Excess mortality for care home residents during the first 23 weeks of the COVID-19 pandemic in England: a national cohort study

All-cause mortality and hospital admissions for nursing home residents during the COVID-19 pandemic: a Norwegian register-based cohort study

BACKGROUND

This paper investigates the consequences of the COVID-19 pandemic on mortality and hospitalization among nursing home residents in Norway. While existing evidence shows that nursing home residents were overrepresented among COVID-19-related deaths, suggesting inadequate protection measures, this study argues that the observed overrepresentation in mortality and hospitalization may partly stem from the inherent frailty of this demographic. Using nationwide administrative data, we assessed excess deaths and hospitalization by comparing pandemic-era rates to those of a pre-pandemic cohort.

METHODS

We compared mortality and hospitalization rates between a pandemic cohort of nursing home residents as of September 2019 (N = 30,052), and a pre-pandemic cohort as of September 2017 (N = 30,429). Both cohorts were followed monthly for two years, beginning in September 2019 and 2017, respectively. This analysis was conducted at the national level and separately for nursing home residents in areas with low, medium, and high SARS-CoV-2 community transmission. Event studies and difference-in-difference models allowed us to separate the impact of the pandemic on mortality and hospitalization from secular and seasonal changes.

RESULTS

The pandemic cohort experienced a non-significant 0.07 percentage points (95% confidence interval (CI): - 0.081 to 0.221) increase in all-cause mortality during the 18 months following pandemic onset, compared to the pre-pandemic cohort. Moreover, our findings indicate a substantial reduction in hospitalizations of 0.27 percentage points (95% CI: - 0.464 to - 0.135) and a non-significant decrease of 0.80 percentage points (95% CI: - 2.529 to 0.929) in the proportion of nursing home residents hospitalized before death. The effect on mortality remained consistent across regions with both high and low levels of SARS-CoV-2 community transmission.

CONCLUSIONS

Our findings indicate no clear evidence of excess all-cause mortality in Norway during the pandemic, neither nationally nor in areas with high infection rates. This suggests that early implementation of nationwide and nursing home-specific infection control measures during the pandemic effectively protected nursing home residents. Furthermore, our results revealed a decrease in hospitalizations, both overall and prior to death, suggesting that nursing homes adhered to national guidelines promoting on-site treatment for residents.

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.

Excess Deaths in Assisted Living and Nursing Homes during the COVID-19 Pandemic in Alberta, Canada

OBJECTIVES

Assisted living (AL) is a significant and growing congregate care option for vulnerable older adults designed to reduce the use of nursing homes (NHs). However, work on excess mortality in congregate care during the COVID-19 pandemic has primarily focused on NHs with only a few US studies examining AL. The objective of this study was to assess excess mortality among AL and NH residents with and without dementia or significant cognitive impairment in Alberta, Canada, during the first 2 years of the COVID-19 pandemic, relative to the 3 years before.

DESIGN

Population-based, retrospective cohort study.

SETTING AND PARTICIPANTS

Residents who lived in an AL or NH facility operated or contracted by the Provincial health care system to provide publicly funded care in Alberta between January 1, 2017, and December 31, 2021.

METHODS

We used administrative health care data, including Resident Assessment Instrument - Home Care (RAI-HC, AL) and Minimum Data Set 2.0 (RAI-MDS 2.0, NHs) records, linked with data on residents' vital statistics, COVID-19 testing, emergency room registrations, and hospital stays. The outcome was excess deaths during COVID-19 (ie, the number of deaths beyond that expected based on pre-pandemic data), estimated, using overdispersed Poisson generalized linear models.

RESULTS

Overall, the risk of excess mortality [adjusted incidence rate ratio (95% confidence interval)] was higher in ALs than in NHs [1.20 (1.14-1.26) vs 1.10 (1.07-1.13)]. Weekly peaks in excess deaths coincided with COVID-19 pandemic waves and were higher among those with diagnosed dementia or significant cognitive impairment in both, AL and NHs.

CONCLUSIONS AND IMPLICATIONS

Finding excess mortality within both AL and NH facilities should lead to greater focus on infection prevention and control measures across all forms of congregate housing for vulnerable older adults. The specific needs of residents with dementia in particular will have to be addressed.

Using Palliative Care Needs Rounds in the UK for care home staff and residents: an implementation science study

Background

Care home residents often lack access to end-of-life care from specialist palliative care providers. Palliative Care Needs Rounds, developed and tested in Australia, is a novel approach to addressing this.

Objective

To co-design and implement a scalable UK model of Needs Rounds.

Design

A pragmatic implementation study using the integrated Promoting Action on Research Implementation in Health Services framework.

Setting

Implementation was conducted in six case study sites (England, n = 4, and Scotland, n = 2) encompassing specialist palliative care service working with three to six care homes each.

Participants

Phase 1: interviews (n = 28 care home staff, specialist palliative care staff, relatives, primary care, acute care and allied health practitioners) and four workshops (n = 43 care home staff, clinicians and managers from specialist palliative care teams and patient and public involvement and engagement representatives). Phase 2: interviews (n = 58 care home and specialist palliative care staff); family questionnaire (n = 13 relatives); staff questionnaire (n = 171 care home staff); quality of death/dying questionnaire (n = 81); patient and public involvement and engagement evaluation interviews (n = 11); fidelity assessment (n = 14 Needs Rounds recordings).

Interventions

(1) Monthly hour-long discussions of residents' physical, psychosocial and spiritual needs, alongside case-based learning, (2) clinical work and (3) relative/multidisciplinary team meetings.

Main outcome measures

A programme theory describing what works for whom under what circumstances with UK Needs Rounds. Secondary outcomes focus on health service use and cost effectiveness, quality of death and dying, care home staff confidence and capability, and the use of patient and public involvement and engagement.

Data sources

Semistructured interviews and workshops with key stakeholders from the six sites; capability of adopting a palliative approach, quality of death and dying index, and Canadian Health Care Evaluation Project Lite questionnaires; recordings of Needs Rounds; care home data on resident demographics/health service use; assessments and interventions triggered by Needs Rounds; semistructured interviews with academic and patient and public involvement and engagement members.

Results

The programme theory: while care home staff experience workforce challenges such as high turnover, variable skills and confidence, Needs Rounds can provide care home and specialist palliative care staff the opportunity to collaborate during a protected time, to plan for residents' last months of life. Needs Rounds build care home staff confidence and can strengthen relationships and trust, while harnessing services' complementary expertise. Needs Rounds strengthen understandings of dying, symptom management, advance/anticipatory care planning and communication. This can improve resident care, enabling residents to be cared for and die in their preferred place, and may benefit relatives by increasing their confidence in care quality.

Limitations

COVID-19 restricted intervention and data collection. Due to an insufficient sample size, it was not possible to conduct a cost-benefit analysis of Needs Rounds or calculate the treatment effect or family perceptions of care.

Conclusions

Our work suggests that Needs Rounds can improve the quality of life and death for care home residents, by enhancing staff skills and confidence, including symptom management, communications with general practitioners and relatives, and strengthen relationships between care home and specialist palliative care staff.

Future work

Conduct analysis of costs-benefits and treatment effects. Engagement with commissioners and policy-makers could examine integration of Needs Rounds into care homes and primary care across the UK to ensure equitable access to specialist care.

Study registration

This study is registered as ISRCTN15863801.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128799) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 19. See the NIHR Funding and Awards website for further award information.

Drivers of COVID-19 Outcomes in Long-Term Care Facilities Using Multi-Level Analysis: A Systematic Review

This study aimed to identify the individual, organizational, and environmental factors which contributed to COVID-19-related outcomes in long-term care facilities (LTCFs). A systematic review was conducted to summarize and synthesize empirical studies using a multi-level analysis approach to address the identified influential factors. Five databases were searched on 23 May 2023. To be included in the review, studies had to be published in peer-reviewed journals or as grey literature containing relevant statistical data. The Joanna Briggs Institute critical appraisal tool was employed to assess the methodological quality of each article included in this study. Of 2137 citations identified after exclusions, 99 records met the inclusion criteria. The predominant individual, organizational, and environmental factors that were most frequently found associated with the COVID-19 outbreak comprised older age, higher dependency level; lower staffing levels and lower star and subset domain ratings for the facility; and occupancy metrics and co-occurrences of outbreaks in counties and communities where the LTCFs were located, respectively. The primary individual, organizational, and environmental factors frequently linked to COVID-19-related deaths comprised age, and male sex; higher percentages of racial and ethnic minorities in LTCFs, as well as ownership types (including private, for-profit, and chain membership); and higher occupancy metrics and LTCF's size and bed capacity, respectively. Unfolding the risk factors collectively may mitigate the risk of outbreaks and pandemic-related mortality in LTCFs during future endemic and pandemics through developing and improving interventions that address those significant factors.

Epidemiology of COVID-19 outbreaks in aged care facilities during postvaccine period: a systematic review and meta-analysis

OBJECTIVE

We aimed to define the epidemiology of COVID-19 outbreaks in aged care facilities (ACFs) during the postvaccine period, including vaccine effectiveness (VE) for this high-risk group.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ovid Medline, Ovid Embase, Scopus, Web of Science and Cochrane databases were searched through 1 September 2023.

ELIGIBILITY CRITERIA

Any original observational studies and trials reporting data on COVID-19 outbreaks among the partially/fully vaccinated residents from ACFs during or after the worldwide implementation of vaccine roll-out.

DATA EXTRACTION AND SYNTHESIS

We estimated the attack rate, case fatality rate, mortality rate and VE during postvaccine period. Random effect model was adopted for meta-analysis. Quality assessment on all included studies was performed using the Meta Quality Appraisal Tool.

RESULTS

38 articles were included from 12 countries reporting 79 outbreaks with 1708 confirmed cases of COVID-19 from 78 ACFs. The pooled attack rate was 28% (95% CI 20% to 37%) among the fully vaccinated residents. Two-thirds (62.5%) of the index cases were unvaccinated healthcare professionals (eg, physicians, nurses) and caregivers. Unvaccinated residents had a significantly higher rates (12%) (95% CI 7% to 19%) of mortality compared with the vaccinated residents (2%) (95% CI% 1 to 4%) and the post-COVID-19 vaccine estimates for case fatality rate (13% vs 23%) and hospitalisation rate (17% vs 37%) were substantially lower. VE in preventing disease among residents in ACFs was 73% (95% CI 49% to 86). Overall, the included studies were heterogeneous in nature, however, the risk of bias was low to moderate.

CONCLUSIONS

Our study reaffirmed the impact of vaccination as a key public health measure to minimise the burden of COVID-19 in ACFs. Facilities with higher crowding indexes should be prioritised for vaccination and should advocate for higher vaccination targets among staff and residents as a critical intervention strategy to minimise disease burden in this vulnerable population.

What remains after the money ends? Evidence on whether admission reductions continued following the largest health and social care integration programme in England

We study the long-term effects on hospital activity of a three-year national integration programme. We use administrative data spanning from 24 months before to 22 months after the programme, to estimate the effect of programme discontinuation using difference-in-differences method. Our results show that after programme discontinuation, emergency admissions were slower to increase in Vanguard compared to non-Vanguard sites. These effects were heterogeneous across sites, with greater reductions in care home Vanguard sites and concentrated among the older population. Care home Vanguards showed significant reductions beginning early in the programme but falling away more rapidly after programme discontinuation. Moreover, there were greater reductions for sites performing poorly before the programme. Overall, this suggests the effects of the integration programme might have been lagged but transitory, and more reliant on continued programme support.

Analysis of the impact of COVID-19 on Scotland's care-homes from March 2020 to October 2021: national linked data cohort analysis

BACKGROUND

The impact of the COVID-19 pandemic on long-term care residents remains of wide interest, but most analyses focus on the initial wave of infections.

OBJECTIVE

To examine change over time in: (i) The size, duration, classification and pattern of care-home outbreaks of COVID-19 and associated mortality and (ii) characteristics associated with an outbreak.

DESIGN

Retrospective observational cohort study using routinely-collected data.

SETTING

All adult care-homes in Scotland (1,092 homes, 41,299 places).

METHODS

Analysis was undertaken at care-home level, over three periods. Period (P)1 01/03/2020-31/08/2020; P2 01/09/2020-31/05/2021 and P3 01/06/2021-31/10/2021. Outcomes were the presence and characteristics of outbreaks and mortality within the care-home. Cluster analysis was used to compare the pattern of outbreaks. Logistic regression examined care-home characteristics associated with outbreaks.

RESULTS

In total 296 (27.1%) care-homes had one outbreak, 220 (20.1%) had two, 91 (8.3%) had three, and 68 (6.2%) had four or more. There were 1,313 outbreaks involving residents: 431 outbreaks in P1, 559 in P2 and 323 in P3. The COVID-19 mortality rate per 1,000 beds fell from 45.8 in P1, to 29.3 in P2, and 3.5 in P3. Larger care-homes were much more likely to have an outbreak, but associations between size and outbreaks were weaker in later periods.

CONCLUSIONS

COVID-19 mitigation measures appear to have been beneficial, although the impact on residents remained severe until early 2021. Care-home residents, staff, relatives and providers are critical groups for consideration and involvement in future pandemic planning.

COVID-19, deaths at home and end-of-life cancer care

During the COVID-19 pandemic there was a period of high excess deaths from cancer at home as opposed to in hospitals or in care homes. In this paper we aim to explore whether healthcare utilisation trajectories of cancer patients in the final months of life during the COVID-19 pandemic reveal any potential unmet healthcare need. We use English hospital records linked to data on all deaths in and out of hospital which identifies the cause and location of death. Our analysis shows that during the periods of peak COVID-19 caseload, patients dying of cancer experienced up to 42% less hospital treatment in their final month of life compared to historical controls. We find reductions in end-of-life hospital care for cancer patients dying in hospitals, care homes/hospices and at home, however the effect is amplified by the shift to more patients dying at home. Through the first year of the pandemic in England, we estimate the number of inpatient bed-days for end-of-life cancer patients in their final month reduced by approximately 282,282, or 25%. For outpatient appointments in the final month of life we find a reduction in face-to-face appointments and an increase in remote appointments which persists through the pandemic year and is not confined only to the periods of peak COVID-19 caseload. Our results suggest reductions in care provision during the COVID-19 pandemic may have led to unmet need, and future emergency reorganisations of health care systems must ensure consistent care provision for vulnerable groups such as cancer patients.

Anti-SARS-CoV-2 Antibody Testing: Role and Indications

Since the onset of the COVID-19 pandemic in March 2020, over 769 million confirmed COVID-19 cases, including close to 7 million COVID-19-related deaths, have been reported. Although mortality rates have dropped notably compared to the first months of the pandemic, spikes in reported cases and mortality rates continue to be registered. Both recent spikes in case numbers and the continued emergence of new variants suggest that vulnerable patient groups, including older adults, immunocompromised patients, and patients with severe comorbidities, are going to continue to be affected by COVID-19. In order to curb the pandemic, relieve the pressure on primary care facilities, and reduce mortality rates, global vaccination programs have been established by the WHO, with over 13.5 billion vaccine doses having been administered globally. In most immunocompetent individuals, vaccination against COVID-19 results in the production of anti-SARS-CoV-2 spike antibodies. However, certain patient subsets have inadequate or reduced immune responses, and immune responses are known to decrease with age. General recommendations on the timing of booster vaccinations may therefore be insufficient to protect vulnerable patients. This review aims to evaluate the clinical role of anti-SARS-CoV-2 antibodies, focusing on measurement indications, prognostic value, and potential as a correlate of protection to guide future booster vaccination strategies.

Factors influencing staff attitudes to COVID-19 vaccination in care homes in England: a qualitative study

BACKGROUND

The COVID-19 pandemic disproportionately affected people living and working in UK care homes causing high mortality rates. Vaccinating staff members and residents is considered the most effective intervention to reduce infection and its transmission rates. However, uptake of the first dose of the COVID-19 vaccine in care homes was variable. We sought to investigate factors influencing uptake of COVID-19 vaccination in care home staff to inform strategies to increase vaccination uptake and inform future preparedness.

METHODS

Twenty care home staff including managerial and administrative staff, nurses, healthcare practitioners and support staff from nine care homes across England participated in semi-structured telephone interviews (March-June 2021) exploring attitudes towards the COVID-19 vaccine and factors influencing uptake. We used thematic analysis to generate themes which were subsequently deductively mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) model. The Behavioural Change Wheel (BCW) was used to identify potential intervention strategies to address identified influences.

RESULTS

Enablers to vaccine uptake included the willingness to protect care home residents, staff and family/friends from infection and the belief that vaccination provided a way back to normality (reflective motivation); convenience of vaccination and access to accurate information (physical opportunity); and a supporting social environment around them favouring vaccination (social opportunity). Barriers included fears about side-effects (automatic motivation); a lack of trust due to the quick release of the vaccine (reflective motivation); and feeling pressurised to accept vaccination if mandatory (automatic motivation).

CONCLUSIONS

We identified influences on COVID-19 vaccine uptake by care home staff that can inform the implementation of future vaccination programmes. Strategies likely to support uptake include information campaigns and facilitating communication between staff and managers to openly discuss concerns regarding possible vaccination side effects. Freedom of choice played an important role in the decision to be vaccinated suggesting that the decision to mandate vaccination may have unintended behavioural consequences.

Excess mortality among older adults institutionalized in long-term care facilities during the COVID-19 pandemic: a population-based analysis in Catalonia

Objectives

To assess excess mortality among older adults institutionalized in nursing homes within the successive waves of the COVID-19 pandemic in Catalonia (north-east Spain).

Design

Observational, retrospective analysis of population-based central healthcare registries.

Setting and participants

Individuals aged >65 years admitted in any nursing home in Catalonia between January 1, 2015, and April 1, 2022.

Methods

Deaths reported during the pre-pandemic period (2015-2019) were used to build a reference model for mortality trends (a Poisson model, due to the event counting nature of the variable "mortality"), adjusted by age, sex, and clinical complexity, defined according to the adjusted morbidity groups. Excess mortality was estimated by comparing the observed and model-based expected mortality during the pandemic period (2020-2022). Besides the crude excess mortality, we estimated the standardized mortality rate (SMR) as the ratio of weekly deaths' number observed to the expected deaths' number over the same period.

Results

The analysis included 175,497 older adults institutionalized (mean 262 days, SD 132), yielding a total of 394,134 person-years: 288,948 person-years within the reference period (2015-2019) and 105,186 within the COVID-19 period (2020-2022). Excess number of deaths in this population was 5,403 in the first wave and 1,313, 111, -182, 498, and 329 in the successive waves. The first wave on March 2020 showed the highest SMR (2.50; 95% CI 2.45-2.56). The corresponding SMR for the 2nd to 6th waves were 1.31 (1.27-1.34), 1.03 (1.00-1.07), 0.93 (0.89-0.97), 1.13 (1.10-1.17), and 1.07 (1.04-1.09). The number of excess deaths following the first wave ranged from 1,313 (2nd wave) to -182 (4th wave). Excess mortality showed similar trends for men and women. Older adults and those with higher comorbidity burden account for higher number of deaths, albeit lower SMRs.

Conclusion

Excess mortality analysis suggest a higher death toll of the COVID-19 crisis in nursing homes than in other settings. Although crude mortality rates were far higher among older adults and those at higher health risk, younger individuals showed persistently higher SMR, indicating an important death toll of the COVID-19 in these groups of people.

Impact of prior SARS-COV-2 infection and vaccination on COVID-19 hospital admission and mortality amongst nursing home residents

BACKGROUND

Nursing home residents (NHRs) have experienced disproportionately high risk of severe outcomes due to COVID-19 infection.

AIM

We investigated the impact of COVID-19 vaccinations and previous SARS-CoV-2 episodes in preventing hospitalization and mortality in NHRs.

METHODS

Retrospective study of a cohort of all NHRs in our area who were alive at the start of the vaccination campaign. The first three doses of SARS-CoV-2 vaccine and prior COVID-19 infections were registered. The main outcomes were hospital admission and mortality during each follow up. Random effects time-varying Cox models adjusted for age, sex, and comorbidities were fitted to estimate hazard ratios (HRs) according to vaccination status.

RESULTS

COVID-19 hospitalization and death rates for unvaccinated NHRs were respectively 2.39 and 1.42 per 10,000 person-days, falling after administration of the second dose (0.37 and 0.34) and rising with the third dose (1.08 and 0.8). Rates were much lower amongst people who had previously had COVID-19. Adjusted HRs indicated a significant decrease in hospital admission amongst those with a two- and three-dose status; those who had had a previous COVID-19 infection had even lower hospital admission rates. Death rates decreased as NHRs received two and three doses, and the probability of death was much lower among those who had previously had the infection.

CONCLUSIONS

The effectiveness of current vaccines against severe COVID-19 disease in NHRs remains high and SARS-CoV-2 episodes prior to vaccination entail a major reduction in hospitalization and mortality rates. The protection conferred by vaccines appears to decline in the following months.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04463706.

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.

Hybrid immunity in older adults is associated with reduced SARS-CoV-2 infections following BNT162b2 COVID-19 immunisation

BACKGROUND

Older adults, particularly in long-term care facilities (LTCF), remain at considerable risk from SARS-CoV-2. Data on the protective effect and mechanisms of hybrid immunity are skewed towards young adults precluding targeted vaccination strategies.

METHODS

A single-centre longitudinal seroprevalence vaccine response study was conducted with 280 LCTF participants (median 82 yrs, IQR 76-88 yrs; 95.4% male). Screening by SARS-CoV-2 polymerase chain reaction with weekly asymptomatic/symptomatic testing (March 2020-October 2021) and serology pre-/post-two-dose Pfizer-BioNTech BNT162b2 vaccination for (i) anti-nucleocapsid, (ii) quantified anti-receptor binding domain (RBD) antibodies at three time-intervals, (iii) pseudovirus neutralisation, and (iv) inhibition by anti-RBD competitive ELISA were conducted. Neutralisation activity: antibody titre relationship was assessed via beta linear-log regression and RBD antibody-binding inhibition: post-vaccine infection relationship by Wilcoxon rank sum test.

RESULTS

Here we show neutralising antibody titres are 9.2-fold (95% CI 5.8-14.5) higher associated with hybrid immunity (p < 0.00001); +7.5-fold (95% CI 4.6-12.1) with asymptomatic infection; +20.3-fold, 95% (CI 9.7-42.5) with symptomatic infection. A strong association is observed between antibody titre: neutralising activity (p < 0.00001) and rising anti-RBD antibody titre: RBD antibody-binding inhibition (p < 0.001), although 18/169 (10.7%) participants with high anti-RBD titre (>100BAU/ml), show inhibition <75%. Higher RBD antibody-binding inhibition values are associated with hybrid immunity and reduced likelihood of infection (p = 0.003).

CONCLUSIONS

Hybrid immunity in older adults was associated with considerably higher antibody titres, neutralisation and inhibition capacity. Instances of high anti-RBD titre with lower inhibition suggests antibody quantity and quality as independent potential correlates of protection, highlighting added value of measuring inhibition over antibody titre alone to inform vaccine strategy.

Video Calls as a Replacement for Family Visits During Lockdowns in Aged Care: Interview Study with Family Members

BACKGROUND

Lockdowns have been employed to prevent the spread of transmissible illnesses such as influenza, norovirus, and COVID-19 in care homes. However, lockdowns deny care home residents supplemental care and socioemotional enrichment that comes from seeing family members. Video calling has the potential to enable ongoing contact between residents and family members during lockdowns. Yet video calls can be considered by some as being a poor substitute for in-person visits. It is important to understand family members' experiences with video calling during lockdowns to ensure effective use of this technology in the future.

OBJECTIVE

This study aimed to understand how family members used video calls to communicate with relatives living in aged care during lockdowns. We focused on experiences during the COVID-19 pandemic, which involved extensive lockdowns in aged care homes.

METHODS

We conducted semi-structured interviews with 18 adults who had been using video calls with relatives living in aged care during pandemic lockdowns. The interviews focused on how participants had been using video calls, what benefits they gained from video-based interactions, and what challenges they encountered when using the technology. We analysed the data using Braun & Clarke's 6-phase reflexive approach to thematic analysis.

RESULTS

We developed 4 themes through our analysis. Theme 1 interprets video calling as a medium for continuation of care during lockdowns. Using video calls, family members were able to provide social enrichment for residents and engaged in health monitoring to uphold residents' welfare. Theme 2 highlights how video calling extended care by supporting frequent contact, by transmitting non-verbal cues that were essential for communication, and by negating the need for face masks. Theme 3 interprets organizational issues such as lack of technology and staff time as impediments to continuation of familial care through video. Finally, theme 4 highlights the need for two-way communication, interpreting residents' unfamiliarity with video calling and their health conditions as further barriers to continuation of care.

CONCLUSIONS

This study suggests that, during restrictions arising from the COVID-19 pandemic, video calls became a medium for enabling family members to continue participating in the care of their relatives. The use of video calls to continue care illustrates their value for families during times of mandatory lockdown, and supports the use of video to complement face-to-face visits at other times. However, better support is needed for video calling in aged care homes. This study also reveals a need for video calling systems that are designed for the aged care context.

CLINICALTRIAL

Causes of deaths in long-term care and hospice care facilities during the first year of COVID-19 pandemic: a snapshot of Italy during 2020

BACKGROUND

Older adults living in long-term care facilities (LTCF) have been severely affected by COVID-19. Hospice care (HC) facilities and palliative care are essential in treating patients dying from COVID-19. In Italy, little is known about the impact of COVID-19 on deaths in LTCF and the care provided in HC to COVID-19 patients.

AIM

To assess overall and case-specific mortality in 2020 in LTC and HC facilities in comparison to the previous five years (2015-2019).

METHODS

We performed a descriptive study using data derived from the Italian national "Cause of Death" registry-managed by the Italian National Institute of Statistics-on deaths occurred in LTC and HC facilities during 2020 and the period 2015-2019.

RESULTS

Number of deaths significantly increased in 2020 compared with 2015-2019 in LTCF (83,062 deaths vs. 59,200) and slightly decreased in hospices (38,788 vs. 39,652). COVID-19 caused 12.5% of deaths in LTCF and only 2% in hospices. Other than COVID-19, in 2020, cancer accounted for 77% of all deaths that occurred in HC, while cardiovascular diseases (35.6%) and psychotic and behavioral disorders (10%) were the most common causes of death in LTCF. Overall, 22% of the excess mortality registered in Italy during 2020 is represented by the deaths that occurred in LTCF.

DISCUSSION AND CONCLUSION

LTCF were disproportionally affected by COVID-19, while the response to the pandemic in HC was limited. These data can help plan strategies to limit the impact of future epidemics and to better understand residential care response to COVID-19 epidemic.

Outcome measures from international older adult care home intervention research: a scoping review

BACKGROUND

Care homes are increasingly important settings for intervention research to enhance evidence-informed care. For such research to demonstrate effectiveness, it is essential that measures are appropriate for the population, setting and practice contexts.

OBJECTIVE

To identify care home intervention studies and describe the resident outcome measures used.

DESIGN

Scoping review.

METHODS

We reviewed international care home research published from 2015 to August 2022. We searched MEDLINE, EMBASE, CINAHL and ASSIA. We included any intervention study conducted in a care home, reporting resident outcomes. We extracted resident outcome measures, organised these using the domains of an adapted framework and described their use.

RESULTS

From 7,330 records screened, we included 396 datasets reported in 436 publications. These included 12,167 care homes and 836,842 residents, with an average of 80 residents per study. The studies evaluated 859 unique resident outcomes 2,030 times using 732 outcome measures. Outcomes were evaluated between 1 and 112 times, with 75.1% of outcomes evaluated only once. Outcome measures were used 1-120 times, with 68.4% of measures used only once. Only 14 measures were used ≥20 times. Functional status, mood & behaviour and medications were the commonest outcome domains assessed. More than half of outcomes were assessed using scales, with a fifth using existing records or administrative data.

CONCLUSIONS

There is significant heterogeneity in the choice and assessment of outcomes for intervention research in care homes. There is an urgent need to develop a consensus on useful and sensitive tools for care homes, working with residents, families and friends and staff.

A Molecular and Epidemiological Investigation of a Large SARS-CoV-2 Outbreak in a Long-Term Care Facility in Luxembourg, 2021

In spring 2021, a long-term care facility (LTCF) of 154 residents in Luxembourg experienced a large severe, acute respiratory-syndrome coronavirus 2 (SARS-CoV-2) outbreak a few days after a vaccination campaign. We conducted an outbreak investigation and a serosurvey two months after the outbreak, compared attack rates (AR) among residents and staff, and calculated hospitalization and case-fatality rates (CFR). Whole genome sequencing (WGS) was performed to detect variants in available samples and results were compared to genomes published on GISAID. Eighty-four (55%) residents and forty-five (26%) staff members tested positive for SARS-CoV-2; eighteen (21%) residents and one (2.2%) staff member were hospitalized, and twenty-three (CFR: 27%) residents died. Twenty-seven (21% of cases) experienced a reinfection. Sequencing identified seventy-seven cases (97% of sequenced cases) with B.1.1.420 and two cases among staff with B.1.351. The outbreak strain B.1.1.420 formed a separate cluster from cases from other European countries. Convalescent and vaccinated residents had higher anti-SARS-CoV-2 IgG antibody concentrations than vaccinated residents without infection (98% vs. 52%, respectively, with >120 RU/mL, p < 0.001). We documented an extensive outbreak of SARS-CoV-2 in an LTCF due to the presence of a specific variant leading to high CFR. Infection in vaccinated residents increased antibody responses. A single vaccine dose was insufficient to mitigate the outbreak.

Informal care, older people, and COVID-19: Evidence from the UK

The negative health effects and mortality caused by the COVID-19 pandemic disproportionately fell upon older and disabled people. Protecting these vulnerable groups has been a key policy priority throughout the pandemic and related vaccination campaigns. Using data from the latest survey of the UK Household Longitudinal Study on COVID-19 we found that people who receive informal care have higher probability of being infected when compared to those not receiving informal care. Further, we found that care recipients who are in the lowest income groups have a higher probability of catching the virus when compared to those in the highest income groups. We also estimated the likelihood of being infected for informal carers versus those who did not provide any care during the pandemic and found no significant differences between these two groups. Our empirical findings suggest that the standard measures introduced with the aim of protecting vulnerable groups, such as closing care homes or prioritising the vaccination of their staff, were not sufficient to avoid the spread of the virus amongst disabled and older people. Informal carers play an important role in the social care sector. As such, protecting vulnerable people by investing in the informal care sector should be a priority for future health policy.

Evolution of antibody profiles against SARS-CoV-2 in experienced and naïve vaccinated elderly people

Introduction

The third dose of the COVID-19 vaccine is especially necessary in people over 65 years of age due to their lower immune response.

Methods

We designed a multicentre, prospective observational study including 98 people ≤65 years old who lived in two nursing homes in Valladolid, Spain. One of the groups had previous experience with SARS-CoV-2 (n=68;69.4%) and the other was naïve (n=30;30.6%). We evaluated the response to the three doses of the Comirnaty vaccine and the dynamics of antibodies during 5 consecutive serum samplings: 2 after the first two doses of vaccination, one three months after the first dose, another at 6 months and the last one month after the third dose. IgG antibodies against SARS-CoV-2 S1, RBD and N antigens were analysed.

Results

Both groups increased the level of Abs against S1 and RBD, but the experienced group showed a 130-fold higher humoral response due to hybrid immunisation (infection+vaccination). The response to vaccination with Comirnaty against COVID-19 was higher in those ≤65 years with previous experience than those who were naïve. However, the amount of antibodies against S1 and RBD equalised at 6 months. After the third dose, both groups raised the amount of antibodies to a similar level. The reinfections suggested by the analysis of antibodies against N were frequent in both groups.

Discussion

The third dose showed a clear benefit for elderly people, with the reinforcement of the antibody levels after the decline suffered after six months of the first two doses.

A typology of integrated care policies in the care home sector: A policy document analysis

Background

Health and social care systems in many countries have begun to trial and adopt "integrated" approaches. Yet, the significant role care homes play within the health and social care system is often understated. A key first step to identifying the care home integration interventions that are most (cost-)effective is the ability to precisely identify and record what has been implemented, where, and when-a "policy map."

Methods

To address gaps relating to the identification and recording of (cost-)effective integrated care home interventions, we developed a new typology tool. We conducted a policy mapping exercise in a devolved region of England-Greater Manchester (GM). Specifically, we carried out systematic policy documentary searches and extracted a range of qualitative data relating to integrated health and social care initiatives in the GM region for care homes. The data were then classified according to existing national ambitions for England as well as a generic health systems framework to illustrate gaps in existing recording tools and to iteratively develop a novel approach.

Results

A combined total of 124 policy documents were identified and screened, in which 131 specific care home integration initiatives were identified. Current initiatives emphasized monitoring quality in care homes, workforce training, and service delivery changes (such as multi-disciplinary teams). There was comparatively little emphasis on financing or other incentive changes to stimulate provider behavior for the care home setting. We present a novel typology for capturing and comparing care home integration policy initiatives, largely conceptualizing which part of the system or specific transition point the care home integration is targeting, or whether there is a broader cross-cutting system intervention being enacted, such as digital or financial interventions.

Conclusions

Our typology builds on the gaps in current frameworks, including previous lack of specificity to care homes and lack of adaptability to new and evolving initiatives internationally. It could provide a useful tool for policymakers to identify gaps in the implementation of initiatives within their own areas, while also allowing researchers to evaluate what works most effectively and efficiently in future research based on a comprehensive policy map.

“It’s the worst thing I’ve ever been put through in my life”: the trauma experienced by essential family caregivers of loved ones in long-term care during the COVID-19 pandemic in Canada

Background

Essential family caregivers (EFCs) of relatives living in long-term care homes (LTCHs) experienced restricted access to their relatives due to COVID-19 visitation policies. Residents’ experiences of separation have been widely documented; yet, few have focused on EFCs’ traumatic experiences during the pandemic. Objective: This study aims to explore the EFCs’ trauma of being locked out of LTCHs and unable to visit their loved ones in-person during COVID-19.

Methods

Seven online focus groups with a total of 30 EFCs from Ontario and British Columbia, Canada were conducted as part of a larger mixed-method study. We used an inductive approach to thematic analysis to understand the lived experiences of trauma.

Results

Four trauma-related themes emerged: 1) trauma from prolonged separation from loved ones; 2) trauma from uncompassionate interactions with the LTCH’s staff and administrators; 3) trauma from the inability to provide care to loved ones, and 4) trauma from experiencing prolonged powerlessness and helplessness.

Discussion

The EFCs experienced a collective trauma that deeply impacted their relationships with their relatives as well as their perception of the LTC system. Experiences endured by EFCs highlighted policy and practice changes, including the need for trauma-centred approaches to repair relational damage and post-pandemic decision-making that collaborates with EFCs.

Effects of chain ownership and private equity financing on quality in the English care home sector: retrospective observational study

BACKGROUND

the structure of care homes markets in England is changing with the emergence of for-profit homes organised in chains and financed by private equity. Previous literature shows for-profit homes were rated lower quality than not-for-profit homes when inspected by the national regulator, but has not considered new forms of financing.

OBJECTIVES

to examine whether financing and organisation of care homes is associated with regulator assessments of quality.

METHODS

retrospective observational study of the Care Quality Commission's ratings of 10,803 care homes providing services to older people as of January 2020. We used generalised ordered logistic models to assess whether ratings differed between not-for-profit and for-profit homes categorised into three groups: (i) chained ownership, financed by private equity; (ii) chained ownership, not financed by private equity and (iii) independent ownership. We compared Overall and domain (caring, effective, responsive, safe, well-led) ratings adjusted for care home size, age and location.

RESULTS

all three for-profit ownership types had lower average overall ratings than not-for-profit homes, especially independent (6.8% points (p.p.) more likely rated as 'Requires Improvement/Inadequate', 95% CI: 4.7-8.9) and private equity chains (6.6 p.p. more likely rated as 'Requires Improvement/Inadequate', 95% CI: 2.9-10.2). Independent homes scored better than private equity chains in the safe, effective and responsive domains but worst in the well-led domain.

DISCUSSION

private equity financing and independent for-profit ownership are associated with lower quality. The consequences of the changing care homes market structure for quality of services should be monitored.

Has COVID-19 changed carer's views of health and care integration in care homes? A sentiment difference-in-difference analysis of on-line service reviews

Closer integration of health and social care is a policy priority in many countries. The COVID-19 pandemic has reinforced the necessity of joining up health and social care systems, especially in care home settings. However, the meaning and perceived importance of integration for residents' and carers' experience is unclear and we do not know whether it has changed during the pandemic. Using unique data from on-line care home service reviews, we combined multiple methods. We used Natural Language Processing with supervised machine learning to construct a measure of sentiment for care home residents' and their relatives' (measured by AFINN score). Difference-in-difference analysis was used to examine whether experiencing integrated care altered these sentiments by comparing changes in sentiment in reviews related to integration (containing specific terms) to those which were not. Finally, we used network analysis on post-estimation results to assess which specific attributes stakeholders focus on most when detailing their most/least positive experiences of health and care integration in care homes, and whether these attributes changed over the pandemic. Reviews containing integration words were more positive than reviews unrelated to integration in the pre-pandemic period (about 2.3 points on the AFINN score) and remained so during the first year of the pandemic. Overall positive sentiment increased during the COVID-19 period (average by +1.1 points), mainly in reviews mentioning integration terms at the beginning of the first (+2.17, p-value 0.175) and second waves (+3.678, p-value 0.027). The role of care home staff was pivotal in both positive and negative reviews, with a shift from aspects related to care in pre-pandemic to information services during the pandemic, signalling their importance in translating integrated needs-based paradigms into policy and practice.

Informal caregiving during the COVID-19 pandemic: findings from a representative, population-based study during the second wave of the pandemic in Germany

OBJECTIVES

This study investigates how the COVID-19 pandemic has affected the informal caregiving situation in terms of prevalence of caregivers, infection rates, perception of impairment and danger by the pandemic, and changes in the caregiving performance among long-term caregivers from before to during the peak of the pandemic.

METHODS

Informal caregivers (N = 489 during the pandemic) from a population-based sample, representative for individuals aged ≥40 years from Germany (N = 3022, assessed March 2021), were questioned. Sociodemographic information, prevalence and performance of informal care before and during the second pandemic wave, infection rates and perceived impairment and danger of the pandemic were assessed.

RESULTS

Results indicate no significantly different prevalence of informal caregiving during the pandemic compared to before. Few caregivers and few of their care recipients were infected. Overall, a low to moderate level of impairment was reported by caregivers, but a moderately high perceived danger, particularly for care recipients. Among long-term caregivers, caregiving intensity and time increased during the pandemic, less ambulatory care but more shopping help was used and care task distribution and use of support changed.

CONCLUSION

While the prevalence of informal caregivers remained unchanged, the caregiving situation worsened among long-term caregivers. Infection rates among caregivers were low, but they perceived themselves and their care recipients to be endangered. Future research and policy should focus more on this vulnerable group during a health crisis, primarily on long-term caregivers, in order to effectively support them in their care provision for the high risk group of older care recipients.

Years of life lost during the Covid-19 pandemic in Sweden considering variation in life expectancy by level of geriatric care

The Covid-19 pandemic has not affected the population evenly. This must be acknowledged when it comes to understanding the Covid-19 death toll and answering the question of how many life years have been lost. We use level of geriatric care to account for variation in remaining life expectancy among individuals that died during 2020. Based on a linkage of administrative registers, we estimate remaining life expectancy stratified by age, sex, and care status using an incidence-based multistate model and analyze the number of years of life lost (YLL) during 2020 in Sweden. Our results show that remaining life expectancy between individuals with and without care differs substantially. More than half of all Covid-19 deaths had a remaining life expectancy lower than 4 years. Yet, in a 1-year perspective, Covid-19 did not seem to replace other causes of death. Not considering the differences in remaining life expectancy in the affected populations overestimated YLL by 40% for women and 30% for men, or around 2 years per death. While the unadjusted YLL from Covid-19 amounted to an average of 7.5 years for women and 8.6 years for men, the corresponding YLL adjusted for care status were 5.4 and 6.6, respectively. The total number of YLL to Covid-19 in 2020 is comparable to YLL from ischemic heart disease in 2019 and 2020. Our results urge the use of subgroup specific mortality when counting the burden of Covid-19. YLL are considerably reduced when the varying susceptibility for death is considered, but even if most lifespans were cut in the last years of life, the YLL are still substantial.

Novel methods for estimating the instantaneous and overall COVID-19 case fatality risk among care home residents in England

The COVID-19 pandemic has had high mortality rates in the elderly and frail worldwide, particularly in care homes. This is driven by the difficulty of isolating care homes from the wider community, the large population sizes within care facilities (relative to typical households), and the age/frailty of the residents. To quantify the mortality risk posed by disease, the case fatality risk (CFR) is an important tool. This quantifies the proportion of cases that result in death. Throughout the pandemic, CFR amongst care home residents in England has been monitored closely. To estimate CFR, we apply both novel and existing methods to data on deaths in care homes, collected by Public Health England and the Care Quality Commission. We compare these different methods, evaluating their relative strengths and weaknesses. Using these methods, we estimate temporal trends in the instantaneous CFR (at both daily and weekly resolutions) and the overall CFR across the whole of England, and dis-aggregated at regional level. We also investigate how the CFR varies based on age and on the type of care required, dis-aggregating by whether care homes include nursing staff and by age of residents. This work has contributed to the summary of measures used for monitoring the UK epidemic.

During an epidemic, the case fatality risk (CFR), i.e. the probability that an individual dies after testing positive for a disease, is a key parameter informing the public health response. However, calculating the CFR is not trivial, since there are cases who may die in the future but have not died yet. Therefore, statistical methods are required to correct for the distribution of times between testing positive and dying. In this paper, we derive multiple methods, some existing and some novel, within a consistent methodological framework. This allows us to understand how these different approaches are related and their relative strengths and weaknesses. During the COVID-19 pandemic, care homes have been particularly affected, due to the high risk of COVID-19-associated mortality in the frail and elderly. We apply our CFR methods to data from English care homes to analyse changes in the care home CFR throughout the pandemic.

Epidemiological model based periodic intervention policies for COVID-19 mitigation in the United Kingdom

As the UK, together with numerous countries in the world, moves towards a new phase of the COVID-19 pandemic, there is a need to be able to predict trends in sufficient time to limit the pressure faced by the National Health Service (NHS) and maintain low hospitalisation levels. In this study, we explore the use of an epidemiological compartmental model to devise a periodic adaptive suppression/intervention policy to alleviate the pressure on the NHS. The proposed model facilitates the understanding of the progression of the specific stages of COVID-19 in communities in the UK including: the susceptible population, the infected population, the hospitalised population, the recovered population, the deceased population, and the vaccinated population. We identify the parameters of the model by relying on past data within the period from 1 October 2020 to 1 June 2021. We use the total number of hospitalised patients and the fraction of those infected who are being admitted to hospital to develop adaptive policies: these modulate the recommended level of social restriction measures and realisable vaccination target adjustments. The analysis over the period 1 October 2020 to 1 June 2021 demonstrates our periodic adaptive policies have the potential to reduce the hospitalisation by 58% on average per month. In a further prospective analysis over the period August 2021 to May 2022, we analyse several future scenarios, characterised by the relaxation of restrictions, the vaccination ineffectiveness and the gradual decay of the vaccination-induced immunity within the population. In addition, we simulate the surge of plausible variants characterised by an higher transmission rate. In such scenarios, we show that our periodic intervention is effective and able to maintain the hospitalisation rate to a manageable level.

Long-Term Care Home Size Association with COVID-19 Infection and Mortality in Catalonia in March and April 2020

We aim to assess how COVID-19 infection and mortality varied according to facility size in 965 long-term care homes (LTCHs) in Catalonia during March and April 2020. We measured LTCH size by the number of authorised beds. Outcomes were COVID-19 infection (at least one COVID-19 case in an LTCH) and COVID-19 mortality. Risks of these were estimated with logistic regression and hurdle models. Models were adjusted for county COVID-19 incidence and population, and LTCH types. Sixty-five per cent of the LTCHs were infected by COVID-19. We found a strong association between COVID-19 infection and LTCH size in the adjusted analysis (from 45% in 10-bed homes to 97.5% in those with over 150 places). The average COVID-19 mortality in all LTCHs was 6.8% (3887 deaths) and 9.2% among the COVID-19-infected LTCHs. Very small and large homes had higher COVID-19 mortality, whereas LTCHs with 30 to 70 places had the lowest level. COVID-19 mortality sharply increased with LTCH size in counties with a cumulative incidence of COVID-19 which was higher than 250/100,000, except for very small homes, but slightly decreased with LTCH size when the cumulative incidence of COVID-19 was lower. To prevent infection and preserve life, the optimal size of an LTCH should be between 30 and 70 places.

Managing the Impact of COVID-19 in Nursing Homes and Long-Term Care Facilities: An Update

Older adults in nursing homes are at greatest risk of morbidity and mortality from SARS-CoV-2 infection. Nursing home residents constituted one-third to more than half of all deaths during the early waves of the COVID-19 pandemic. Following this, widespread adaptation of infection prevention and control measures and the supply and use of personal protective equipment resulted in a significant decrease in nursing home infections and deaths. For nursing homes, the most important determinant of experiencing a SARS-CoV-2 outbreak in the first instance appears to be community-transmission levels (particularly with variants of concern), although nursing home size and quality, for-profit status, and sociodemographic characteristics are also important. Use of visitation bans, imposed to reduce the impact of COVID-19 on residents, must be delicately balanced against their impact on resident, friend or family, and staff well-being. The successful rollout of primary vaccination has resulted in a sharp decrease in morbidity and mortality from SARS-CoV-2 in nursing homes. However, emerging evidence suggests that vaccine efficacy may wane over time, and the use of a third or additional vaccine "booster" doses in nursing home residents restores protection afforded by primary vaccination. Ongoing monitoring of vaccine efficacy in terms of infection, morbidity, and mortality is crucial in this vulnerable group in informing ongoing SARS-CoV-2 vaccine boosting strategies. Here, we detail the impact of SARS-CoV-2 on nursing home residents and discuss important considerations in the management of nursing home SARS-CoV-2 outbreaks. We additionally examine the use of testing strategies, nonpharmacologic outbreak control measures and vaccination strategies in this cohort. Finally, the impact of SARS-CoV-2 on the sector is reflected on as we emphasize the need for adoption of universal standards of medical care and integration with wider public health infrastructure in nursing homes in order to provide a safe and effective long-term care sector.

Indirect effect of the COVID-19 pandemic on hospital mortality in patients with hip fracture: a competing risk survival analysis using linked administrative data

BACKGROUND

Hip fracture is a leading cause of disability and mortality among older people. During the COVID-19 pandemic, orthopaedic care pathways in the National Health Service in England were restructured to manage pressures on hospital capacity. We examined the indirect consequences of the pandemic for hospital mortality among older patients with hip fracture, admitted from care homes or the community.

METHODS

Retrospective analysis of linked care home and hospital inpatient data for patients with hip fracture aged 65 years and over admitted to hospitals in England during the first year of the pandemic (1 March 2020 to 28 February 2021) or during the previous year. We performed survival analysis, adjusting for case mix and COVID-19 infection, and considered live discharge as a competing risk. We present cause-specific hazard ratios (HR_CS) for the effect of admission year on hospital mortality risk.

RESULTS

During the first year of the pandemic, there were 55 648 hip fracture admissions: a 5.2% decrease on the previous year. 9.5% of patients had confirmed or suspected COVID-19. Hospital stays were substantially shorter (p<0.05), and there was a higher daily chance of discharge (HR_CS 1.40, 95% CI 1.38 to 1.41). Overall hip fracture inpatient mortality increased (7.2% in 2020/2021 vs 6.4% in 2019/2020), but patients without concomitant COVID-19 infection had lower mortality rates compared with the year before (5.3%). Admission during the pandemic was associated with a 11% increase in the daily risk of hospital death for patients with hip fracture (HR_CS 1.11, 95% CI 1.05 to 1.16).

CONCLUSIONS

Although COVID-19 infections led to increases in hospital mortality, overall hospital mortality risk for older patients with hip fracture remained largely stable during the first year of the pandemic.

A process mining- deep learning approach to predict survival in a cohort of hospitalized COVID-19 patients

BACKGROUND

Various machine learning and artificial intelligence methods have been used to predict outcomes of hospitalized COVID-19 patients. However, process mining has not yet been used for COVID-19 prediction. We developed a process mining/deep learning approach to predict mortality among COVID-19 patients and updated the prediction in 6-h intervals during the first 72 h after hospital admission.

METHODS

The process mining/deep learning model produced temporal information related to the variables and incorporated demographic and clinical data to predict mortality. The mortality prediction was updated in 6-h intervals during the first 72 h after hospital admission. Moreover, the performance of the model was compared with published and self-developed traditional machine learning models that did not use time as a variable. The performance was compared using the Area Under the Receiver Operator Curve (AUROC), accuracy, sensitivity, and specificity.

RESULTS

The proposed process mining/deep learning model outperformed the comparison models in almost all time intervals with a robust AUROC above 80% on a dataset that was imbalanced.

CONCLUSIONS

Our proposed process mining/deep learning model performed significantly better than commonly used machine learning approaches that ignore time information. Thus, time information should be incorporated in models to predict outcomes more accurately.

Duration of vaccine effectiveness against SARS-CoV-2 infection, hospitalisation, and death in residents and staff of long-term care facilities in England (VIVALDI): a prospective cohort study

Background

Residents and staff in long-term care facilities have been prioritised for vaccination against SARS-CoV-2, but data on potential waning of vaccine effectiveness and the effect of booster doses in this vulnerable population are scarce. We aimed to evaluate effectiveness of one, two, and three vaccine doses against infection and severe clinical outcomes in staff and residents of long-term care facilities in England over the first year following vaccine roll-out.

Methods

The VIVALDI study is a prospective cohort study done in 331 long-term care facilities in England. Residents aged 65 years or older and staff aged 18 years or older were eligible for participation. Participants had routine PCR testing throughout the study period between Dec 8, 2020, and Dec 11, 2021. We retrieved all PCR results and cycle threshold values for PCR-positive samples from routine testing in long-term care facilities, and positive PCR results from clinical testing in hospitals through the UK's COVID-19 Datastore. PCR results were linked to participants using pseudo-identifiers based on individuals' unique UK National Health Service (NHS) numbers, which were also used to retrieve vaccination records from the National Immunisation Management Service, hospitalisation records from NHS England, and deaths data from the Office for National Statistics through the COVID-19 Datastore. In a Cox proportional hazards regression, we estimated vaccine effectiveness against SARS-CoV-2 infection, COVID-19-related hospitalisation, and COVID-19-related death after one, two, and three vaccine doses, separately by previous SARS-CoV-2 exposure. This study is registered with the ISRCTN Registry, ISRCTN 14447421.

Findings

80 186 residents and staff of long-term care facilities had records available for the study period, of whom 15 518 eligible residents and 19 515 eligible staff were included in the analysis. For residents without evidence of previous SARS-CoV-2 exposure, vaccine effectiveness decreased from 61·7% (95% CI 35·1 to 77·4) to 22·0% (-14·9 to 47·0) against infection; from 89·0% (70·6 to 95·9) to 56·3% (30·1 to 72·6) against hospitalisation; and from 96·4% (84·3 to 99·2) to 64·4% (36·1 to 80·1) against death, when comparing 14-83 days after dose two and 84 days or more after dose two. For staff without evidence of previous exposure, vaccine effectiveness against infection decreased slightly from 57·9% (43·1 to 68·9) at 14-83 days after dose two to 42·1% (29·9 to 52·2) at 84 days or more after dose two. There were no hospitalisations or deaths among unexposed staff at 14-83 days, but seven hospitalisations (vaccine effectiveness 91·0% [95% CI 74·3 to 96·8]) and one death were observed at 84 days or more after dose two. High vaccine effectiveness was restored following a third vaccine dose, with vaccine effectiveness in unexposed residents of 72·7% (55·8 to 83·1) against infection, 90·1% (80·6 to 95·0) against hospitalisation, and 97·5% (88·1 to 99·5) against death; and vaccine effectiveness in unexposed staff of 78·2% (70·0 to 84·1) against infection and 95·8% (49·9 to 99·6) against hospitalisation. There were no COVID-19-related deaths among unexposed staff after the third vaccine dose.

Interpretation

Our findings showed substantial waning of SARS-CoV-2 vaccine effectiveness against all outcomes in residents of long-term care facilities from 12 weeks after a primary course of ChAdOx1-S or mRNA vaccines. Boosters restored protection, and maximised immunity across all outcomes. These findings show the importance of boosting and the need for ongoing surveillance in this vulnerable cohort.

Funding

UK Government Department of Health and Social Care.

The Impact of Long-Term Care Home Ownership and Administration Type on All-Cause Mortality from March to April 2020 in Madrid, Spain

Our aim is to assess whether long-term care home (LTCH) ownership and administration type were associated with all-cause mortality in 470 LTCHs in the Community of Madrid (Spain) during March and April 2020, the first two months of the COVID-19 pandemic. There are eight categories of LTCH type, including various combinations of ownership type (for-profit, nonprofit, and public) and administration type (completely private, private with places rented by the public sector, administrative management by procurement, and completely public). Multilevel regression was used to examine the association between mortality and LTCH type, adjusting for LTCH size, the spread of the COVID-19 infection, and the referral hospital. There were 9468 deaths, a mortality rate of 18.3%. Public and private LTCHs had lower mortality than LTCHs under public-private partnership (PPP) agreements. In the fully adjusted model, mortality was 7.4% (95% CI, 3.1-11.7%) in totally public LTCHs compared with 21.9% (95% CI, 17.4-26.4%) in LTCHs which were publicly owned with administrative management by procurement. These results are a testimony to the fatal consequences that pre-pandemic public-private partnerships in long-term residential care led to during the first months of the COVID-19 pandemic in the Community of Madrid, Spain.

Infodemiological study on the impact of the COVID-19 pandemic on increased headache incidences at the world level

The analysis of the public interest as reflected by Internet queries has become a highly valuable tool in many fields. The Google Trends platform, providing timely and informative data, has become increasingly popular in health and medical studies. This study explores whether Internet search frequencies for the keyword “headache” have been increasing after the COVID-19 pandemic outbreak, which could signal an increased incidence of the health problem. Weekly search volume data for 5 years spanning February 2017 to February 2022 were sourced from Google Trends. Six statistical and machine-learning methods were implemented on training and testing sets via pre-set automated forecasting algorithms. Holt-Winters has been identified as overperforming in predicting web query trends through several accuracy measures and the DM test for forecasting superiority and has been employed for producing the baseline level in the estimation of excess query level over the first pandemic wave. Findings indicate that the COVID-19 pandemic resulted in an increased global incidence of headache (as proxied by related web queries) in the first 6 months after its outbreak, with an excess occurrence of 4.53% globally. However, the study also concludes that the increasing trend in headache incidence at the world level would have continued in the absence of the pandemic, but it has been accelerated by the pandemic event. Results further show mixed correlations at the country-level between COVID-19 infection rates and population web-search behavior, suggesting that the increased headache incidence is caused by pandemic-related factors (i.e. increased stress and mental health problems), rather than a direct effect of coronavirus infections. Other noteworthy findings entail that in the Philippines, the term "headache" was the most frequently searched term in the period spanning February 2020 to February 2022, indicating that headache occurrences are a significant aspect that defines population health at the country level. High relative interest is also detected in Kenya and South Africa after the pandemic outbreak. Additionally, research findings indicate that the relative interest has decreased in some countries (i.e. US, Canada, and Australia), whereas it has increased in others (i.e. India and Pakistan) after the pandemic outbreak. We conclude that observing Internet search habits can provide timely information for policymakers on collective health trends, as opposed to ex-post statistics, and can furthermore yield valuable information for the pain management drug market key players about aggregate consumer behavior.

Unpacking the 'black box of horrendousness': a qualitative exploration of the barriers and facilitators to conducting trials involving adults lacking capacity to consent

Background

Trials involving adults who lack capacity to consent encounter a range of ethical and methodological challenges, resulting in these populations frequently being excluded from research. Currently, there is little evidence regarding the nature and extent of these challenges, nor strategies to improve the design and conduct of such trials. This qualitative study explored researchers’ and healthcare professionals’ experiences of the barriers and facilitators to conducting trials involving adults lacking capacity to consent.

Methods

Semi-structured interviews were conducted remotely with 26 researchers and healthcare professionals with experience in a range of roles, trial populations and settings across the UK. Data were analysed using thematic analysis.

Results

A number of inter-related barriers and facilitators were identified and mapped against key trial processes including during trial design decisions, navigating ethical approval, assessing capacity, identifying and involving alternative decision-makers and when revisiting consent. Three themes were identified: (1) the perceived and actual complexity of trials involving adults lacking capacity, (2) importance of having access to appropriate support and resources and (3) need for building greater knowledge and expertise to support future trials. Barriers to trials included the complexity of the legal frameworks, the role of gatekeepers, a lack of access to expertise and training, and the resource-intensive nature of these trials. The ability to conduct trials was facilitated by having prior experience with these populations, effective communication between research teams, public involvement contributions, and the availability of additional data to inform the trial. Participants also identified a range of context-specific recruitment issues and highlighted the importance of ‘designing in’ flexibility and the use of adaptive strategies which were especially important for trials during the COVID-19 pandemic. Participants identified a need for better training and support.

Conclusions

Researchers encountered a number of barriers, including both generic and context or population-specific challenges, which may be reinforced by wider factors such as resource limitations and knowledge deficits. Greater access to expertise and training, and the development of supportive interventions and tailored guidance, is urgently needed in order to build research capacity in this area and facilitate the successful delivery of trials involving this under-served population.

Robust SARS-CoV-2-specific and heterologous immune responses in vaccine-naïve residents of long-term care facilities who survive natural infection

We studied humoral and cellular immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 152 long-term care facility staff and 124 residents over a prospective 4-month period shortly after the first wave of infection in England. We show that residents of long-term care facilities developed high and stable levels of antibodies against spike protein and receptor-binding domain. Nucleocapsid-specific responses were also elevated but waned over time. Antibodies showed stable and equivalent levels of functional inhibition against spike-angiotensin-converting enzyme 2 binding in all age groups with comparable activity against viral variants of concern. SARS-CoV-2 seropositive donors showed high levels of antibodies to other beta-coronaviruses but serostatus did not impact humoral immunity to influenza or other respiratory syncytial viruses. SARS-CoV-2-specific cellular responses were similar across all ages but virus-specific populations showed elevated levels of activation in older donors. Thus, survivors of SARS-CoV-2 infection show a robust and stable immunity against the virus that does not negatively impact responses to other seasonal viruses.

Mortality of care home residents and community-dwelling controls during the covid-19 pandemic in 2020: matched cohort study

Objective

This study aimed to estimate and compare mortality of care home residents, and matched community-dwelling controls, during the COVID-19 pandemic from primary care electronic health records in England.

Design

Matched cohort study.

Setting and Participants

Family practices in England in the Clinical Practice Research Datalink Aurum database. There were 83,627 care home residents in 2020, with 26,923 deaths; 80,730 (97%) were matched on age, sex, and family practice with 300,445 community-dwelling adults.

Methods

All-cause mortality was evaluated and adjusted rate ratios by negative binomial regression were adjusted for age, sex, number of long-term conditions, frailty category, region, calendar month or week, and clustering by family practice.

Results

Underlying mortality of care home residents was higher than community controls (adjusted rate ratio 5.59, 95% confidence interval 5.23‒5.99, P < .001). During April 2020, there was a net increase in mortality of care home residents over that of controls. The mortality rate of care home residents was 27.2 deaths per 1000 patients per week, compared with 2.31 per 1000 for controls. Excess deaths for care home residents, above that predicted from pre-pandemic years, peaked between April 13 and 19 (men, 27.7, 95% confidence interval 25.1‒30.3; women, 17.4, 15.9‒18.8 per 1000 per week). Compared with care home residents, long-term conditions and frailty were differentially associated with greater mortality in community-dwelling controls.

Conclusions and Implications

Individual-patient data from primary care electronic health records may be used to estimate mortality in care home residents. Mortality is substantially higher than for community-dwelling comparators and showed a disproportionate increase in the first wave of the COVID-19 pandemic. Care home residents require particular protection during periods of high infectious disease transmission.

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 .

Mortality among Care Home Residents in England during the first and second waves of the COVID-19 pandemic: an observational study of 4.3 million adults over the age of 65

BACKGROUND

Residents in care homes have been severely impacted by COVID-19. We describe trends in the mortality risk among residents of care homes compared to private homes.

METHODS

On behalf of NHS England we used OpenSAFELY-TPP to calculate monthly age-standardised risks of death due to all causes and COVID-19 among adults aged >=65 years between 1/2/2019 and 31/03/2021. Care home residents were identified using linkage to Care and Quality Commission data.

FINDINGS

We included 4,340,648 people aged 65 years or older on the 1st of February 2019, 2.2% of whom were classified as residing in a care or nursing home. Age-standardised mortality risks were approximately 10 times higher among care home residents compared to those in private housing in February 2019: comparative mortality figure (CMF) = 10.59 (95%CI = 9.51, 11.81) among women, and 10.87 (9.93, 11.90) among men. By April 2020 these relative differences had increased to more than 17 times with CMFs of 17.57 (16.43, 18.79) among women and 18.17 (17.22, 19.17) among men. CMFs did not increase during the second wave, despite a rise in the absolute age-standardised COVID-19 mortality risks.

INTERPRETATION

COVID-19 has had a disproportionate impact on the mortality of care home residents in England compared to older residents of private homes, but only in the first wave. This may be explained by a degree of acquired immunity, improved protective measures or changes in the underlying frailty of the populations. The care home population should be prioritised for measures aimed at controlling COVID-19.

FUNDING

Medical Research Council MR/V015737/1.

Previous SARS-CoV-2 Infection, Age, and Frailty Are Associated With 6-Month Vaccine-Induced Anti-Spike Antibody Titer in Nursing Home Residents

OBJECTIVES

Older nursing home residents make up the population at greatest risk of morbidity and mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. No studies have examined the determinants of long-term antibody responses post vaccination in this group.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

Residents from 5 nursing homes assessed before vaccination, and 5 weeks and 6 months post vaccination, with the BNT162b2 messenger RNA SARS-CoV-2 vaccine.

METHODS

Comprehensive clinical assessment was performed, including assessment for comorbidity, frailty, and SARS-CoV-2 infection history. Serum nucleocapsid and anti-spike receptor binding domain (RBD) antibodies were analyzed at all timepoints. An in vitro angiotensin-converting enzyme (ACE2) receptor-spike RBD neutralization assay assessed serum neutralization capacity.

RESULTS

Of 86 participants (81.1 ± 10.8 years; 65% female), just under half (45.4%; 39 of 86) had evidence of previous SARS-CoV-2 infection. All participants demonstrated a significant antibody response to vaccination at 5 weeks and a significant decline in this response by 6 months. SARS-CoV-2 infection history was the strongest predictor of antibody titer (log-transformed) at both 5 weeks [β: 3.00; 95% confidence interval (CI): 2.32-3.70; P < .001] and 6 months (β: 3.59; 95% CI: 2.89-4.28; P < .001). Independent of SARS-CoV-2 infection history, both age in years (β: -0.05; 95% CI: -0.08 to -0.02; P < .001) and frailty (β: -0.22; 95% CI: -0.33 to -0.11; P < .001) were associated with a significantly lower antibody titer at 6 months. Anti-spike antibody titers at both 5 weeks and 6 months significantly correlated with in vitro neutralization capacity.

CONCLUSIONS AND IMPLICATIONS

In older nursing home residents, SARS-CoV-2 infection history was the strongest predictor of anti-spike antibody titers at 6 months, whereas age and frailty were independently associated with lower titers at 6 months. Antibody titers significantly correlated with in vitro neutralization capacity. Although older SARS-CoV-2 naïve nursing home residents may be particularly vulnerable to breakthrough SARS-CoV-2 infection, the relationship between antibody titers, SARS-CoV-2 infection, and clinical outcomes remains to be fully elucidated in this vulnerable population.

Paediatric pneumonia research priorities in the context of COVID-19: A eDelphi study

Background

Pneumonia remains the leading cause of infectious deaths in children under-five globally. We update the research priorities for childhood pneumonia in the context of the COVID-19 pandemic and explore whether previous priorities have been addressed.

Methods

We conducted an eDelphi study from November 2019 to June 2021. Experts were invited to take part, targeting balance by: gender, profession, and high (HIC) and low- and middle-income countries (LMIC). We followed a three-stage approach: 1. Collating questions, using a list published in 2011 and adding newly posed topics; 2. Narrowing down, through participant scoring on importance and whether they had been answered; 3. Ranking of retained topics. Topics were categorized into: prevent and protect, diagnosis, treatment and cross-cutting.

Results

Overall 379 experts were identified, and 108 took part. We started with 83 topics, and 81 further general and 40 COVID-19 specific topics were proposed. In the final ranking 101 topics were retained, and the highest ranked was to "explore interventions to prevent neonatal pneumonia". Among the top 20 topics, epidemiological research and intervention evaluation was commonly prioritized, followed by the operational and implementation research. Two COVID-19 related questions were ranked within the top 20. There were clear differences in priorities between HIC and LMIC respondents, and academics vs non-academics.

Conclusions

Operational research on health system capacities, and evaluating optimized delivery of existing treatments, diagnostics and case management approaches are needed. This list should act as a catalyst for collaborative research, especially to meet the top priority in preventing neonatal pneumonia, and encourage multi-disciplinary partnerships.

Excess years of life lost to COVID-19 and other causes of death by sex, neighbourhood deprivation, and region in England and Wales during 2020: A registry-based study

BACKGROUND

Deaths in the first year of the Coronavirus Disease 2019 (COVID-19) pandemic in England and Wales were unevenly distributed socioeconomically and geographically. However, the full scale of inequalities may have been underestimated to date, as most measures of excess mortality do not adequately account for varying age profiles of deaths between social groups. We measured years of life lost (YLL) attributable to the pandemic, directly or indirectly, comparing mortality across geographic and socioeconomic groups.

METHODS AND FINDINGS

We used national mortality registers in England and Wales, from 27 December 2014 until 25 December 2020, covering 3,265,937 deaths. YLLs (main outcome) were calculated using 2019 single year sex-specific life tables for England and Wales. Interrupted time-series analyses, with panel time-series models, were used to estimate expected YLL by sex, geographical region, and deprivation quintile between 7 March 2020 and 25 December 2020 by cause: direct deaths (COVID-19 and other respiratory diseases), cardiovascular disease and diabetes, cancer, and other indirect deaths (all other causes). Excess YLL during the pandemic period were calculated by subtracting observed from expected values. Additional analyses focused on excess deaths for region and deprivation strata, by age-group. Between 7 March 2020 and 25 December 2020, there were an estimated 763,550 (95% CI: 696,826 to 830,273) excess YLL in England and Wales, equivalent to a 15% (95% CI: 14 to 16) increase in YLL compared to the equivalent time period in 2019. There was a strong deprivation gradient in all-cause excess YLL, with rates per 100,000 population ranging from 916 (95% CI: 820 to 1,012) for the least deprived quintile to 1,645 (95% CI: 1,472 to 1,819) for the most deprived. The differences in excess YLL between deprivation quintiles were greatest in younger age groups; for all-cause deaths, a mean of 9.1 years per death (95% CI: 8.2 to 10.0) were lost in the least deprived quintile, compared to 10.8 (95% CI: 10.0 to 11.6) in the most deprived; for COVID-19 and other respiratory deaths, a mean of 8.9 years per death (95% CI: 8.7 to 9.1) were lost in the least deprived quintile, compared to 11.2 (95% CI: 11.0 to 11.5) in the most deprived. For all-cause mortality, estimated deaths in the most deprived compared to the most affluent areas were much higher in younger age groups, but similar for those aged 85 or over. There was marked variability in both all-cause and direct excess YLL by region, with the highest rates in the North West. Limitations include the quasi-experimental nature of the research design and the requirement for accurate and timely recording.

CONCLUSIONS

In this study, we observed strong socioeconomic and geographical health inequalities in YLL, during the first calendar year of the COVID-19 pandemic. These were in line with long-standing existing inequalities in England and Wales, with the most deprived areas reporting the largest numbers in potential YLL.

Investigating the association between COVID-19 vaccination and care home outbreak frequency and duration

OBJECTIVES

At the end of 2020, many countries commenced a vaccination programme against SARS-CoV-2. Public health authorities aim to prevent and interrupt outbreaks of infectious disease in social care settings. We aimed to investigate the association between the introduction of the vaccination programme and the frequency and duration of COVID-19 outbreaks in Northern Ireland (NI).

STUDY DESIGN

We undertook an ecological study using routinely available national data.

METHODS

We used Poisson regression to measure the relationship between the number of RT-PCR confirmed COVID-19 outbreaks in care homes, and as a measure of community COVID-19 prevalence, the Office for National Statistics COVID-19 Infection Survey estimated the number of people testing positive for COVID-19 in NI. We estimated the change in this relationship and estimated the expected number of care home outbreaks in the absence of the vaccination programme. A Cox proportional hazards model estimated the hazard ratio of a confirmed COVID-19 care home outbreak closure.

RESULTS

Care home outbreaks reduced by two-thirds compared to expected following the introduction of the vaccination programme, from a projected 1625 COVID-19 outbreaks (95% prediction interval 1553-1694) between 7 December 2020 and 28 October 2021 to an observed 501. We estimated an adjusted hazard ratio of 2.53 of the outbreak closure assuming a 21-day lag for immunity.

CONCLUSIONS

These findings describe the association of the vaccination with a reduction in outbreak frequency and duration across NI care homes. This indicates probable reduced harm and disruption from COVID-19 in social care settings following vaccination. Future research using individual level data from care home residents will be needed to investigate the effectiveness of the vaccines and the duration of their effects.

Outcomes in patients with and without disability admitted to hospital with COVID-19: a retrospective cohort study

Background:

Disability-related considerations have largely been absent from the COVID-19 response, despite evidence that people with disabilities are at elevated risk for acquiring COVID-19. We evaluated clinical outcomes in patients who were admitted to hospital with COVID-19 with a disability compared with patients without a disability.

Methods:

We conducted a retrospective cohort study that included adults with COVID-19 who were admitted to hospital and discharged between Jan. 1, 2020, and Nov. 30, 2020, at 7 hospitals in Ontario, Canada. We compared in-hospital death, admission to the intensive care unit (ICU), hospital length of stay and unplanned 30-day readmission among patients with and without a physical disability, hearing or vision impairment, traumatic brain injury, or intellectual or developmental disability, overall and stratified by age (≤ 64 and ≥ 65 yr) using multivariable regression, controlling for sex, residence in a long-term care facility and comorbidity.

Results:

Among 1279 admissions to hospital for COVID-19, 22.3% had a disability. We found that patients with a disability were more likely to die than those without a disability (28.1% v. 17.6%), had longer hospital stays (median 13.9 v. 7.8 d) and more readmissions (17.6% v. 7.9%), but had lower ICU admission rates (22.5% v. 28.3%). After adjustment, there were no statistically significant differences between those with and without disabilities for in-hospital death or admission to ICU. After adjustment, patients with a disability had longer hospital stays (rate ratio 1.36, 95% confidence interval [CI] 1.19–1.56) and greater risk of readmission (relative risk 1.77, 95% CI 1.14–2.75). In age-stratified analyses, we observed longer hospital stays among patients with a disability than in those without, in both younger and older subgroups; readmission risk was driven by younger patients with a disability.

Interpretation:

Patients with a disability who were admitted to hospital with COVID-19 had longer stays and elevated readmission risk than those without disabilities. Disability-related needs should be addressed to support these patients in hospital and after discharge.

‘It’s harder to assess and the risk was probably greater’; GP perspectives on safeguarding in the COVID-19 pandemic

Background

The COVID-19 pandemic required general practice to rapidly adapt to remote consultations and assessment of patients, creating new, and exacerbating existing, vulnerabilities for many patients.

Aim

To explore GP perspectives and concerns about safeguarding practice during the pandemic, focusing on challenges and opportunities created by remote consultation.

Design and setting

Qualitative interview study.

Method

Eighteen GPs from Oxford, London, Southampton, Liverpool, Manchester, and Reading were interviewed between June and November 2020, using a flexible topic guide and fictional vignettes to explore child and adult safeguarding scenarios. Interviews were audio-recorded, thematically coded, and analysed.

Results

GPs worried about missing observational information during remote consultations and that conversations might not be private or safe. Loss of continuity and pooled triage lists were seen as further weakening safeguarding opportunities. GPs experienced remote consulting as more ‘transactional’, with reduced opportunities to explore ‘other reasons’ including new safeguarding needs. However, they also recognised that remote consulting created opportunities for some vulnerable patients. While supporting known vulnerable patients was difficult, identifying new or unknown vulnerabilities was harder still. Most reported that remote consulting during COVID-19 was harder, riskier, and emotionally draining, contributing to increased GP anxiety and reduced job satisfaction.

Conclusion

The GPs interviewed raised important concerns about how to identify and manage safeguarding in the context of remote consultations. Current guidance recommends face-to-face consultation for safeguarding concerns, but pressure to use remote forms of access (within or beyond the pandemic) and the fact that safeguarding needs may be unknown makes this an issue that warrants urgent attention.

COVID-19 excess mortality among long-term care residents in Ontario, Canada

The coronavirus disease 2019 (COVID-19) has had devastating consequences worldwide, including a spike in global mortality. Residents of long-term care homes have been disproportionately affected. We conducted a retrospective cohort study to determine the scale of pandemic-related deaths of long-term care residents in the province of Ontario, Canada, and to estimate excess mortality due to a positive COVID-19 test adjusted for demographics and regional variations. Crude mortality rates for 2019 and 2020 were compared, as were predictors of mortality among residents with positive and negative tests from March 2020 to December 2020. We found the crude mortality rates were higher from April 2020 to June 2020 and from November 2020 to December 2020, corresponding to Wave 1 and Wave 2 of the pandemic in Ontario. There were also substantial increases in mortality among residents with a positive COVID-19 test. The significant differences in excess mortality observed in relation to long-term care home ownership category and geographic region may indicate gaps in the healthcare system that warrant attention from policymakers. Further investigation is needed to identify the most relevant factors in explaining these differences.