COVID-19 prevalence and mortality in longer-term care facilities

VIVALDI ASCOT and Ethnography Study: protocol for a mixed-methods longitudinal study to evaluate the impact of COVID-19 and other respiratory infection outbreaks on care home residents' quality of life and psychosocial well-being

INTRODUCTION

Older adults in care homes experienced some of the highest rates of mortality from SARS-CoV-2 globally and were subjected to strict and lengthy non-pharmaceutical interventions, which severely impacted their daily lives. The VIVALDI ASCOT and Ethnography Study aims to assess the impact of respiratory outbreaks on care home residents' quality of life, psychological well-being, loneliness, functional ability and use of space. This study is linked to the VIVALDI-CT, a randomised controlled trial of staff's asymptomatic testing and sickness payment support in care homes (ISRCTN13296529).

METHODS AND ANALYSIS

This is a mixed-methods, longitudinal study of care home residents (65+) in Southeast England. Group 1-exposed includes residents from care homes with a recent COVID-19 or other respiratory infection outbreak. Group 2-non-exposed includes residents from care homes without a recent outbreak. The study has two components: (a) a mixed-methods longitudinal face-to-face interviews with 100 residents (n=50 from group 1 and n=50 from group 2) to assess the impact of outbreaks on residents' quality of life, psychological well-being, loneliness, functional ability and use of space at time 1 (study baseline) and time 2 (at 3-4 weeks after the first visit); (b) ethnographic observations in communal spaces of up to 10 care homes to understand how outbreaks and related restrictions to the use of space and social activities impact residents' well-being. The study will interview only care home residents who have the mental capacity to consent. Data will be compared and integrated to gain a more comprehensive understanding of the impact of outbreaks on residents' quality of life and well-being.

ETHICS AND DISSEMINATION

The VIVALDI ASCOT and Ethnography Study obtained ethical approval from the Health Research Authority (HRA) Social Care REC (24/IEC08/0001). Only residents with the capacity to consent will be included in the study. Findings will be published in scientific journals.

COVID-19 outbreaks in residential aged care facilities: an agent-based modeling study

Introduction

A disproportionate number of COVID-19 deaths occur in Residential Aged Care Facilities (RACFs), where better evidence is needed to target COVID-19 interventions to prevent mortality. This study used an agent-based model to assess the role of community prevalence, vaccination strategies, and non-pharmaceutical interventions (NPIs) on COVID-19 outcomes in RACFs in Victoria, Australia.

Methods

The model simulated outbreaks in RACFs over time, and was calibrated to distributions for outbreak size, outbreak duration, and case fatality rate in Victorian RACFs over 2022. The number of incursions to RACFs per day were estimated to fit total deaths and diagnoses over time and community prevalence.Total infections, diagnoses, and deaths in RACFs were estimated over July 2023-June 2024 under scenarios of different: community epidemic wave assumptions (magnitude and frequency); RACF vaccination strategies (6-monthly, 12-monthly, no further vaccines); additional non-pharmaceutical interventions (10, 25, 50% efficacy); and reduction in incursions (30% or 60%).

Results

Total RACF outcomes were proportional to cumulative community infections and incursion rates, suggesting potential for strategic visitation/staff policies or community-based interventions to reduce deaths. Recency of vaccination when epidemic waves occurred was critical; compared with 6-monthly boosters, 12-monthly boosters had approximately 1.2 times more deaths and no further boosters had approximately 1.6 times more deaths over July 2023-June 2024. Additional NPIs, even with only 10-25% efficacy, could lead to a 13-31% reduction in deaths in RACFs.

Conclusion

Future community epidemic wave patterns are unknown but will be major drivers of outcomes in RACFs. Maintaining high coverage of recent vaccination, minimizing incursions, and increasing NPIs can have a major impact on cumulative infections and deaths.

Sequencing analysis of SARS-CoV-2 cases in Slovenian long-term care facilities to support outbreak control

Introduction

Residents of long-term care facilities (LTCFs) are at high risk of morbidity and mortality due to COVID-19, especially when new variants of concern (VOC) emerge. To provide intradisciplinary data in order to tailor public health interventions during future epidemics, available epidemiologic and genomic data from Slovenian LTCFs during the initial phases of the COVID-19 pandemic was analyzed.

Methods

The first part of the study included SARS-CoV-2 reverse-transcription Real-Time PCR (rtRT-PCR) positive LTCF residents, from 21 facilities with COVID-19 outbreaks occurring in October 2020. The second part of the study included SARS-CoV-2 rtRT-PCR positive LTCF residents and staff between January and April 2021, when VOC Alpha emerged in Slovenia. Next-generation sequencing (NGS) was used to acquire SARS-CoV-2 genomes, and lineage determination. In-depth phylogenetic and mutational profile analysis were performed and coupled with available field epidemiological data to assess the dynamics of SARS-CoV-2 introduction and transmission.

Results

370/498 SARS-CoV-2 positive residents as well as 558/699 SARS-CoV-2 positive residents and 301/358 staff were successfully sequenced in the first and second part of the study, respectively. In October 2020, COVID-19 outbreaks in the 21 LTCFs were caused by intra-facility transmission as well as multiple independent SARS-CoV-2 introductions. The Alpha variant was confirmed in the first LTCF resident approximately 1.5 months after the first Alpha case was identified in Slovenia. The data also showed a slower replacement of existing variants by Alpha in residents compared to staff and the general population.

Discussion

Multiple SARS CoV-2 introductions as well as intra-facility spreading impacted disease transmission in Slovenian LTCFs. Timely implementation of control measures aimed at limiting new introductions while controlling in-facility transmission are of paramount importance, especially as new VOCs emerge. Sequencing, in conjunction with epidemiological data, can facilitate the determination of the need for future improvements in control measures to protect LTCF residents from COVID-19 or other respiratory infections.

Immune response kinetics to SARS-CoV-2 infection and COVID-19 vaccination among nursing home residents-Georgia, October 2020-July 2022

BACKGROUND

Understanding the immune response kinetics to SARS-CoV-2 infection and COVID-19 vaccination is important in nursing home (NH) residents, a high-risk population.

METHODS

An observational longitudinal evaluation of 37 consenting vaccinated NH residents with/without SARS-CoV-2 infection from October 2020 to July 2022 was conducted to characterize the immune response to spike protein due to infection and/or mRNA COVID-19 vaccine. Antibodies (IgG) to SARS-CoV-2 full-length spike, nucleocapsid, and receptor binding domain protein antigens were measured, and surrogate virus neutralization capacity was assessed using Meso Scale Discovery immunoassays. The participant's spike exposure status varied depending on the acquisition of infection or receipt of a vaccine dose. Longitudinal linear mixed effects modeling was used to describe trajectories based on the participant's last infection or vaccination; the primary series mRNA COVID-19 vaccine was considered two spike exposures. Mean antibody titer values from participants who developed an infection post receipt of mRNA COVID-19 vaccine were compared with those who did not. In a subset of participants (n = 15), memory B cell (MBC) S-specific IgG (%S IgG) responses were assessed using an ELISPOT assay.

RESULTS

The median age of the 37 participants at enrollment was 70.5 years; 30 (81%) had prior SARS-CoV-2 infection, and 76% received Pfizer-BioNTech and 24% Moderna homologous vaccines. After an observed augmented effect with each spike exposure, a decline in the immune response, including %S IgG MBCs, was observed over time; the percent decline decreased with increasing spike exposures. Participants who developed an infection at least two weeks post-receipt of a vaccine were observed to have lower humoral antibody levels than those who did not develop an infection post-receipt.

CONCLUSIONS

These findings suggest that understanding the durability of immune responses in this vulnerable NH population can help inform public health policy regarding the timing of booster vaccinations as new variants display immune escape.

"COVID-19 - A Perfect Storm": A Qualitative Exploration of Residential Care Facility Managers Perspectives on the Psychosocial Impacts of COVID-19

Growing evidence highlights the negative impact of managing the COVID-19 pandemic on the wellbeing of the healthcare workforce, including in the aged care sector. We undertook a qualitative study during the pandemic's third year to explore the psychosocial impacts on nine managers of residential care facilities (RCFs) across metropolitan and rural New South Wales, the largest state in Australia. Four themes were identified: (1) Increased pressure on maintaining aged care services, (2) Increased responsibility on RCF managers, (3) Psychosocial impacts due to accumulating pressures, and (4) Experience of beneficial supports. COVID-19 compounded pre-pandemic sector challenges and added new stressors. While resilient and resourceful, RCF managers experienced workplace stress and burnout, which may affect quality of resident care and impact on staff retention. There is a need for more investment to effectively support staff, and research to identify optimal psychosocial and management supports.

Nursing Home Residents' COVID-19 Infections in the United States: A Systematic Review of Personal and Contextual Factors

Background: This mixed methods systemic review synthesizes the evidence about nursing home risks for COVID-19 infections. Methods: Four electronic databases (PubMed, Web of Science, Scopus, and Sage Journals Online) were searched between January 2020 and October 2022. Inclusion criteria were studies reported on nursing home COVID-19 infection risks by geography, demography, type of nursing home, staffing and resident's health, and COVID-19 vaccination status. The Mixed Methods Appraisal Tool (MMAT) was used to assess the levels of evidence for quality, and a narrative synthesis for reporting the findings by theme. Results: Of 579 initial articles, 48 were included in the review. Findings suggest that highly populated counties and urban locations had a higher likelihood of COVID-19 infections. Larger nursing homes with a low percentage of fully vaccinated residents also had increased risks for COVID-19 infections than smaller nursing homes. Residents with advanced age, of racial minority, and those with chronic illnesses were at higher risk for COVID-19 infections. Discussion and implications: Findings suggest that along with known risk factors for COVID-19 infections, geographic and resident demographics are also important preventive care considerations. Access to COVID-19 vaccinations for vulnerable residents should be a priority.

The experience and reflections of GC labs as an independent clinical laboratory to the COVID-19 pandemic in South Korea

BACKGROUND

Amid the COVID-19 pandemic, extensive testing was undertaken by independent clinical laboratories (ICLs), yet limited research exists on this matter. Drawing from Green Cross Laboratories (GC Labs)' pandemic response experience, this study seeks to offer insights for preparation for the next pandemic.

METHODS

This retrospective study analyzed the outcomes of SARS-CoV-2 real-time reverse transcription polymerase chain reaction (SARS-CoV-2 rRT PCR) tests administered by GC Labs for COVID-19 diagnosis, upon request by different organizations, between February 2020 and April 2022. The distribution of institutions that requested the tests, the type of tests, and the positive rate were analyzed. We investigated resource allocation details.

RESULTS

ICLs were responsible for conducting 85.6% of all tests carried out under South Korea's COVID-19 testing policy during the pandemic. The availability of free testing regardless of symptoms led to a significant increase in the use of pooled tests, which accounted for more than 80% of all tests conducted after August 2021. The gender and age distribution of COVID-19 cases nationwide and GC Labs' positive cases were similar. When we analyzed the positive rate by requesting organizations during the COVID-19 pandemic, despite an overall nationwide positivity rate of 35%, high-risk facilities exhibited a positivity rate of less than 5% by maintaining preemptive testing. The most notable increase in resources during the pandemic was seen in human resource input.

CONCLUSIONS

South Korea's ICLs were able to conduct large volumes of testing during the COVID-19 pandemic because of their logistics and computer systems, scalable testing space, and trained testing personnel. They also had the flexibility to bring in additional resources to expand testing capacity because they are specialized testing organizations. Hence, ICLs could execute the pooled test that the government had introduced for extensive general population screening. The preemptive periodic testing of high-risk populations kept the positive rate much lower than in the general population. This study's findings will aid in refining mass testing-based policies for the next pandemic.

A Web-Based COVID-19 Tool for Testing Residents in Retirement Homes: Development Study

BACKGROUND

Long-term care facilities have been widely affected by the COVID-19 pandemic. Empirical evidence demonstrated that older people are the most impacted and are at higher risk of mortality after being infected. Regularly testing care facility residents is a practical approach to detecting infections proactively. In many cases, the care staff must perform the tests on the residents while also providing essential care, which in turn causes imbalances in their working time. Once an outbreak occurs, suppressing the spread of the virus in retirement homes (RHs) is challenging because the residents are in contact with each other, and isolation measures cannot be widely enforced. Regular testing strategies, on the other hand, have been shown to effectively prevent outbreaks in RHs. However, high-frequency testing may consume substantial staff working time, which results in a trade-off between the time invested in testing and the time spent providing essential care to residents.

OBJECTIVE

We developed a web application (Retirement Home Testing Optimizer) to assist RH managers in identifying effective testing schedules for residents. The outcome of the app, called the "testing strategy," is based on dividing facility residents into groups and then testing no more than 1 group per day.

METHODS

We created the web application by incorporating influential factors such as the number of residents and staff, the average rate of contacts, the amount of time spent to test, and constraints on the test interval and size of groups. We developed mixed integer nonlinear programming models for balancing staff workload in long-term care facilities while minimizing the expected detection time of a probable infection inside the facility. Additionally, by leveraging symmetries in the problem, we proposed a fast and efficient local search method to find the optimal solution.

RESULTS

Considering the number of residents and staff and other practical constraints of the facilities, the proposed application computes the optimal trade-off testing strategy and suggests the corresponding grouping and testing schedule for residents. The current version of the application is deployed on the server of the Where2Test project and is accessible on their website. The application is open source, and all contents are offered in English and German. We provide comprehensive instructions and guidelines for easy use and understanding of the application's functionalities. The application was launched in July 2022, and it is currently being tested in RHs in Saxony, Germany.

CONCLUSIONS

Recommended testing strategies by our application are tailored to each RH and the goals set by the managers. We advise the users of the application that the proposed model and approach focus on the expected scenarios, that is, the expected risk of infection, and they do not guarantee the avoidance of worst-case scenarios.

Shaping care home COVID-19 testing policy: a protocol for a pragmatic cluster randomised controlled trial of asymptomatic testing compared with standard care in care home staff (VIVALDI-CT)

INTRODUCTION

Care home residents have experienced significant morbidity, mortality and disruption following outbreaks of SARS-CoV-2. Regular SARS-CoV-2 testing of care home staff was introduced to reduce transmission of infection, but it is unclear whether this remains beneficial. This trial aims to investigate whether use of regular asymptomatic staff testing, alongside funding to reimburse sick pay for those who test positive and meet costs of employing agency staff, is a feasible and effective strategy to reduce COVID-19 impact in care homes.

METHODS AND ANALYSIS

The VIVALDI-Clinical Trial is a multicentre, open-label, cluster randomised controlled, phase III/IV superiority trial in up to 280 residential and/or nursing homes in England providing care to adults aged >65 years. All regular and agency staff will be enrolled, excepting those who opt out. Homes will be randomised to the intervention arm (twice weekly asymptomatic staff testing for SARS-CoV-2) or the control arm (current national testing guidance). Staff who test positive for SARS-CoV-2 will self-isolate and receive sick pay. Care providers will be reimbursed for costs associated with employing temporary staff to backfill for absence arising directly from the trial.The trial will be delivered by a multidisciplinary research team through a series of five work packages.The primary outcome is the incidence of COVID-19-related hospital admissions in residents. Secondary outcomes include the number and duration of outbreaks and home closures. Health economic and modelling analyses will investigate the cost-effectiveness and cost consequences of the testing intervention. A process evaluation using qualitative interviews will be conducted to understand intervention roll out and identify areas for optimisation to inform future intervention scale-up, should the testing approach prove effective and cost-effective. Stakeholder engagement will be undertaken to enable the sector to plan for results and their implications and to coproduce recommendations on the use of testing for policy-makers.

ETHICS AND DISSEMINATION

The study has been approved by the London-Bromley Research Ethics Committee (reference number 22/LO/0846) and the Health Research Authority (22/CAG/0165). The results of the trial will be disseminated regardless of the direction of effect. The publication of the results will comply with a trial-specific publication policy and will include submission to open access journals. A lay summary of the results will also be produced to disseminate the results to participants.

TRIAL REGISTRATION NUMBER

ISRCTN13296529.

Anticoagulant treatment and COVID-19 mortality among older adults living in nursing homes in Sweden

Background

Anticoagulants (AC) were introduced in March 2020 as standard of care in nursing home (NH) residents affected with COVID-19 in the Stockholm region, Sweden. ACs are proven to reduce the risk of complications and mortality from COVID-19 among patients of other ages and settings, but there is limited scientific evidence underpinning this practice in the NH setting.

Methods

This matched cohort study included 182 NH residents in the Stockholm Region diagnosed with COVID-19 in March-May 2020. The main exposure was any AC treatment. Exposed (n = 91), 49% prevalent (pre-COVID-19 diagnosis) AC and 51% incident AC were compared with unexposed controls (n = 91). The outcome was 28-days all-cause mortality after COVID-19 infection. The mortality odds ratios (OR) were assessed using logistic regression, adjusted for age, sex, multimorbidity, and mobility, also stratified by incident or prevalent AC-type, age group, and sex.

Results

Of the 182 individuals diagnosed with COVID-19 (median age 88 years, 68% women), 39% died within 28 days after diagnosis. Use of either incident or prevalent AC was associated with a reduced, adjusted 28-day mortality (OR[95% CI]: 0.31[0.16-0.62]). In stratified analyses, the association was significant in both age groups: 70-89 (OR: 0.37 [0.15-0.89]) and 90-99 years of age (OR: 0.22 [0.07-0.65]. In sex-stratified analysis, the AC-lowering effect was significant in women only (OR: 0.28[0.11-0.67]). In the analyses stratified by AC type, the mortality-lowering effect was observed for both prevalent AC (OR: 0.35[0.12-0.99]) and incident AC (OR: 0.29[0.11-0.76]).

Conclusions

Both prevalent and incident use of ACs in prophylactic dosing was associated with reduced 28-day mortality among older individuals with COVID-19 in a NH setting. The effect was seen across age-strata and in women. The findings present new insight in best practice for individuals diagnosed with COVID-19 in the NH setting.

The Epidemiological Analysis of COVID-19 Outbreaks in Nursing Homes during the Period of Omicron Variant Predominance

BACKGROUND

The main purpose of this study was to evaluate the epidemic trend and risk factors associated with COVID-19 outbreaks in nursing homes during the period of Omicron variant predominance.

METHODS

The study analyzed the risk factors associated with SARS-CoV-2 infection and death among the 327 residents and 129 healthcare workers (HCWs) in three hospital-affiliated nursing homes through a multivariate Cox regression model.

RESULTS

The rates of receiving a COVID-19 booster dose were 70.3% for the residents and 93.0% for the healthcare workers (HCWs), respectively. A number of asymptomatic individuals, including 54 (16.5%) residents and 15 (11.6%) HCWs, were detected through mass screening surveillance tests. The COVID-19 infection rates during the outbreaks were 41.6% among residents and 48.1% among HCWs, respectively. The case fatality rate among residents was 10.3%. None of the HCWs were hospitalized or died. The multivariate Cox regression model showed that the risk of COVID-19 infection increased in males (HR 2.46; 95% CI 1.47-4.11; p = 0.001), Barthel index ≥ 61 (HR 1.93; 95% CI 1.18-3.17; p = 0.009), and dementia (HR 1.61; 95% CI 1.14-2.27; p = 0.007). The risk of COVID-19 death increased with pneumonia (HR 11.03; 95% CI 3.02-40.31; p < 0.001), hospitalization (HR 7.18; 95% CI 1.97-26.25; p = 0.003), and admission to an intensive care unit (HR 8.67; 95% CI 2.79-26.89; p < 0.001).

CONCLUSIONS

This study highlighted the high infection rates with a substantial proportion of asymptomatic infections for both residents and HCWs, as well as a high case fatality rate for the residents among nursing homes during the Omicron epidemic period. We suggest implementing mass screening through regular surveillance testing as an effective strategy for early detection of COVID-19 and for preventing transmission during an epidemic period. Pneumonia is the primary risk associated with COVID-19 death. Early detection and prompt treatment of pneumonia for vulnerable residents in nursing homes are crucial to protect them from potential mortality.

Factors impacting resident outcomes from COVID-19 outbreaks in Residential Aged Care Facilities in Sydney Local Health District: testing an infection prevention and control scoring system

BACKGROUND

COVID-19 outbreaks have disproportionately affected Residential Aged Care Facilities (RACFs) around the world, with devastating impacts for residents and their families. Many factors such as community prevalence, facility layout, and infection control practices have been linked to resident outcomes. At present, there are no scoring systems designed to quantify these factors and assess their level of association with resident attack rates and mortality rates.

METHODS

We constructed a novel Infection Prevention and Control (IPC) scoring system to quantify facility layout, ability to cohort residents, and IPC practices in RACFs. We conducted a retrospective observational cohort study of COVID-19 outbreaks, applying our IPC scoring system to all COVID-19 outbreaks occurring in RACFs in Sydney Local Health District during the Delta and Omicron waves of the COVID-19 pandemic in New South Wales, Australia.

RESULTS

Twenty-six COVID-19 outbreaks in 23 facilities in the Delta wave, and 84 outbreaks in 53 facilities in the Omicron wave were included in the study. A linear Generalised Estimating Equation model was fitted to the Omicron data. Higher IPC scores were associated with higher attack rates and mortality rates. Facilities with IPC scores greater than 75.0% had attack rates 19.6% higher [95% CI: 6.4%-32.8%] and mortality rates 1.7% higher [95% CI: 0.6%-2.7%] than facilities with an IPC score of less than 60.0%.

CONCLUSIONS

The results of this study suggest the utility of the IPC scoring system for identifying facilities at greater risk of adverse outcomes from COVID-19 outbreaks. While further validation and replication of accuracy is required, the IPC scoring system could be used and adapted to improve planning, policy, and resource allocation for future outbreaks.

A new automated national register-based surveillance system for outbreaks in long-term care facilities in Norway detected three times more severe acute respiratory coronavirus virus 2 (SARS-CoV-2) clusters than traditional methods

OBJECTIVE

To develop and test a new automated surveillance system that can detect, define and characterize infection clusters, including coronavirus disease 2019 (COVID-19), in long-term care facilities (LTCFs) in Norway by combining existing national register data.

BACKGROUND

The numerous outbreaks in LTCFs during the COVID-19 pandemic highlighted the need for accurate and timely outbreak surveillance. As traditional methods were inadequate, we used severe acute respiratory coronavirus virus 2 (SARS-CoV-2) as a model to test automated surveillance.

METHODS

We conducted a nationwide study using data from the Norwegian preparedness register (Beredt C19) and defined the study population as an open cohort from January 2020 to December 2021. We analyzed clusters (≥3 individuals with positive SARS-CoV-2 test ≤14 days) by 4-month periods including cluster size, duration and composition, and residents' mortality associated with clusters.

RESULTS

The study population included 173,907 individuals; 78% employees and 22% residents. Clusters were detected in 427 (43%) of 993 LTCFs. The median cluster size was 4-8 individuals (maximum, 50) by 4-month periods, with a median duration of 9-17 days. Employees represented 60%-82% of cases in clusters and were index cases in 60%-90%. In the last 4-month period of 2020, we detected 107 clusters (915 cases) versus 428 clusters (2,998 cases) in the last period of 2021. The 14-day all-cause mortality rate was higher in resident cases from the clusters. Varying the cluster definitions changed the number of clusters.

CONCLUSION

Automated national surveillance for SARS-CoV-2 clusters in LTCFs is possible based on existing data sources and provides near real-time detailed information on size, duration, and composition of clusters. Thus, this system can assist in early outbreak detection and improve surveillance.

Antibody response in elderly vaccinated four times with an mRNA anti-COVID-19 vaccine

The humoral response after the fourth dose of a mRNA vaccine against COVID-19 has not been adequately described in elderly recipients, particularly those not exposed previously to SARS-CoV-2. Serum anti-RBD IgG levels (Abbott SARS-CoV-2 IgG II Quant assay) and neutralizing capacities (spike SARS-CoV-2 pseudovirus Wuhan and Omicron BA.1 variant) were measured after the third and fourth doses of a COVID-19 mRNA vaccine among 46 elderly residents (median age 85 years [IQR 81; 89]) of an assisted living facility. Among participants never infected by SARS-CoV-2, the mean serum IgG levels against RBD (2025 BAU/ml), 99 days after the fourth vaccine, was as high as 76 days after the third vaccine (1987 BAU/ml), and significantly higher (p = 0.030) when the latter were corrected for elapsed time. Neutralizing antibody levels against the historical Wuhan strain were significantly higher (Mean 1046 vs 1573; p = 0.002) and broader (against Omicron) (Mean 170 vs 375; p = 0.018), following the fourth vaccine. The six individuals with an Omicron breakthrough infection mounted strong immune responses for anti-RBD and neutralizing antibodies against the Omicron variant indicating that the fourth vaccine dose did not prevent a specific adaptation of the immune response. These findings point out the value of continued vaccine boosting in the elderly population.

Immunogenicity, effectiveness and safety of COVID-19 vaccine in older adults living in nursing homes: A real-life study

INTRODUCTION

BNT162b2 (BioNTech and Pfizer) is a nucleoside-modified mRNA vaccine that provides protection against SARS-CoV-2 infection and is generally well tolerated. However, data about its efficacy, immunogenicity and safety in people of old age or with underlying chronic conditions are scarce.

PURPOSE

To describe BNT162b2 (BioNTech and Pfizer) COVID-19 vaccine immunogenicity, effectiveness and reactogenicity after complete vaccination (two doses), and immunogenicity and reactogenicity after one booster, in elders residing in nursing homes (NH) and healthy NH workers in real-life conditions.

METHODS

Observational, ambispective, multicenter study. Older adults and health workers were recruited from three nursing homes of a private hospital corporation located in three Spanish cities. The primary vaccination was carried out between January and March 2021. The follow-up was 13 months. Humoral immunity, adverse events, SARS-CoV-2 infections, hospitalizations and deaths were evaluated. Cellular immunity was assessed in a participant subset.

RESULTS

A total of 181 residents (mean age 84.1 years; 89.9% females, Charlson index ≥2: 45%) and 148 members of staff (mean age 45.2 years; 70.2% females) were surveyed (n:329). After primary vaccination of 327 participants, vaccine response in both groups was similar; ≈70% of participants, regardless of the group, had an antibody titer above the cut-off considered currently protective (260BAU/ml). This proportion increased significantly to ≈ 98% after the booster (p<0.0001 in both groups). Immunogenicity was largely determined by a prior history of COVID-19 infection. Twenty residents and 3 workers were tested for cellular immunity. There was evidence of cellular immunity after primary vaccination and after booster. During the study, one resident was hospitalized for SARS-CoV-2. No SARS-CoV-2-related deaths were reported and most adverse events were mild.

CONCLUSIONS

Our results suggest that the BNT162b2 mRNA COVID-19 vaccine is immunogenic, effective and safe in elderly NH residents with underlying chronic conditions.

COVID-19 outbreak trends in Canada, 2021

Background

In January 2021, the Public Health Agency of Canada launched an outbreak surveillance system, the Canadian COVID-19 Outbreak Surveillance System (CCOSS), with the goal of monitoring incidence and severity of coronavirus disease 2019 (COVID-19) outbreaks across various community settings and complementing case surveillance.

Methods

Seven provinces were included in this report; these provinces submitted weekly cumulative COVID-19 outbreak line lists to CCOSS in 2021. Data includes administrative variables (e.g. date outbreak declared, date outbreak declared over, outbreak identifier), 24 outbreak settings, and number of confirmed cases and outcomes (hospitalization, death). Descriptive analyses for COVID-19 outbreaks across Canada from January 3, 2021, to January 1, 2022, were performed examining trends over time, severity, and outbreak size.

Results

Incidence of outbreaks followed similar trends to case incidence. Outbreaks were most common in school and childcare settings (39%) and industrial/agricultural settings (21%). Outbreak size ranged from 2 to 639 cases per outbreak; the median size was four cases per outbreak. Correctional facilities had the largest median outbreak size with 18 cases per outbreak, followed by long-term care facilities with 10 cases per outbreak. During periods of high case incidence, outbreaks may be under-ascertained due to limited public health capacity, or reporting may be biased towards high-risk settings prioritized for testing. Outbreaks reported to CCOSS were dominated by jurisdictions with the largest populations.

Conclusion

The trends illustrate that COVID-19 outbreaks in 2021 were reported most frequently in community settings such as schools; however, the largest outbreaks occurred in congregate living settings. The information gathered from outbreak surveillance complemented case incidence trends and furthered understanding of COVID-19 in Canada.

Predictors of COVID-19 Outcomes Among Residents of Swedish Long-Term Care Facilities-A Nationwide Study of the Year 2020

OBJECTIVE

We analyzed predictors of SARS-CoV-2 infection and COVID-19 death among residents of long-term care facilities (LTCFs) in Sweden for the pandemic year 2020 and its different waves.

METHODS

The study included 99% of Swedish LTCF residents (N = 82,488). Information on COVID-19 outcomes, sociodemographic factors, and comorbidities were obtained from Swedish registers. Fully adjusted Cox regression models were used to analyze predictors of COVID-19 infection and death.

RESULTS

For the entirety of 2020, age, male sex, dementia, cardiovascular-, lung-, and kidney disease, hypertension, and diabetes mellitus were predictors of COVID-19 infection and death. During 2020 and the two waves, dementia remained the strongest predictor of COVID-19 outcomes, with the strongest effect on death being among those aged 65-75 years.

CONCLUSION

Dementia emerged as a consistent and potent predictor of COVID-19 death among Swedish residents of LTCFs in 2020. These results provide important information on predictors associated with negative COVID-19 outcomes.

Differential COVID-19 infection rates in children, adults, and elderly: Systematic review and meta-analysis of 38 pre-vaccination national seroprevalence studies

Background

Debate exists about whether extra protection of elderly and other vulnerable individuals is feasible in COVID-19. We aimed to assess the relative infection rates in the elderly vs the non-elderly and, secondarily, in children vs adults.

Methods

We performed a systematic review and meta-analysis of seroprevalence studies conducted in the pre-vaccination era. We identified representative national studies without high risk of bias through SeroTracker and PubMed searches (last updated May 17, 2022). We noted seroprevalence estimates for children, non-elderly adults, and elderly adults, using cut-offs of 20 and 60 years (or as close to these ages, if they were unavailable) and compared them between different age groups.

Results

We included 38 national seroprevalence studies from 36 different countries comprising 826 963 participants. Twenty-six of these studies also included pediatric populations and twenty-five were from high-income countries. The median ratio of seroprevalence in elderly vs non-elderly adults (or non-elderly in general, if pediatric and adult population data were not offered separately) was 0.90-0.95 in different analyses, with large variability across studies. In five studies (all in high-income countries), we observed significant protection of the elderly with a ratio of <0.40, with a median of 0.83 in high-income countries and 1.02 elsewhere. The median ratio of seroprevalence in children vs adults was 0.89 and only one study showed a significant ratio of <0.40. The main limitation of our study is the inaccuracies and biases in seroprevalence studies.

Conclusions

Precision shielding of elderly community-dwelling populations before the availability of vaccines was indicated in some high-income countries, but most countries failed to achieve any substantial focused protection.

Registration

Open Science Framework (available at: https://osf.io/xvupr).

Lessons from COVID-19 for future disasters: an opinion paper

A "Pandemic/Disaster Law" is needed to condense and organize the current dispersed and multiple legislation. The State must exercise a single power and command appropriate to each situation, with national validity. The production of plans for the use of land and real estate as potential centers for health care, shelter or refuge is recommended. There should be specific disaster plans at least for Primary Health Care, Hospitals and Socio-sanitary Centers. The guarantee of the maintenance of communication and supply routes is essential, as well as the guarantee of the autochthonous production of basic goods. The pandemic has highlighted the need to redefine the training plans for physicians who, in their different specialties, have to undertake reforms that allow a more versatile and transversal training. National research must have plans to be able to respond quickly to questions posed by the various crises, using all the nation's resources and in particular, all the data and capabilities of the health sector. Contingency plans must consider ethical aspects, and meet the needs of patients and families with a humanized approach. In circumstances of catastrophe, conflicts increase and require a bioethical response that allows the best decisions to be made, with the utmost respect for people's values. Rapid, efficient and truthful communication systems must be contained in a special project for this sector in critic circumstances. Finally, we believe that the creation of National Coordination Centers for major disasters and Public Health can contribute to better face the crises of the future.

Epidemiological and Serological Analysis of a SARS-CoV-2 Outbreak in a Nursing Home: Impact of SARS-CoV-2 Vaccination and Enhanced Neutralizing Immunity Following Breakthrough Infection

Background: Despite a vaccination rate of 82.0% (n = 123/150), a SARS-CoV-2 (Alpha) outbreak with 64.7% (n = 97/150) confirmed infections occurred in a nursing home in Bavaria, Germany. Objective: the aim of this retrospective cohort study was to examine the effects of the Corminaty vaccine in a real-life outbreak situation and to obtain insights into the antibody response to both vaccination and breakthrough infection. Methods: the antibody status of 106 fully vaccinated individuals (54/106 breakthrough infections) and epidemiological data on all 150 residents and facility staff were evaluated. Results: SARS-CoV-2 infections (positive RT-qPCR) were detected in 56.9% (n = 70/123) of fully vaccinated, compared to 100% (n = 27/27) of incompletely or non-vaccinated individuals. The proportion of hospitalized and deceased was 4.1% (n = 5/123) among fully vaccinated and therewith lower compared to 18.5% (n = 5/27) hospitalized and 11.1% (n = 3/27) deceased among incompletely or non-vaccinated. Ct values were significantly lower in incompletely or non-vaccinated (p = 0.02). Neutralizing antibodies were detected in 99.1% (n = 105/106) of serum samples with significantly higher values (p < 0.001) being measured post-breakthrough infection. α-N-antibodies were detected in 37.7% of PCR positive but not in PCR negative individuals. Conclusion: Altogether, our data indicate that SARS-CoV-2 vaccination does provide protection against infection, severe disease progression and death with regards to the Alpha variant. Nonetheless, it also shows that infection and transmission are possible despite full vaccination. It further indicates that breakthrough infections can significantly enhance α-S- and neutralizing antibody responses, indicating a possible benefit from booster vaccinations.

Safety, Effectiveness, and Immunogenicity 6 Months After BNT162B2 mRNA Vaccine in Frail Nursing Home Residents

BACKGROUND

Elderly people who reside in long-term care facilities form a frail and vulnerable population, with multiple pathologies and high percentages of cognitive and functional disability.

OBJECTIVES

The aims of this study were to assess the safety of vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in frail nursing home residents and to evaluate its effectiveness 6 months after full vaccination.

DESIGN

This was an ambispective observational study.

SETTING

Residents of a long-term care facility in Madrid, Spain.

PARTICIPANTS

One hundred and thirty-seven nursing home residents (81.8% female, mean age 87.77 ± 8.31 years) with high comorbidity (61.3% Charlson Index ≥ 3) and frailty (75% Clinical Frail Scale ≥ 7) who received the BNT162B2 mRNA vaccine.

MEASUREMENTS

Safety data were collected to evaluate the type of adverse drug reactions and their duration, severity, and causality. Immunogenicity was tested 6 months after the primary vaccination and effectiveness was evaluated by the incidence of SARS-CoV-2 infection, the number of hospital admissions, and mortality due to coronavirus disease 2019 (COVID-19).

RESULTS

Safety: Of the residents, 21.9% had some adverse reaction and 5.8% had a severe or more serious adverse reaction. The most frequent adverse reactions were fatigue (13.1%), pyrexia (12.4%), and headache (7.3%). No association was observed between frailty (including a need for palliative care) and clinical, functional or cognitive status of the participants and the occurrence of adverse events. Immunogenicity and Effectiveness: After 6 months of vaccination, only one case of SARS-CoV-2 infection was confirmed in the vaccinated residents. Most of the nursing home residents presented positive serology (95.2%). Loss of immunogenicity was associated with older age (95.12 ± 3.97 vs. 87.24 ± 8.25 years; p = 0.03) and no previous COVID-19 infection (16.6% vs. 70%; p < 0.001). Binary logistic regression models did not reveal this association.

CONCLUSION

The BNT162B2 vaccine is well tolerated and effective in nursing home residents, independently of their clinical, functional, cognitive, or frailty characteristics. For the most part, immunogenicity has been maintained over time, regardless of comorbidity, functional status or frailty.

Analyzing Communication Strategies Used in Long Term Care Facilities during the COVID-19 pandemic in New Brunswick, Canada

Purpose:

Effective communication is a key component to managing an event such as a global pandemic. In Canada, federal/provincial reports indicated that effective communication was a challenge in the early days of the COVID-19 pandemic. The purpose of this study was to examine the communication strategies used within long term care facilities in the Canadian province of New Brunswick.

Methods:

Online surveys were used to collect data from administrators, staff, and individuals with family members living in long-term care facilities.

Results:

The findings show an overall satisfaction with the information received by staff and families, however the frequency and format in which information was communicated were inconsistent. All participants indicated that too much information and poor quality information was a challenge. The importance of digital platforms to provide COVID-19 information was consistently identified as a successful communication strategy.

Conclusion:

The findings of this study reveal that the quantity and quality of information provided during the pandemic created challenges for administrators, staff, and families. This is in line with reports from Canadian provincial/federal reports on COVID-19 and long-term care. Recommendations have been made that would benefit the long-term care sector, not only for pandemics, but for communication in general.