Recommendations for the management of COVID-19 pandemic in long-term care facilities

Development of morbidity and mortality of SARS-CoV-2 in nursing homes for the elderly in Frankfurt am Main, Germany, 2020-2022: What protective measures are still required?

Introduction

Nursing-home residents are among the highest risk group in the SARS-CoV-2 pandemic. At the onset of the SARS-CoV-2 pandemic, the majority of all deaths from or with SARS-CoV-2 occurred in long-term care facilities (LTCFs), so that maximum protective measures were mandated for these facilities. This study analyzed the impact of the new virus variants and the vaccination campaign on disease severity and mortality among nursing home residents and staff through 2022 as a basis for determining which protective measures remain necessary and appropriate.

Methods

In five homes in Frankfurt am Main, Germany, with a total capacity for 705 residents, all cases occurring in the facility among residents and staff were recorded and documented (date of birth and diagnosis, hospitalization and death, vaccination status) and were descriptively analyzed with SPSS.

Results

By 31^st August 2022, 496 residents tested positive for SARS-CoV-2, 93 in 2020, 136 in 2021, and 267 in 2022; 14 residents presented with a second SARS-CoV-2 infection in 2022, having previously experienced an infection in 2020 or 2021. The percentage of hospitalizations decreased from 24.7% (2020) and 17.6% (2021) to 7.5% (2022), and the percentage of deaths decreased from 20.4% and 19.1% to 1.5%. In 2021, 61.8% of those infected were vaccinated (at least 2x); in 2022, 86.2% of residents had been vaccinated twice, 84% of whom had already had a booster vaccination. Hospitalization and death rates were significantly higher among the unvaccinated than the vaccinated throughout all years (unvaccinated 21.5% and 18.0%; vaccinated 9.8% and 5.5%; KW test p=0.000). However, this difference was no longer significant under the prevalence of the Omicron variant in 2022 (unvaccinated 8.3% and 0%; p=0.561; vaccinated 7.4% and 1.7%; p=0.604). From 2020 to 2022, 400 employees were documented as infected, with 25 having second infections in 2022. Only one employee showed a second infection in 2021 following the first in 2020. Three employees were hospitalized; no deaths occurred.

Discussion and conclusion

Severe COVID-19 courses occurred with the Wuhan Wild type in 2020, with a high death rate among nursing-home residents. In contrast, during the waves in 2022 with the relatively mildly pathogenic Omicron variant, many infections but few severe courses and deaths were observed among the now mostly vaccinated and boostered nursing-home residents. Given the high immunity of the population and the low pathogenicity of the circulating virus - even in nursing-home residents - protective measures in nursing homes that restrict people's right to self-determination and quality of life no longer seem justified. Instead, the general hygiene rules and the recommendations of the KRINKO (German Commission for Hospital Hygiene and Infection Prevention) on infection prevention should be followed, and the recommendations of the STIKO (German Standing Commission on Vaccination) on vaccination not only against SARS-CoV-2 but also against influenza and pneumococci should be observed.

Management of patients with SARS-CoV-2 infections with focus on patients with chronic lung diseases (as of 10 January 2022) : Updated statement of the Austrian Society of Pneumology (ASP)

The Austrian Society of Pneumology (ASP) launched a first statement on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in May 2020, at a time when in Austria 285 people had died from this disease and vaccinations were not available. Lockdown and social distancing were the only available measures to prevent more infections and the breakdown of the health system. Meanwhile, in Austria over 13,000 patients have died in association with a SARS-CoV‑2 infection and coronavirus disease 2019 (COVID-19) was among the most common causes of death; however, SARS-CoV‑2 has been mutating all the time and currently, most patients have been affected by the delta variant where the vaccination is very effective but the omicron variant is rapidly rising and becoming predominant. Particularly in children and young adults, where the vaccination rate is low, the omicron variant is expected to spread very fast. This poses a particular threat to unvaccinated people who are at elevated risk of severe COVID-19 disease but also to people with an active vaccination. There are few publications that comprehensively addressed the special issues with SARS-CoV‑2 infection in patients with chronic lung diseases. These were the reasons for this updated statement. Pulmonologists care for many patients with an elevated risk of death in case of COVID-19 but also for patients that might be at an elevated risk of vaccination reactions or vaccination failure. In addition, lung function tests, bronchoscopy, respiratory physiotherapy and training therapy may put both patients and health professionals at an increased risk of infection. The working circles of the ASP have provided statements concerning these risks and how to avoid risks for the patients.

[The SARS-CoV-2 Pandemic in Long-Term Care Facilities for the Elderly: Analysis of Data from Frankfurt am Main, Germany, March 2020 - September 2021]

BACKGROUND

Residents in long-term care facilities (LTCF) are particularly vulnerable during the SARS-CoV-2 pandemic. In the first wave of the pandemic in many countries, 30-70% of all deaths from or with SARS-CoV-2 were LTCF residents, although their proportion in the population is typically less than 1%. Findings from LTCFs in Frankfurt am Main (March 2020-September 2021) are presented below and discussed in terms of necessary improvements.

MATERIAL AND METHODS

The reports of positive PCR tests for SARS-CoV-2 in residents and staff of the LTCF in Frankfurt am Main and their symptoms were descriptively evaluated. In addition, the total deaths in nursing homes from 2018 to June 2021 were surveyed per quarter.

RESULTS

In the first pandemic wave (March-May 2020), 111 SARS-CoV-2-positive LTCF residents were reported to the Public Health Department in Frankfurt am Main, of whom 40% were asymptomatic, 48% were hospitalized, and 23% died. In the subsequent pandemic phases through September 30, 2021, additional 1196 residents infected with SARS-CoV-2 were reported, with most of them being asymptomatic (70%); they were hospitalized less frequently (27%). Mortality was also lower (17.6%). Overall mortality in LTCF was 7.6% higher in 2020 than in 2019 and 1.1% higher than in the "flu year" of 2018.

DISCUSSION

In contrast to the first wave, when only a few LTCF residents contracted COVID-19, in the second pandemic wave in autumn/winter 2020/21, with high incidences in the general population, SARS-CoV-2 outbreaks in LTCF in Frankfurt could not be prevented, despite extensive hygiene, infection prevention, and contact mitigation measures (including visitor restrictions) that massively limited residents' quality of life and their personal rights. Only when vaccination rates increased among residents and staff from April 2021 onwards, there were no massive outbreaks. To better protect LTCF residents, an appropriate balance was called for between protecting against infection and avoiding collateral damage by maintaining the freedom and quality of life of nursing home residents as best as possible.

[Long-term care facilities during the COVID-19 pandemic : Considerations on the way back to normality]

Langzeitpflegeeinrichtungen (LPE) waren und sind von der COVID-19-Pandemie besonders betroffen. Die Dimension der Ausbrüche und die hohe Letalität unter den Bewohner(innen) (BW) führten zu massiven Einschränkungen, v. a. im Bereich der sozialen Kontakte und Aktivitäten, aber auch in Bereichen der medizinischen Versorgung. Mit dem Start der Impfungen und den verbesserten Testmöglichkeiten haben sich nun aber die Voraussetzungen geändert, und bestehende Beschränkungen müssen auf ihre Zweckmäßigkeit evaluiert werden. In einer interprofessionellen und interdisziplinären Expertengruppe wurden Überlegungen erstellt, wie ein Weg zurück in die Normalität für LPE ausehen kann.