprisingly high level of asymptomatic/presymptomatic infections within this cohort during the early months of the pandemic and show genetic epidemiological analyses that add novel insights into both the origin and transmission of SARS-CoV-2 within LTCFs.

Analysis of COVID-19 outbreaks in 3 long-term care facilities in Graz, Austria

Background

Nursing homes and long-term care facilities (LTCF) caring for elderly and chronically ill residents are at high risk to experience severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) outbreaks. We report an outbreak of coronavirus disease 2019 (COVID-19) in 3 LTCFs of the Geriatric Health Centres of Graz, Austria lasting from March 22 to April 14, 2020.

Aim

The objectives of our study were: (1) to elucidate contributing factors and transmission pathways of SARS-CoV-2, (2) to analyze symptoms of COVID-19 in the residents and health care workers.

Methods

We carried out a retrospective outbreak analysis.

Findings

Thirty-six of /277 residents of 3 LTCFs were infected with SARS-CoV-2. Only a quarter of COVID-19 cases among residents had fever ≥38.1°C and 19% suffered from cough. Six of 36 residents remained asymptomatic. Hospitalization rate was 58% in residents. Overall, 33% (12/36) residents infected with SARS-CoV-2 died. Nineteen of 214 health care workers were tested positive for SARS-CoV-2. Universal rt-PCR testing for SARS-CoV-2 of all residents and health care workers as well as infection control measures contributed to ending the outbreaks.

Conclusions

Delayed recognition of possible COVID-19 cases due to either mild symptoms or symptoms that were perceived as atypical early in the pandemic contributed to the transmission of SARS-CoV-2 in LTCFs. This emphasizes the importance of low-threshold testing in LTCF residents.

Rapid Assessment and Containment of Candida auris Transmission in Postacute Care Settings-Orange County, California, 2019

BACKGROUND

Candida auris, a multidrug-resistant yeast, can spread rapidly in ventilator-capable skilled-nursing facilities (vSNFs) and long-term acute care hospitals (LTACHs). In 2018, a laboratory serving LTACHs in southern California began identifying species of Candida that were detected in urine specimens to enhance surveillance of C auris, and C auris was identified in February 2019 in a patient in an Orange County (OC), California, LTACH. Further investigation identified C auris at 3 associated facilities.

OBJECTIVE

To assess the prevalence of C auris and infection prevention and control (IPC) practices in LTACHs and vSNFs in OC.

DESIGN

Point prevalence surveys (PPSs), postdischarge testing for C auris detection, and assessments of IPC were done from March to October 2019.

SETTING

All LTACHs (n = 3) and vSNFs (n = 14) serving adult patients in OC.

PARTICIPANTS

Current or recent patients in LTACHs and vSNFs in OC.

INTERVENTION

In facilities where C auris was detected, PPSs were repeated every 2 weeks. Ongoing IPC support was provided.

MEASUREMENTS

Antifungal susceptibility testing and whole-genome sequencing to assess isolate relatedness.

RESULTS

Initial PPSs at 17 facilities identified 44 additional patients with C auris in 3 (100%) LTACHs and 6 (43%) vSNFs, with the first bloodstream infection reported in May 2019. By October 2019, a total of 182 patients with C auris were identified by serial PPSs and discharge testing. Of 81 isolates that were sequenced, all were clade III and highly related. Assessments of IPC identified gaps in hand hygiene, transmission-based precautions, and environmental cleaning. The outbreak was contained to 2 facilities by October 2019.

LIMITATION

Acute care hospitals were not assessed, and IPC improvements over time could not be rigorously evaluated.

CONCLUSION

Enhanced laboratory surveillance and prompt investigation with IPC support enabled swift identification and containment of C auris.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Epidemiology of COVID-19 among health personnel in long-term care centers in Seville

Background

Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2 infection, spreads swiftly in nursing homes and assisted living facilities, leading to a high degree of lethality. The data generated by an epidemiological surveillance program allow for obtaining valid information on the diseases’ epidemiology and possible prevention methods.

Objective

This work aims to analyze COVID-19 epidemiology among healthcare staff based in the Seville healthcare district (Spain) and evaluate its role in outbreaks in nursing homes.

Methods

This is an observational, descriptive study of 88 assisted living facilities located in the city of Seville from March 1 to May 23, 2020. Data were obtained via epidemiological surveys on staff at centers where there were outbreaks (n = 732 in 14 nursing homes). The cumulative incidence, epidemic curves, sociodemographic and clinical characteristics, and delays in isolation and notification of cases were calculated. For the statistical analysis, measures of central tendency and dispersion were used as well as confidence intervals and statistical hypothesis tests.

Results

There were 124 cases in staff members (cumulative incidence 16.9%), 79.0% of which were in women. The majority presented with mild symptoms (87.1%). The most common symptoms were fever (31.5%) and cough (49.2%). The median number of days from onset of symptoms to isolation was three.

Conclusions

A high incidence in nursing home staff along with delays in isolation were observed, which could affect the dynamics of transmission in outbreaks. It is necessary to review disease identification and isolation practices among staff as well as emphasize rapid implementation of prevention measures.

Absence of COVID-19 Disease Among Chronically Ventilated Nursing Home Patients

Objective

To describe the experience of COVID-19 disease among chronically ventilated and nonventilated nursing home patients living in 3 separate nursing homes.

Design

Observational study of death, respiratory illness and COVID-19 polymerase chain reaction (PCR) results among residents and staff during nursing home outbreaks in 2020.

Setting and Participants

93 chronically ventilated nursing home patients and 1151 nonventilated patients living among 3 separate nursing homes on Long Island, New York, as of March 15, 2020. Illness, PCR results, and antibody studies among staff are also reported.

Measurements

Data were collected on death rate among chronically ventilated and nonventilated patients between March 15 and May 15, 2020, compared to the same time in 2019; prevalence of PCR positivity among ventilated and nonventilated patients in 2020; reported illness, PCR positivity, and antibody among staff.

Results

Total numbers of deaths among chronically ventilated nursing home patients during this time frame were similar to the analogous period 1 year earlier (9 of 93 in 2020 vs 8 of 100 in 2019, P = .8), whereas deaths among nonventilated patients were greatly increased (214 of 1151 in 2020 vs 55 of 1189 in 2019, P < .001). No ventilated patient deaths were clinically judged to be COVID-19 related. No clusters of COVID-19 illness could be demonstrated among ventilated patients. Surveillance PCR testing of ventilator patients failed to reveal COVID-19 positivity (none of 84 ventilator patients vs 81 of 971 nonventilator patients, P < .002). Illness and evidence of COVID-19 infection was demonstrated among staff working both in nonventilator and in ventilator units.

Conclusions and Implications

COVID-19 infection resulted in illness and death among nonventilated nursing home residents as well as among staff. This was not observed among chronically ventilated patients. The mechanics of chronic ventilation appears to protect chronically ventilated patients from COVID-19 disease.

Risk factors for COVID-19 deaths among elderly nursing home Medicare beneficiaries in the pre-vaccine period

BACKGROUND

Evaluate pre-vaccine pandemic period COVID-19 death risk factors among nursing home (NH) residents.

METHODS

Retrospective cohort study covering Medicare fee-for-service beneficiaries ages ≥65 residing in U.S. NHs. We estimated adjusted hazard ratios (HRs) using multivariate Cox proportional hazards regressions.

RESULTS

Among 608,251 elderly NH residents, 57,398 (9.4%) died of COVID-related illness April 1 to December 22, 2020. About 46.9% (26,893) of these COVID-19 deaths occurred without prior COVID-19 hospitalizations. We observed a consistently increasing age trend for COVID-19 deaths. Racial/ethnic minorities generally shared a similarly high risk of NH COVID-19 deaths with Whites. NH facility characteristics including for-profit ownership and low health inspection ratings were associated with higher death risk. Resident characteristics, including male (HR 1.69), end-stage renal disease (HR 1.42), cognitive impairment (HR 1.34), and immunocompromised status (HR 1.20) were important death risk factors. Other individual-level characteristics were less predictive of death than they were in community-dwelling population.

CONCLUSIONS

Low NH health inspection ratings and private ownership contributed to COVID-19 death risks. Nearly half of NH COVID-19 deaths occurred without prior COVID-19 hospitalization and older residents were less likely to get hospitalized with COVID-19. No substantial differences were observed by race/ethnicity and socioeconomic status for NH COVID-19 deaths.

Excess Deaths in Mexico City and New York City During the COVID-19 Pandemic, March to August 2020

Objectives. To estimate all-cause excess deaths in Mexico City (MXC) and New York City (NYC) during the COVID-19 pandemic. Methods. We estimated expected deaths among residents of both cities between March 1 and August 29, 2020, using log-linked negative binomial regression and compared these deaths with observed deaths during the same period. We calculated total and age-specific excess deaths and 95% prediction intervals (PIs). Results. There were 259 excess deaths per 100 000 (95% PI = 249, 269) in MXC and 311 (95% PI = 305, 318) in NYC during the study period. The number of excess deaths among individuals 25 to 44 years old was much higher in MXC (77 per 100 000; 95% PI = 69, 80) than in NYC (34 per 100 000; 95% PI = 30, 38). Corresponding estimates among adults 65 years or older were 1263 (95% PI = 1199, 1317) per 100 000 in MXC and 1581 (95% PI = 1549, 1621) per 100 000 in NYC. Conclusions. Overall, excess mortality was higher in NYC than in MXC; however, the excess mortality rate among young adults was higher in MXC. Public Health Implications. Excess all-cause mortality comparisons across populations and age groups may represent a more complete measure of pandemic effects and provide information on mitigation strategies and susceptibility factors. (Am J Public Health. 2021;111(10): 1847-1850. https://doi.org/10.2105/AJPH.2021.306430).

Evaluation of a multisectoral intervention to mitigate the risk of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission in long-term care facilities

OBJECTIVE

A Canadian health authority implemented a multisectoral intervention designed to control severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission during long-term care facility (LTCF) outbreaks. The primary objective was to evaluate the effectiveness of the intervention 14 days after implementation.

DESIGN

Quasi-experimental, segmented regression analysis.

INTERVENTION

A series of outbreak measures classified into 4 categories: case and contact management, proactive case detection, rigorous infection control practices and resource prioritization and stewardship.

METHODS

A mixed-effects segmented Poisson regression model was fitted to the incidence rate of coronavirus disease 2019 (COVID-19), calculated every 2 days, within each facility and case type (staff vs residents). For each facility, the outbreak time period was segmented into an early outbreak period (within 14 days of the intervention) and postintervention period (beyond 14 days following the intervention). Model outputs quantified COVID-19 incidence trend and rate changes between these 2 periods. A secondary model was constructed to identify effect modification by case type.

RESULTS

The significant upward trend in COVID-19 incidence rate during the early outbreak period (rate ratio [RR], 1.07; 95% confidence interval [CI], 1.03-1.11; P < .001) reversed during the postintervention period (RR, 0.73; 95% CI, 0.67-0.80; P < .001). The average trend did not differ by case type during the early outbreak period (P > .05) or the postintervention period (P > .05). However, staff had a 70% larger decrease in the average rate of COVID-19 during the postintervention period than residents (RR, 0.30; 95% CI, 0.10-0.88; P < .05).

CONCLUSIONS

Our study provides evidence for the effectiveness of this intervention to reduce the transmission of COVID-19 in LTCFs. This intervention can be adapted and utilized by other jurisdictions to protect the vulnerable individuals in LTCFs.

Protecting Nursing Homes and Long-Term Care Facilities From COVID-19: A Rapid Review of International Evidence

OBJECTIVES

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.

Effects of the Resilience of Nurses in Long-Term Care Hospitals during on Job Stress COVID-19 Pandemic: Mediating Effects of Nursing Professionalism

Purpose: To investigate nursing professionalism as a mediating factor in the relationship between resilience and job stress levels for nurses working in long-term care hospitals during the COVID-19 pandemic. Methods: A cross-sectional survey was conducted from January to March 2021 in seven long-term care hospitals in the Seoul metropolitan area to measure resilience, nursing professionalism, and job stress among nurses. Simple and multiple regression analyses along with the Sobel test were performed to verify the mediating effect of nursing professionalism. Results: Data from 200 nurses were included in the final analysis. Results showed that individual and occupational characteristics could lead to differences in nurses’ resilience, job stress levels, and nursing professionalism. Nursing professionalism had a significant mediating effect on the relationship between resilience and job stress levels. The effect of resilience on job stress levels was significant (β = −0.16, p = 0.024). After controlling for nursing professionalism, the effect declined and was not statistically significant (β = −0.09, p = 0.251). Conclusion: There is a need to increase individual resilience and nursing professionalism through intervention programs and policy proposals to manage job stress among long-term care hospital nurses during the COVID-19 pandemic.

Risk Factors for COVID-19 Morbidity and Mortality in Institutionalised Elderly People

BACKGROUND

SARS-CoV-2 has caused a high mortality in institutionalised individuals. There are very few studies on the involvement and the real impact of COVID-19 in nursing homes. This study analysed factors related to morbidity and mortality of COVID-19 in institutionalised elderly people.

METHODS

This cohort study included 842 individuals from 12 nursing homes in Sant Cugat del Vallès (Spain) from 15 March to 15 May 2020. We evaluated individual factors (demographic, dependence, clinical, and therapeutic) and those related to the nursing homes (size and staff) associated with infection and mortality by SARS-CoV-2. Infection was diagnosed by molecular biology test.

RESULTS

Of the 842 residents included in the analysis, 784 underwent a Polymerase Chain Reaction (PCR) test; 74.2% were women, the mean age was 87.1 years, and 11.1% died. The PCR test was positive in 44%. A total of 33.4% of the residents presented symptoms compatible with COVID-19 and of these, 80.9% were PCR-positive for SARS-CoV-2. Infection by SARS-CoV-2 among residents was associated with the rate of staff infected in the homes. Mortality by SARS-CoV-2 was related to male sex and a greater grade of dependence measured with the Barthel index.

CONCLUSIONS

SARS-Cov-2 infection in institutionalised people is associated with the infection rate in nursing home workers and mortality by SARS-Cov-2 with sex and greater dependency according to the Barthel index. Adequate management of nursing home staff and special attention to measures of infection control, especially of individuals with greater dependence, are keys for successful management of future pandemic situations.

Ecological Analysis of the Decline in Incidence Rates of COVID-19 Among Nursing Home Residents Associated with Vaccination, United States, December 2020-January 2021

OBJECTIVE

To evaluate if facility-level vaccination after an initial vaccination clinic was independently associated with COVID-19 incidence adjusted for other factors in January 2021 among nursing home residents.

DESIGN

Ecological analysis of data from the CDC's National Healthcare Safety Network (NHSN) and from the CDC's Pharmacy Partnership for Long-Term Care Program.

SETTING AND PARTICIPANTS

CMS-certified nursing homes participating in both NHSN and the Pharmacy Partnership for Long-Term Care Program.

METHODS

A multivariable, random intercepts, negative binomial model was applied to contrast COVID-19 incidence rates among residents living in facilities with an initial vaccination clinic during the week ending January 3, 2021 (n = 2843), vs those living in facilities with no vaccination clinic reported up to and including the week ending January 10, 2021 (n = 3216). Model covariates included bed size, resident SARS-CoV-2 testing, staff with COVID-19, cumulative COVID-19 among residents, residents admitted with COVID-19, community county incidence, and county social vulnerability index (SVI).

RESULTS

In December 2020 and January 2021, incidence of COVID-19 among nursing home residents declined to the lowest point since reporting began in May, diverged from the pattern in community cases, and began dropping before vaccination occurred. Comparing week 3 following an initial vaccination clinic vs week 2, the adjusted reduction in COVID-19 rate in vaccinated facilities was 27% greater than the reduction in facilities where vaccination clinics had not yet occurred (95% confidence interval: 14%-38%, P < .05).

CONCLUSIONS AND IMPLICATIONS

Vaccination of residents contributed to the decline in COVID-19 incidence in nursing homes; however, other factors also contributed. The decline in COVID-19 was evident prior to widespread vaccination, highlighting the benefit of a multifaced approach to prevention including continued use of recommended screening, testing, and infection prevention practices as well as vaccination to keep residents in nursing homes safe.

COVID-19 related treatment and outcomes among COVID-19 ICU patients: A retrospective cohort study

Background

The COVID-19 pandemic remains an immediate and present concern, yet as of now there is still no approved therapeutic available for the treatment of COVID-19.This study aimed to investigate and report evidence concerning demographic characteristics and currently-used medications that contribute to the ultimate outcomes of COVID-19 ICU patients.

Methods

A retrospective cohort study was conducted among all COVID-19 patients in the Intensive Care Unit (ICU) of Asir Central Hospital in Saudi Arabia between the 1st and 30th of June 2020. Data extracted from patients’ medical records included their demographics, home medications, medications used to treat COVID-19, treatment durations, ICU stay, hospital stay, and ultimate outcome (recovery or death).Descriptive statistics and regression modelling were used to analyze and compare the results. The study was approved by the Institutional Ethics Committees at both Asir Central Hospital and King Khalid University.

Results

A total of 118 patients with median age of 57 years having definite clinical and disease outcomes were included in the study. Male patients accounted for 87% of the study population, and more than 65% experienced at least one comorbidity. The mean hospital and ICU stay was 11.4 and 9.8 days, respectively. The most common drugs used were tocilizumab (31.4%), triple combination therapy (45.8%), favipiravir (56.8%), dexamethasone (86.7%), and enoxaparin (83%). Treatment with enoxaparin significantly reduced the length of ICU stay (p = 0.04) and was found to be associated with mortality reduction in patients aged 50−75 (p = 0.03), whereas the triple regimen therapy and tocilizumab significantly increased the length of ICU stay in all patients (p = 0.01, p = 0.02 respectively).

Conclusion

COVID-19 tends to affect males more significantly than females. The use of enoxaparin is an important part of COVID-19 treatment, especially for those above 50 years of age, while the use of triple combination therapy and tocilizumab in COVID-19 protocols should be reevaluated and restricted to patients who have high likelihood of benefit.

[Factors associated with the incidence and mortality from COVID-19 in the autonomous communities of Spain]

OBJECTIVE

Analyze the evolution of the epidemic of COVID-19 after the alarm state and identify factors associated with the differences between the autonomous communities.

METHOD

Ecological study that used epidemiological, demographic, environmental and variables on the structure of health services as explanatory variables. The analysis period was from March 15th (the start of the alarm state) until April 22nd, 2020. Incidence and mortality rates were the main response variables. The magnitude of the associations has been estimated using the Spearman correlation coefficient and multiple regression analysis.

RESULTS

Incidence and mortality rates at the time of decree of alarm status are associated with current incidence, mortality and hospital demand rates. Higher mean temperatures are significantly associated with a lower current incidence of COVID-19 in the autonomous communities. Likewise, a higher proportion of older people in nursing homes is significantly associated with a higher current mortality in the autonomous communities.

CONCLUSION

It is possible to predict the evolution of the epidemic through the analysis of incidence and mortality. Lower temperatures and the proportion of older people in residences are factors associated with a worse prognosis. These parameters must be considered in decisions about the timing and intensity of the implementation of containment measures. In this sense, strengthening epidemiological surveillance is essential to improve predictions.

Estimates of COVID-19 Cases and Deaths Among Nursing Home Residents Not Reported in Federal Data

Importance

Federal data underestimate the impact of COVID-19 on US nursing homes because federal reporting guidelines did not require facilities to report case and death data until the week ending May 24, 2020.

Objective

To assess the magnitude of unreported cases and deaths in the National Healthcare Safety Network (NHSN) and provide national estimates of cases and deaths adjusted for nonreporting.

Design, Setting, and Participants

This is a cross-sectional study comparing COVID-19 cases and deaths reported by US nursing homes to the NHSN with those reported to state departments of health in late May 2020. The sample includes nursing homes from 20 states, with 4598 facilities in 12 states that required facilities to report cases and 7401 facilities in 19 states that required facilities to report deaths. Estimates of nonreporting were extrapolated to infer the national (15 397 facilities) unreported cases and deaths in both May and December 2020. Data were analyzed from December 2020 to May 2021.

Exposures

Nursing home ownership (for-profit or not-for-profit), chain affiliation, size, Centers for Medicare & Medicaid Services star rating, and state.

Main Outcomes and Measures

The main outcome was the difference between the COVID-19 cases and deaths reported by each facility to their state department of health vs those reported to the NHSN.

Results

Among 15 415 US nursing homes, including 4599 with state case data and 7405 with state death data, a mean (SE) of 43.7% (1.4%) of COVID-19 cases and 40.0% (1.1%) of COVID-19 deaths prior to May 24 were not reported in the first NHSN submission in sample states, suggesting that 68 613 cases and 16 623 deaths were omitted nationwide, representing 11.6% of COVID-19 cases and 14.0% of COVID-19 deaths among nursing home residents in 2020.

Conclusions and Relevance

These findings suggest that federal NHSN data understated total cases and deaths in nursing homes. Failure to account for this issue may lead to misleading conclusions about the role of different facility characteristics and state or federal policies in explaining COVID outbreaks.

Preventing COVID-19 in assisted living facilities: An impossible task pending vaccination roll out

Here, we aimed to describe the clinical outcomes of the residents of a long-term care facility during its closure to visitors and suppliers in response to the first COVID-19 pandemic from February 23 to June 22, 2020, and the results of the facility-wide SARS-CoV-2 testing of residents and staff in June 2020 before its partially reopening. Seventy-four residents and 53 members of staff were included in the present study. The staff underwent nasopharyngeal swab tests for SARS-CoV-2, and both the staff and residents underwent serological tests to detect IgG antibodies against SARS-CoV-2. The results of all of the tests were negative. Conversely, 94% of residents and 38% members of the staff were tested positive to the nasopharyngeal swab tests during the second COVID-19 pandemic wave (data collected from November 1 to November 30, 2020). Our experience suggests that, in the presence of a life-threatening pandemic such as SARS-CoV-2 infection, the prompt use of restrictive procedures can prevent the spread and progression of disease in assisted living facilities in the short term but may fail in the long term, especially when the prevalence of the COVID-19 greatly increased outside the facility enhancing the risk of import the disease from outside. SARS-CoV-2 vaccination of residents and staff members would contribute to control/limit the prevalence and the spread of the virus.

Postacute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 Infection: A State-of-the-Art Review

The vast majority of patients (>99%) with severe acute respiratory syndrome coronavirus 2 survive immediate infection but remain at risk for persistent and/or delayed multisystem. This review of published reports through May 31, 2021, found that manifestations of postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection (PASC) affect between 33% and 98% of coronavirus disease 2019 survivors and comprise a wide range of symptoms and complications in the pulmonary, cardiovascular, neurologic, psychiatric, gastrointestinal, renal, endocrine, and musculoskeletal systems in both adult and pediatric populations. Additional complications are likely to emerge and be identified over time. Although data on PASC risk factors and vulnerable populations are scarce, evidence points to a disproportionate impact on racial/ethnic minorities, older patients, patients with preexisting conditions, and rural residents. Concerted efforts by researchers, health systems, public health agencies, payers, and governments are urgently needed to better understand and mitigate the long-term effects of PASC on individual and population health.

Obesity, a major risk factor for immunity and severe outcomes of COVID-19

An influenza-like virus named severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is responsible for COVID-19 disease and spread worldwide within a short time. COVID-19 has now become a significant concern for public health. Obesity is highly prevalent worldwide and is considered a risk factor for impairing the adaptive immune system. Although diabetes, hypertension, cardiovascular disease (CVD), and renal failure are considered the risk factors for COVID-19, obesity is not yet well-considered. The present study approaches establishing a systemic association between the prevalence of obesity and its impact on immunity concerning the severe outcomes of COVID-19 utilizing existing knowledge. Overall study outcomes documented the worldwide prevalence of obesity, its effects on immunity, and a possible underlying mechanism covering obesity-related risk pathways for the severe outcomes of COVID-19. Overall understanding from the present study is that being an immune system impairing factor, the role of obesity in the severe outcomes of COVID-19 is worthy.

COVID-19 risk: Adult Medicaid beneficiaries with autism, intellectual disability, and mental health conditions

LAY ABSTRACT

Autistic adults, adults with intellectual disability, and adults with other mental health conditions may have higher risk of contracting COVID-19 or experiencing more severe illness from COVID-19 if infected. We used data from Medicaid to look at whether autistic adults and other adults with intellectual disability and other mental health conditions were more likely to have risk factors for COVID-19, such as living in a residential facility, receiving services regularly in the home from outside caregivers, having had a long hospitalization, having had avoidable hospitalizations, and having high-risk health conditions. We found that autistic adults had higher odds of living in a residential facility, receiving in-home services from outside caregivers, having had an avoidable hospitalization, and having a high-risk health condition, compared to neurotypical adults without mental health conditions. Adults with intellectual disability had similar odds of having these conditions. Adults with other mental health conditions were also more likely to live in a residential facility, receive services from outside caregivers, and have had avoidable hospitalizations compared to the neurotypical population without mental health conditions. They had three times higher odds of having a high-risk health condition. High risk of COVID-19 among autistic adults and adults with intellectual disability and mental health conditions should be recognized by clinicians, and these groups should be prioritized for vaccine outreach.

Risk Factors Associated with Nursing Home COVID-19 Outbreaks: A Retrospective Cohort Study

Background: The coronavirus disease 2019 (COVID-19) pandemic had a devastating impact on nursing homes/long-term care facilities. This study examined the relationship between geography, size, design, organizational characteristics, and implementation of infection prevention and control (IPC) measures and the extent of COVID-19 outbreaks in nursing homes in the Autonomous Province of Trento (Italy) during the time frame of March-May 2020. Methods: The analysis included 57 nursing homes (5145 beds). The association between median cumulative incidence of COVID-19 cases among residents and characteristics of nursing homes was assessed by Mann–Whitney U test, Kruskal–Wallis test or Spearman rho. To evaluate the potential confounding of geographical area, a 2-level random intercept logistic model was fitted, with level 1 units (patients in nursing homes) nested into level 2 units (nursing homes), and “being a COVID-19 case” as the dependent variable. Results: Median cumulative incidence was not significantly associated with any of the variables, except for geographical region (p = 0.002). COVID-19 cases clustered in the part of the province bordering the Italian region most affected by the pandemic (Lombardy) (45.2% median cumulative incidence). Conclusions: Structural/organizational factors and standard IPC measures may not predict the epidemiology of COVID-19 outbreaks and be sufficient alone to protect nursing homes against them.