How timely closure can reduce outbreak duration: gastroenteritis in care homes in North West England, 2012-2016

Environmental sampling for SARS-CoV-2 in long term care facilities: lessons from a pilot study

Background: The SARS-CoV-2 pandemic has highlighted the risk of infection in long-term care facilities (LTCF) and the vulnerability of residents to severe outcomes. Environmental surveillance may help detect pathogens early and inform Infection Prevention and Control (IPC) measures in these settings. Methods: Upon notification of SARS-CoV-2 outbreaks, LTCF within a local authority in South West England were approached to take part in this pilot study. Investigators visited to swab common touch-points and elevated 'non-touch' surfaces (>1.5m above ground level) and samples were analysed for presence of SARS-CoV-2 genetic material (RNA). Data were collected regarding LTCF infrastructure, staff behaviours, clinical and epidemiological risk factors for infection (staff and residents), and IPC measures. Criteria for success were: recruitment of three LTCF; detection of SARS-COV-2 RNA; variation in proportion of SARS-CoV-2 positive surfaces by sampling zone; and collection of clinical and epidemiological data for context. Results: Three LTCFs were recruited, ranging in size and resident demographics. Outbreaks lasted 63, 50 and 30 days with resident attack rates of 53%, 40% and 8%, respectively. The proportion of sample sites on which SARS-CoV-2 was detected was highest in rooms occupied by infected residents and varied elsewhere in the LTCF, with low levels in a facility implementing enhanced IPC measures. The heterogeneity of settings and difficulty obtaining data made it unfeasible to assess association between environmental contamination and infection. A greater proportion of elevated surfaces tested positive for SARS-CoV-2 RNA than common touch-points. Conclusions: SARS-CoV-2 RNA can be detected in a variety of LTCF outbreak settings, both on common-touch items and in elevated sites out of reach. This suggests that further work is justified, to assess feasibility and utility of environmental sampling for infection surveillance in LTCF.

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 .

Environmental screening for SARS-CoV-2 in long term care facilities: lessons from a pilot study

Background: The SARS-CoV-2 pandemic has highlighted the risk of infection transmission in long-term care facilities (LTCF) and the vulnerability of resident populations. It is essential to understand the environmental spread of the virus and risk of indirect transmission to inform Infection Prevention and Control (IPC) measures in these settings. Methods: Upon notification of SARS-CoV-2 outbreaks, LTCF within a local authority in the South West of England were approached to take part in this pilot study. Investigators visited to swab common touch-points and elevated ‘non-touch’ surfaces and samples were analysed for presence of SARS-CoV-2 genetic material (RNA). Data were collected regarding LTCF infrastructure, staff behaviours, clinical and epidemiological risk factors for infection (staff and residents), and IPC measures. Criteria for success were: recruitment of three LTCF; detection of SARS-COV-2 RNA; variation in proportion of SARS-CoV-2 positive surfaces by sampling zone; potential to assess infection risk from SARS-CoV-2 positive surfaces. Results: Three LTCFs were recruited, ranging in size and resident demographics. Outbreaks lasted 63, 50 and 30 days with resident attack rates of 53%, 40% and 8%, respectively. The proportion of sample sites on which SARS-CoV-2 was detected was highest in rooms occupied by infected residents and varied elsewhere in the LTCF, with low levels in a facility implementing enhanced IPC measures. The heterogeneity of settings and difficulty obtaining data made it difficult to assess association between environmental contamination and infection. Elevated surfaces were more likely to test positive for SARS-CoV-2 RNA than common touch-points. Conclusions: SARS-CoV-2 RNA can be detected in a variety of LTCF outbreak settings. We identified variation in environmental spread which could be associated with implementation of IPC measures, though we were unable to assess the impact on infection risk. Sampling elevated surfaces could add to ongoing public health surveillance for SARS-CoV-2 and other airborne pathogens in LTCF.

COVID-19 outbreaks in care homes during the first wave: are Care Quality Commission ratings a good predictor of at-risk homes?

Background

COVID-19 placed a significant burden on the care home population during the first wave. Care Quality Commission’s care quality ratings are given to all English care homes and could be used to identify whether care homes are at risk of COVID-19 outbreaks.

Methods

An audit was performed, April 2020, of Liverpool care homes to identify associations between COVID-19 status and care quality ratings from the Care Quality Commission. Univariable logistic regression was performed to identify whether the Care Quality Commissions ratings were associated with a care home experiencing a COVID-19 outbreak, or a home having asymptomatic cases.

Findings

Over half of the care homes (53.2%, n=41), had laboratory-confirmed clinical cases and 39 (95.1%) of these were reported as outbreaks. A small number of care homes (10.4%, n=8) had asymptomatic cases and over a third had no clinical or asymptomatic cases (36.4%, n=28). There was no significant difference between the overall Care Quality Commission rating of Liverpool and English care homes (p=0.57). There was no significant association between any of the Care Quality Commission rating domains and the presence of COVID-19 outbreaks and/or asymptomatic cases.

Conclusions

During the first wave of the COVID-19 pandemic, Care Quality Commission ratings were not associated with COVID-19 outbreaks or asymptomatic cases in care homes. Infection prevention and control components of Care Quality Commission ratings need to be strengthened to identify care homes at a potential risk of infectious disease outbreaks that may require targeted support. Further large-scale studies will be required to test the findings from this study.

Scope of practice and educational needs of infection prevention and control professionals in Australian residential aged care facilities

BACKGROUND

Healthcare-associated infections are serious and significant complications present across healthcare services, including residential aged care facilities. Although ensuring high quality personal and clinical care delivered to older people residing in these facilities is a high national priority, there is a paucity of evidence published about outbreaks, governance and education programs held for healthcare workers within Australian residential aged care facilities. The aim of this study is to examine the scope of practice of Infection Prevention and Control professionals within Australian residential aged care facilities and the types of infection prevention and control education and training delivered.

METHODS

A cross-sectional study was conducted inviting all Australian residential aged care facilities to participate in an online survey.

RESULTS

A total of 134 residential aged care facilities completed the survey. The majority (88.1%) reported having a designated Infection Prevention and Control professional responsible for surveillance and educational activities. Hand hygiene (94%), personal protective equipment (PPE) (79.9%) and environmental cleaning (70.1%) were some of the available Infection Prevention and Control programs. The lack of access to Infection Prevention and Control education (69.5%) and lack of Infection Prevention and Control expert advice (67.2%) were also reported by some Residential aged care facilities.

CONCLUSION

Australian residential aged care facilities recognise the importance of Infection Prevention and Control training programs to manage infection surveillance and outbreaks. Considerable activities are carried out to increase knowledge on breaking the chain of infection. Yet, more support and resources are needed to assist these efforts.

What proportion of care home outbreaks are caused by norovirus? An analysis of viral causes of gastroenteritis outbreaks in care homes, North East England, 2016-2018

BACKGROUND

Outbreaks of infectious gastroenteritis are common in care homes for the elderly. Norovirus can cause these outbreaks, but diagnosis is frequently based solely on clinical characteristics. Our objective in this study was to describe the epidemiology of norovirus and other gastrointestinal pathogens in these settings.

METHODS

We analysed surveillance data from gastroenteritis outbreaks reported in North East England between 04 July 2016 to 01 July 2018. Stool samples taken during these outbreaks were tested for a range of viral and bacterial pathogens. We described the epidemiology of these outbreaks and explored the characteristics of norovirus outbreaks versus from other viral causes using multivariable logistic regression.

RESULTS

From the 566 care home gastroenteritis outbreaks in this study, we found that norovirus was the pathogen most frequently isolated. Norovirus was detected in 64% of outbreaks with a pathogen identified. Sapovirus was found in 13%; rotavirus in 11%. We found that norovirus outbreaks were associated with higher attack rates (aOR 1.03, 95% CI 1.01-1.05) and fewer cases sampled (aOR 0.74, 95% CI 0.60-0.91), compared to outbreaks caused by other viral pathogens.

CONCLUSIONS

These results are important as they quantify the contribution of norovirus to gastroenteritis outbreaks in care homes. Given this evidence, we emphasize the importance of non-specific outbreak interventions that can affect the impact of all such outbreaks. We further recommend that these findings are used to inform the implementation strategies of any norovirus-specific interventions such as a norovirus vaccine.

Prospective cohort study to investigate the burden and transmission of acute gastroenteritis in care homes: epidemiological results

OBJECTIVES

To estimate the incidence of gastroenteritis in individuals in care homes.

DESIGN

Prospective cohort study.

SETTING

Five participating care homes in North West England, UK.

PARTICIPANTS

Residents and staff present at the five study care homes between 15 August 2017 and 30 May 2019 (n=268).

OUTCOME MEASURES

We calculated incidence rates for all gastroenteritis cases per 1000 person-years at risk and per 1000 bed-days at risk. We also calculated the incidence rate of gastroenteritis outbreaks per 100 care homes per year.

RESULTS

In total 45 cases were reported during the surveillance period, equating to 133.7 cases per 1000 person-years at risk. In residents the incidence rate was 0.62 cases per 1000 bed-days. We observed seven outbreaks in all care homes included in surveillance, a rate of 76.4 outbreaks per 100 care homes per year. 15 stool samples were tested; three were positive for norovirus, no other pathogens were detected.

CONCLUSIONS

We found that surveillance of infectious gastroenteritis disease in care homes based on outbreaks, the current general approach, detected a majority of cases of gastroenteritis. However, if policymakers are to estimate the burden of infectious gastroenteritis in this setting using only routine outbreak surveillance data and not accounting for non-outbreak cases, this study implies that the total burden will be underestimated.

Estimating the burden of care home gastroenteritis outbreaks in England, 2014-2016

BACKGROUND

Outbreaks of infectious gastroenteritis in care homes are common, with norovirus a frequent cause. In England there is no co-ordinated national surveillance system. We aimed to estimate the burden of these outbreaks.

METHODS

Using a generalised linear mixed effects regression model we described the relationship between the observed number of care home outbreaks and covariates. Estimated model parameters were used to infer uplift in the number of outbreaks expected if all areas were subjected to enhanced surveillance. From this we then estimated the total burden of care home gastroenteritis outbreaks in this period.

RESULTS

We estimated a total of 14,146 care home gastroenteritis outbreaks in England during 2014-2016; this is 47% higher than the reported total and a rate of 32.4 outbreaks per 100 care homes per year. The median number of outbreaks from the model estimates was 31 (IQR 20-46) compared to 19 (IQR 12-34) reported from routine surveillance.

CONCLUSIONS

This estimated care home gastroenteritis burden in England indicates that current surveillance substantially underestimates the number of outbreaks, by almost half. Improving this surveillance could provide better epidemiological knowledge of the burden of norovirus to inform public health policy, particularly with the advent of norovirus vaccines.