Can long-term care facilities remain a coronavirus disease 2019 (COVID-19)-free bubble? An outbreak report

COVID-19 burden and influencing factors in Swiss long-term-care facilities: a cross-sectional analysis of a multicentre observational cohort

OBJECTIVES: To describe the burden of COVID-19 in Swiss long-term care facilities in 2020, to identify its influencing factors, and to assess vaccination rates among residents and healthcare workers at the end of the vaccine campaign in Switzerland in May 2021. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: Long-term care facilities from two Swiss cantons (St. Gallen / Eastern Switzerland and Vaud / Western Switzerland). METHODS: We collected numbers of COVID-19 cases and related deaths and all-cause mortality for 2020, potential risk factors at the institutional level (e.g. size, infection prevention and control measures, and resident characteristics), and vaccination rates among residents and healthcare workers. Univariate and multivariate analyses were used to identify factors associated with resident mortality in 2020. RESULTS: We enrolled 59 long-term care facilities with a median of 46 (interquartile range [IQR]: 33–69) occupied beds. In 2020, the median COVID-19 incidence was 40.2 (IQR: 0–108.6) per 100 occupied beds, with higher rates in VD (49.9%) than in SG (32.5%; p = 0.037). Overall, 22.7% of COVID-19 cases died, of which 24.8% were COVID-19-related deaths. In the univariate analysis, higher resident mortality was associated with COVID-19 rates among residents (p < 0.001) and healthcare workers (p = 0.002) and age (p = 0.013). Lower resident mortality was associated with the proportion of single rooms (p = 0.012), isolation of residents with COVID-19 in single rooms (p = 0.003), symptom screening of healthcare workers (p = 0.031), limiting the number of visits per day (p = 0.004), and pre-scheduling visits (p = 0.037). In the multivariate analysis, higher resident mortality was only associated with age (p = 0.03) and the COVID-19 rate among residents (p = 0.013). Among 2936 residents, 2042 (69.9%) received ≥1 dose of the COVID-19 vaccine before 31 May 2021. Vaccine uptake among healthcare workers was 33.8%. CONCLUSION AND IMPLICATIONS: COVID-19 burden was high but also highly variable in Swiss long-term care facilities. severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among healthcare workers was a modifiable factor associated with increased resident mortality. Symptom screening of healthcare workers appeared to be an effective preventive strategy and should be included in routine infection prevention and control measures. Promoting COVID-19 vaccine uptake among healthcare workers should be a priority in Swiss long-term care facilities.

Incidence of healthcare-associated coronavirus disease 2019 (COVID-19) in the state of Geneva

An examination of all coronavirus disease 2019 (COVID-19) cases and patient movements in Geneva indicated important disease activity within the healthcare system since the beginning of the pandemic. We estimate that 4.3% of all COVID-19 cases were likely acquired within the healthcare system, contributing to 62% of the COVID-19-related deaths.

Occupational and community risk of SARS-CoV-2 infection among employees of a long-term care facility: an observational study

BACKGROUND

We investigated the contribution of both occupational and community exposure for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among employees of a university-affiliated long-term care facility (LTCF), during the 1st pandemic wave in Switzerland (March-June 2020).

METHODS

We performed a nested analysis of a seroprevalence study among all volunteering LTCF staff to determine community and nosocomial risk factors for SARS-CoV-2 seropositivity using modified Poison regression. We also combined epidemiological and genetic sequencing data from a coronavirus disease 2019 (COVID-19) outbreak investigation in a LTCF ward to infer transmission dynamics and acquisition routes of SARS-CoV-2, and evaluated strain relatedness using a maximum likelihood phylogenetic tree.

RESULTS

Among 285 LTCF employees, 176 participated in the seroprevalence study, of whom 30 (17%) were seropositive for SARS-CoV-2. Most (141/176, 80%) were healthcare workers (HCWs). Risk factors for seropositivity included exposure to a COVID-19 inpatient (adjusted prevalence ratio [aPR] 2.6; 95% CI 0.9-8.1) and community contact with a COVID-19 case (aPR 1.7; 95% CI 0.8-3.5). Among 18 employees included in the outbreak investigation, the outbreak reconstruction suggests 4 likely importation events by HCWs with secondary transmissions to other HCWs and patients.

CONCLUSIONS

These two complementary epidemiologic and molecular approaches suggest a substantial contribution of both occupational and community exposures to COVID-19 risk among HCWs in LTCFs. These data may help to better assess the importance of occupational health hazards and related legal implications during the COVID-19 pandemic.

Explosive nosocomial outbreak of SARS-CoV-2 in a rehabilitation clinic: the limits of genomics for outbreak reconstruction

BACKGROUND

Nosocomial outbreaks of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are frequent despite implementation of conventional infection control measures. An outbreak investigation was undertaken using advanced genomic and statistical techniques to reconstruct likely transmission chains and assess the role of healthcare workers (HCWs) in SARS-CoV-2 transmission.

METHODS

A nosocomial SARS-CoV-2 outbreak in a university-affiliated rehabilitation clinic was investigated, involving patients and HCWs, with high coverage of pathogen whole-genome sequences (WGS). The time-varying reproduction number from epidemiological data (R_t) was estimated, and maximum likelihood phylogeny was used to assess genetic diversity of the pathogen. Genomic and epidemiological data were combined into a Bayesian framework to model the directionality of transmission, and a case-control study was performed to investigate risk factors for nosocomial SARS-CoV-2 acquisition in patients.

FINDINGS

The outbreak lasted from 14^th March to 12^th April 2020, and involved 37 patients (31 with WGS) and 39 employees (31 with WGS), 37 of whom were HCWs. Peak R_t was estimated to be between 2.2 and 3.6. The phylogenetic tree showed very limited genetic diversity, with 60 of 62 (96.7%) isolates forming one large cluster of identical genomes. Despite the resulting uncertainty in reconstructed transmission events, the analyses suggest that HCWs (one of whom was the index case) played an essential role in cross-transmission, with a significantly greater fraction of infections (P<2.2e-16) attributable to HCWs (70.7%) than expected given the number of HCW cases (46.7%). The excess of transmission from HCWs was higher when considering infection of patients [79.0%; 95% confidence interval (CI) 78.5-79.5%] and frail patients (Clinical Frailty Scale score >5; 82.3%; 95% CI 81.8-83.4%). Furthermore, frail patients were found to be at greater risk for nosocomial COVID-19 than other patients (adjusted odds ratio 6.94, 95% CI 2.13-22.57).

INTERPRETATION

This outbreak report highlights the essential role of HCWs in SARS-CoV-2 transmission dynamics in healthcare settings. Limited genetic diversity in pathogen genomes hampered the reconstruction of individual transmission events, resulting in substantial uncertainty in who infected whom. However, this study shows that despite such uncertainty, significant transmission patterns can be observed.

Impact of a Serious Game (Escape COVID-19) on the Intention to Change COVID-19 Control Practices Among Employees of Long-term Care Facilities: Web-Based Randomized Controlled Trial

BACKGROUND

Most residents of long-term care facilities (LTCFs) are at high risk of complications and death following SARS-CoV-2 infection. In these facilities, viral transmission can be facilitated by shortages of human and material resources, which can lead to suboptimal application of infection prevention and control (IPC) procedures. To improve the dissemination of COVID-19 IPC guidelines, we developed a serious game called "Escape COVID-19" using Nicholson's RECIPE for meaningful gamification, as engaging serious games have the potential to induce behavioral change.

OBJECTIVE

As the probability of executing an action is strongly linked to the intention of performing it, the objective of this study was to determine whether LTCF employees were willing to change their IPC practices after playing "Escape COVID-19."

METHODS

This was a web-based, triple-blind, randomized controlled trial, which took place between November 5 and December 4, 2020. The health authorities of Geneva, Switzerland, asked the managers of all LTCFs under their jurisdiction to forward information regarding the study to all their employees, regardless of professional status. Participants were unaware that they would be randomly allocated to one of two different study paths upon registration. In the control group, participants filled in a first questionnaire designed to gather demographic data and assess baseline knowledge before accessing regular online IPC guidelines. They then answered a second questionnaire, which assessed their willingness to change their IPC practices and identified the reasons underlying their decision. They were then granted access to the serious game. Conversely, the serious game group played "Escape COVID-19" after answering the first questionnaire but before answering the second one. This group accessed the control material after answering the second set of questions. There was no time limit. The primary outcome was the proportion of LTCF employees willing to change their IPC practices. Secondary outcomes included the factors underlying participants' decisions, the domains these changes would affect, changes in the use of protective equipment items, and attrition at each stage of the study.

RESULTS

A total of 295 answer sets were analyzed. Willingness to change behavior was higher in the serious game group (82% [119/145] versus 56% [84/150]; P<.001), with an odds ratio of 3.86 (95% CI 2.18-6.81; P<.001) after adjusting for professional category and baseline knowledge, using a mixed effects logistic regression model with LTCF as a random effect. For more than two-thirds (142/203) of the participants, the feeling of playing an important role against the epidemic was the most important factor explaining their willingness to change behavior. Most of the participants unwilling to change their behavior answered that they were already applying all the guidelines.

CONCLUSIONS

The serious game "Escape COVID-19" was more successful than standard IPC material in convincing LTCF employees to adopt COVID-19-safe IPC behavior.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/25595.