COVID-19 and Long Term Care


Collection of articles on COVID and LTC is available here

COVID-19 and Resident Care

Clinical Outcomes of Early Treatment With Doxycycline for 89 High-Risk COVID-19 Patients in Long-Term Care Facilities in New York.
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M. M. Alam, S. Mahmud, M. M. Rahman, J. Simpson, S. Aggarwal and Z. Ahmed.
Cureus 2020 Aug 11;12(8):e9658
Due to the cluster and associated comorbidities in residents of long-term care facilities (LTCFs), COVID-19-associated morbidity and mortality are significantly increased. Multiple therapeutic options, including hydroxychloroquine (HCQ) and azithromycin (AZI), were tried initially to treat moderate to severe COVID-19 and high-risk patients in LTCFs, but they were abandoned due to unfavorable reports. As a less toxic option, we initiated treatment with doxycycline (DOXY) very early in the course of illness. DOXY has antiviral, cardioprotective, immunomodulatory, and anti-inflammatory properties, but the efficacy of early intervention with DOXY in high-risk COVID-19 patients in LTCFs is unknown. Objective The goal of this retrospective study is to describe the clinical outcomes of high-risk COVID-19 patients with moderate to severe symptoms in LTCFs after early intervention with DOXY. Design Case-series analysis Setting LTCFs in New York Participants This observational study examines 89 patients who were diagnosed with COVID-19 from March 18 to May 13, 2020. Exposure All patients who were diagnosed with COVID-19 received DOXY and regular standard of care within 12 hours of the onset of symptoms. Additionally, four patients received meropenem, three patients received Zosyn, two patients received linezolid, and two patients received Bactrim DS. Four patients were on chronic ventilator support. No patients received any steroids or any other antiviral or immunomodulatory agents. The majority of the patients received zinc and calcium supplements as well. Main outcomes and measures Assessed measures were patients’ characteristics, fever, shortness of breath (SOB), cough, oxygen saturation/pulse oximetry (POX), radiologic improvements, laboratory tests, DOXY side effects, hospital transfers, and death. Results Eighty-nine (89) high-risk patients, who developed a sudden onset of fever, cough, SOB, and hypoxia and were diagnosed with COVID-19, were treated with DOXY (100 mg PO or intravenous (IV) for seven days) and regular standard of care. Eighty-five percent (85%) of patients (n=76) demonstrated clinical recovery that is defined as resolution of fever (average 3.7 days, Coeff = -0.96, p = 0.0001), resolution of SOB (average 4.2 days), and improvement of POX: average 84% before treatment and average 95% after treatment (84.7 ± 7% vs. 95 ± 2.6%, p = 0.0001). Higher pre- and post-treatment POX is associated with lower mortality (oxygen saturation (Spo2) vs. Death, Coeff = -0.01, p = 0.023; post-Spo2 vs. Death, Coeff = -0.05, p = 0.0002). Within 10 days of symptom onset, 3% of patients (n=3) were transferred to hospital due to clinical deterioration and 11% of patients (n=10) died. The result was followed for 30 days from the onset of symptoms in each patient. Conclusion Early treatment with DOXY for high-risk patients with moderate to severe COVID-19 infections in non-hospital settings, such as LTCFs, is associated with early clinical recovery, decreased hospitalization, and decreased mortality.

Nursing Home Resident Weight Loss during COVID-19 Restrictions

Margaret K. Danilovich, Christine R. Norrick, K. C. Hill and David E. Conroy.
Journal of the American Medical Directors Association 2020/09.
We analyzed nursing home resident body weight data before and after COVID restrictions were implemented. Results showed statistically significant decreases in body weight and highlight an area of urgent attention in long-term care.

Bedside wireless lung ultrasound for the evaluation of COVID-19 lung injury in senior nursing home residents.
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F. L. Dini, C. Bergamini, A. Allegrini, et al.
Monaldi Arch Chest Dis 2020 Sep 2;90(3):10.4081/monaldi.2020.1446
Lung Ultrasound (LUS) is regarded to be potentially useful to diagnose lung injury in older adults living in nursing homes with suspected COVID-19 pneumonia. We aimed at evaluating presence lung injury among senior nursing home residents by LUS performed with portable wireless scanner echography. The study population consisted of 150 residents with a mean age of 88 years (85% female) residing in 12 nursing homes in Northern Italy. Subjects had to have a history of recent onset of symptoms compatible with COVID-19 pneumonia or have been exposed to the contagion of patients carrying the disease. COVID-19 testing was performed with SARS-CoV-2 nasal-pharyngeal (NP) swabs. Positive subjects to LUS scanning were considered those with non-coascelent B-lines in >3 zones, coalescent B-lines in >3 zones and with iperdensed patchy non-consolidated lungs. Sixty-three percent had positive NP testing and 65% had LUS signs of pulmonary injury. LUS had a sensitivity of 79% in predicting positive NP testing. Sixteen percent of residents tested negative for SARSCoV-2 carried the signs of COVID-19 lung injury at LUS. There were 92 patients (61%) with current or recent symptoms.Positivity to LUS scanning was reported in 73% of residents with symptoms, while it was 53% in those without (P=0.016). A positive NP testing was observed in 66% of residents with symptoms and in 57% of those without (P=0.27). We conclude that assessment of LUS by portable wireless scanner echography can be profitability utilized to diagnose lung injury among senior nursing home residents with or without symptoms compatible with COVID-19 pneumonia.

Comment on: COVID-19 Deaths in Long-Term Care Facilities: A Critical Piece of the Pandemic Puzzle
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T. K. Kong.
J Am Geriatr Soc 2020 Aug 24
I read with interest the editorial by Lau-Ng et al1 who reviewed COVID-19 deaths in longterm care facilities (LTCFs) in the USA. They commented that Hong Kong has been an exception to the general pattern of LTCFs frequently being sites for COVID-19 outbreaks and deaths.

Risk Factors, Presentation, and Course of COVID-19 in a Large, Academic Long-term Care Facility.

Sandra M. Shi, Innokentiy Bakaev, Helen Chen, Thomas G. Travison and Sarah D. Berry.
Journal of the American Medical Directors Association 2020/09
To describe clinical characteristics, and risk factors associated with COVID-19 in long-stay nursing home residents.

Health Care Administration and Organization

Confinement of staff with residents in nursing homes: a solution against COVID-19?
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J. Belmin, N. Um Din, S. Pariel and C. Lafuente-Lafuente.
Geriatr Psychol Neuropsychiatr Vieil 2020 Sep 1;18(3):238-240
The Coronarovirus disease 2019 (Covid-19) outbreak strongly affected nursing and was responsible for a high mortality rate. During the pandemic of March-May 2020, 17 French nursing homes organized staff confinement periods with residents 24 hours a day and 7 days a week, to reduce the risk of entry of the SARS-CoV-2 virus into their facilities, in a context where visits to residents were prohibited. By means of a telephone survey of their directors, we observed that 16 nursing homes (94%) had no cases of COVID-19 among the residents, and that mortality from COVID-19 was very low compared to that recorded at the national level by Santé publique France (p<10(-4)). Moreover, the number of cases of Covid-19 among the staff of these nursing homes was also lower than that recorded by Santé publique France (p<10(-4)). These establishments experienced certain difficulties which the directors managed to overcome and the investment of these teams was widely appreciated by the families of the residents and through the press.

Coronavirus Disease 2019 Outcomes in French Nursing Homes That Implemented Staff Confinement With Residents.
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J. Belmin, N. Um-Din, C. Donadio, et al.
JAMA Netw Open 2020 Aug 3;3(8):e2017533
Coronavirus disease 2019 (COVID-19) is a major threat to nursing homes. During the COVID-19 pandemic wave that hit France in March and April 2020, staff members of some French nursing homes decided to confine themselves with their residents on a voluntary basis to reduce the risk of entry of the severe acute respiratory syndrome coronavirus 2 into the facility. OBJECTIVE: To investigate COVID-19-related outcomes in French nursing homes that implemented voluntary staff confinement with residents. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted in French nursing homes from March 1 to May 11, 2020. Participants included residents and staff members of the nursing homes where staff participated in voluntary self-confinement as well as those of the facilities for elderly people where staff did not practice self-confinement. Rates of COVID-19 cases and mortality in the cohort of nursing homes with self confinement were compared with those derived from a population-based survey of nursing homes conducted by French health authorities. EXPOSURES: Nursing homes with staff who self-confined were identified from the media and included if the confinement period of staff with residents was longer than 7 days. MAIN OUTCOMES AND MEASURES: Mortality related to COVID-19 among residents and COVID-19 cases among residents and staff members. COVID-19 was diagnosed by primary care or hospital physicians on the basis of fever and respiratory signs (eg, cough, dyspnea) or a clinical illness compatible with COVID-19; COVID-19 diagnoses were considered confirmed if real-time reverse transcriptase-polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 on nasopharyngeal swab was positive and considered possible if the test had not been performed or results were negative. Cases of COVID-19 were recorded by a telephone interview with the directors of nursing homes with staff who self-confined and by a nationwide declaration survey to health authorities for all facilities. RESULTS: This study included 17 nursing homes in which 794 staff members confined themselves to the facility with their 1250 residents. The national survey included 9513 facilities with 385 290 staff members and 695 060 residents. Only 1 nursing home with staff who self-confined (5.8%) had cases of COVID-19 among residents, compared with 4599 facilities in the national survey (48.3%) (P < .001). Five residents (0.4%) in the nursing homes with staff who self-confined had confirmed COVID-19, compared with 30 569 residents (4.4%) with confirmed COVID-19 in the national survey (P < .001); no residents of facilities with self-confinement had possible COVID-19, compared with 31 799 residents (4.6%) with possible COVID-19 in the national survey (P < .001). Five residents (0.4%) in the nursing homes with staff who self-confined died of COVID-19, compared with 12 516 (1.8%) in the national survey (odds ratio, 0.22; 95% CI, 0.09-0.53; P < .001). Twelve staff members (1.6%) from the facilties with self-confinement had confirmed or possible COVID-19, compared with 29 463 staff members (7.6%) in the national survey (P < .001). CONCLUSIONS AND RELEVANCE: In this cohort study of French nursing homes during the COVID-19 pandemic, mortality rates related to COVID-19 were lower among nursing homes that implemented staff confinement with residents compared with those in a national survey. These findings suggest that self-confinement of staff members with residents may help protect nursing home residents from mortality related to COVID-19 and residents and staff from COVID-19 infection.

Migrant carers in Europe in times of COVID-19: a call to action for European health workforce governance and a public health approach.
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E. Kuhlmann, M. Falkenbach, K. Klasa, E. Pavolini and M. I. Ungureanu.
Eur J Public Health 2020 Sep 7
The present study explores the situation of migrant carers in long-term care (LTC) in European Union Member States and the disruptions caused by the COVID-19 pandemic from a public health perspective. The aim is to bring LTC migrant carers into health workforce research and highlight a need for trans-sectoral and European heath workforce governance. We apply an exploratory approach based on secondary sources, document analysis and expert information. A framework comprising four major dimensions was developed for data collection and analysis: LTC system, LTC health labour market, LTC labour migration policies and specific LTC migrant carer policies during the COVID-19 crisis March to May 2020. Material from Austria, Italy, Germany, Poland and Romania was included in the study. Results suggest that undersupply of carers coupled with cash benefits and a culture of family responsibility may result in high inflows of migrant carers, who are channelled in low-level positions or the informal care sector. COVID-19 made the fragile labour market arrangements of migrant carers visible, which may create new health risks for both the individual carer and the population. Two important policy recommendations are emerging: to include LTC migrant carers more systematically in public health and health workforce research and to develop European health workforce governance which connects health system needs, health labour markets and the individual migrant carers.

Factors Associated with Nursing Homesʼ Late Participation in COVID‐19 Reporting

Y. Li, F. Fang and M. He.
J Am Geriatr Soc 2020 Sep 7
On April 19, 2020, the Centers for Medicare & Medicaid Services (CMS) announced the requirement that nursing homes should inform residents and their families of COVID‐19 outbreaks. In addition, nursing homes were required to report COVID‐19–related cases and deaths directly to the Centers for Disease Control and Prevention. The initial deadline for the submission of COVID‐19 data was May 17, 2020, and CMS extended the grace period to May 31, 2020. The COVID‐19 Nursing Home Data were published by May 31, 2020. Still, about 12% of nursing homes did not follow the requirement to report the COVID‐19 data. Starting on June 7, 2020, nursing homes that did not submit COVID‐19 data would receive a warning notice of $1,000 with $500 for each additional week.

Nursing Home Social Workers Perceptions of Preparedness and Coping for COVID-19.
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V. J. Miller, N. L. Fields, K. A. Anderson, N. Kusmaul and C. Maxwell.
J Gerontol B Psychol Sci Soc Sci 2020 Aug 29
Social work has a long history of responding to the needs of vulnerable populations during times of crisis and disaster. Social workers are working at the front lines responding to the current COVID-19 pandemic in a variety of health care practice settings, including nursing homes, however it is unclear how social workers perceive their preparedness during this time. METHODS: This study employed a cross-sectional survey to nursing home social workers via social media on feelings of preparedness for COVID-19, what has been most professionally helpful for social workers during these times in their role in COVID-19, as well as demographic questions. Demographic data were analyzed using SPSS and qualitative data were analyzed using the rigorous and accelerated data reduction (RADaR) technique. RESULTS: Data are based on a sample of 63 (N=63) nursing home social workers. Findings revealed that while some social workers felt prepared for the coronavirus, many respondents stated that they were unprepared to meet the demands and challenges they were facing. Moreover, participants shared that professional support was critically important to get through COVID-19. DISCUSSION: These findings are important, as social workers are tasked with ensuring each resident attains their highest level of psychosocial well-being, which can be achieved only when nursing home staff are supported. Findings from the present study suggest that additional support for nursing home staff ought to include peer mentoring and mutual support. Additionally, improved leadership across health care settings is worth assessing.

Modelling resource requirements and physician staffing to provide virtual urgent medical care for residents of long-term care homes: a cross-sectional study.
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F. Razak, S. Shin, F. Pogacar, et al.
CMAJ Open 2020 Aug 20;8(3):E514-E521
The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities. METHODS: We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments. RESULTS: There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each. INTERPRETATION: The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.

Communication modality preferences by hospitalized and institutionalized frail older adults during COVID-19 confinement: Cross-sectional survey.
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G. Sacco, S. LlÉonart, R. Simon, F. Noublanche and C. Annweiler.
JMIR Mhealth Uhealth 2020 Jul 22
Technological communication supports such as phone-calls or video-calls could help prevent social isolation and loneliness in frail older adults during confinement. OBJECTIVE: Our objectives were to determine i) which virtual communication modality (i.e. phone-call versus video-call) was preferred by confined older patients and residents, and ii) the variables influencing this choice. METHODS: Telephony Or Videophony for Isolated elDerly (TOVID) was a Cross-sectional study designed to examine the preference between phone-calls and video-calls among frail older adults either hospitalized in a geriatric acute care unit (GACU) or institutionalized in a long-term care and nursing-home (LTC/NH) during COVID-19 confinement. RESULTS: A total of 132 seniors were included between March 25 and May 11, 2020 (mean±SD, 88.2±6.2 years; 59% women). Patients hospitalized in GACU were more often independent to establish communication than residents institutionalized in LTC/NH (p=0.03) and were more satisfied (p=0.02). Overall, seniors tended to favor phone-calls (55%) over video-calls (45%), but their satisfaction degree was similar regardless of the device chosen (p=0.1), with no effect of age (p=0.97) or gender (p=0.2). In GACU, the satisfaction degree was similar between phone-calls (98%) and video-calls (87%) in older patients (p=0.1). Conversely, in LTC/NH, residents were more satisfied with the use of video-calls to communicate with their relatives (93% versus 50%, p=0.02). CONCLUSIONS: Seniors confined to healthcare settings were more independent with phone-calls than with video-calls, and tended to use the telephone more often. The satisfaction degree was similar with both modalities and even greater with video-calls in LTC/NH when they were assisted to establish communication. CLINICALTRIAL: ClinicalTrials.gov Identifier: NCT04333849 https://www.clinicaltrials.gov/ct2/show/NCT04333849.

Mapping community-level determinants of COVID-19 transmission in nursing homes: A multi-scale approach.
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M. M. Sugg, T. J. Spaulding, S. J. Lane, et al.
Sci Total Environ 2020 Aug 25;752:141946
Deaths from the COVID-19 pandemic have disproportionately affected older adults and residents in nursing homes. Although emerging research has identified place-based risk factors for the general population, little research has been conducted for nursing home populations. This GIS-based spatial modeling study aimed to determine the association between nursing home-level metrics and county-level, place-based variables with COVID-19 confirmed cases in nursing homes across the United States. A cross-sectional research design linked data from Centers for Medicare & Medicaid Services, American Community Survey, the 2010 Census, and COVID-19 cases among the general population and nursing homes. Spatial cluster analysis identified specific regions with statistically higher COVID-19 cases and deaths among residents. Multivariate analysis identified risk factors at the nursing home level including, total count of fines, total staffing levels, and LPN staffing levels. County-level or place-based factors like per-capita income, average household size, population density, and minority composition were significant predictors of COVID-19 cases in the nursing home. These results provide a framework for examining further COVID-19 cases in nursing homes and highlight the need to include other community-level variables when considering risk of COVID-19 transmission and outbreaks in nursing homes.

Prevalence and Spread

Transmission of SARS-CoV-2 Involving Residents Receiving Dialysis in a Nursing Home – Maryland, April 2020.
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B. F. Bigelow, O. Tang, G. R. Toci, et al.
MMWR Morb Mortal Wkly Rep 2020 Aug 14;69(32):1089-1094
SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), can spread rapidly in nursing homes once it is introduced (1,2). To prevent outbreaks, more data are needed to identify sources of introduction and means of transmission within nursing homes. Nursing home residents who receive hemodialysis (dialysis) might be at higher risk for SARS-CoV-2 infections because of their frequent exposures outside the nursing home to both community dialysis patients and staff members at dialysis centers (3). Investigation of a COVID-19 outbreak in a Maryland nursing home (facility A) identified a higher prevalence of infection among residents undergoing dialysis (47%; 15 of 32) than among those not receiving dialysis (16%; 22 of 138) (p<0.001). Among residents with COVID-19, the 30-day hospitalization rate among those receiving dialysis (53%) was higher than that among residents not receiving dialysis (18%) (p = 0.03); the proportion of dialysis patients who died was 40% compared with those who did not receive dialysis (27%) (p = 0.42).Careful consideration of infection control practices throughout the dialysis process (e.g., transportation, time spent in waiting areas, spacing of machines, and cohorting), clear communication between nursing homes and dialysis centers, and coordination of testing practices between these sites are critical to preventing COVID-19 outbreaks in this medically vulnerable population.

COVID-19 and care homes in England: What happened and why?
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M. Daly.
Soc Policy Adm 2020 Aug 28
In the context of very high mortality and infection rates, this article examines the policy response to COVID-19 in care homes for older people in the UK, with particular focus on England in the first 10 weeks of the pandemic. The timing and content of the policy response as well as different possible explanations for what happened are considered. Undertaking a forensic analysis of policy in regard to the overall plan, monitoring and protection as well as funding and resources, the first part lays bare the slow, late and inadequate response to the risk and reality of COVID-19 in care homes as against that in the National Health Service (NHS). A two-pronged, multidimensional explanation is offered: structural, sectoral specificities; political and socio-cultural factors. Amongst the relevant structural factors are the institutionalised separation from the health system, the complex system of provision and policy for adult social care, widespread market dependence. There is also the fact that logistical difficulties were exacerbated by years of austerity and resource cutting and a weak regulatory tradition of the care home sector. The effects of a series of political and cultural factors are also highlighted. As well as little mobilisation of the sector and low public commitment to and knowledge of social care, there is a pattern of Conservative government trying to divest the state of responsibilities in social care. This would support an interpretation in terms of policy avoidance as well as a possible political calculation by government that its policies towards the care sector and care homes would be less important and politically damaging than those for the NHS.

Evaluation of testing frequency and sampling for SARS-CoV-2 surveillance strategies in long-term care facilities.

Charlotte Lanièce Delaunay, Sahar Saeed and Quoc Dinh Nguyen.
Journal of the American Medical Directors Association 2020/09
We compared the impact of different SARS-CoV-2 surveillance strategies in long-term care facilities. We recommend weekly testing of at least 50% of staff and residents in order to minimize outbreaks in this priority population.; We compared the impact of different SARS-CoV-2 surveillance strategies in long-term care facilities. We recommend weekly testing of at least 50% of staff and residents in order to minimize outbreaks in this priority population.

Outbreak of COVID-19 at three nursing homes in Bergen.
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B. R. Kittang, S. V. Hofacker, S. P. Solheim, K. Krüger, K. K. Løland and K. Jansen.
Tidsskr Nor Laegeforen 2020 Jun 18;140(11):10.4045/tidsskr.20.0405. Print 2020 Aug 18
Nursing home residents are generally old and frail, and at high risk that COVID-19 will take a serious course. Outbreaks of COVID-19 have not previously been described in Norway, and it is important to identify mechanisms for spread of the infection and course of disease for nursing home residents with this pandemic disease. MATERIAL AND METHOD: We included residents from three nursing homes with outbreaks of COVID-19 in a retrospective observational study, and we retrieved information on the number of staff for whom SARS-CoV-2 was confirmed or who were placed in quarantine. We present resident characteristics, course of disease and mortality associated with COVID-19 in the nursing homes, as well as providing a brief description of the outbreaks. RESULTS: Forty residents were included, 26 of whom were women. The average age was 86.2 years. Thirty-seven of the residents had atypical symptoms, nine of them were asymptomatic at the time of diagnosis, and 21 died during the coronavirus infection. Contact tracing indicated that the outbreaks may have originated from staff in the pre-symptomatic or early and mild phase of the disease. SARS-CoV-2 was detected in forty-two staff members, and a further 115 were placed in quarantine. INTERPRETATION: Many residents had atypical disease presentation, and the mortality from COVID-19 was high. Spread of infection may have originated from staff, also before they displayed obvious symptoms, and contributed to extensive spread of SARS-CoV-2 in the three nursing homes.

Early Intervention Reduces the Spread of COVID-19 in Long-Term Care Facilities in the Republic of Korea.
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S. Y. Park, G. Choi, H. Lee, et al.
Osong Public Health Res Perspect 2020 Aug;11(4):259-264
This study describes the epidemiological characteristics of coronavirus disease 2019 (COVID-19) based on reported cases from long-term care facilities. As of April 20(th), 2020, 3 long-term care facilities in a metropolitan area of South Korea had reported cases of COVID-19. These facilities’ employees were presumed to be the sources of infection. There were 2 nursing hospitals that did not report any additional cases. One nursing home had a total of 25 cases, with an attack rate of 51.4% (95% CI 35.6-67.0), and a fatality rate of 38.9% (95% CI 20.3-61.4) among residents. The results from this study suggest that early detection and maintenance of infection control minimizes the risk of rapid transmission.

Exhaling, Head Turning, and Moving Away: Nonpharmacological Maneuvers to Possibly Decrease Risk of Contracting COVID-19.
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F. T. Sherman.
J Am Geriatr Soc 2020 Aug 8
At about the same time as the CDC issued their respiratory hygiene and cough etiquette recommendations for decreasing the transmission of influenza in 2008 , I thought that rapidly performing three respiratory and physical maneuvers could decrease the chances of inhaling viral respiratory droplets and aerosols from a person who sneezed, coughed or spoke loudly in close proximity.

Predicting COVID-19 infection risk and related risk drivers in nursing homes: A machine learning approach.

Christopher L. F. Sun, Eugenio Zuccarelli, El Ghali A. Zerhouni, et al.
Journal of the American Medical Directors Association 2020/09
Inform COVID-19 infection prevention measures by identifying and assessing risk and possible vectors of infection in nursing homes (NHs) using a machine-learning approach.; ObjectiveInform COVID-19 infection prevention measures by identifying and assessing risk and possible vectors of infection in nursing homes (NHs) using a machine-learning approach.