COVID-19 and Long Term Care

Collection of articles on COVID and LTC is available here

COVID-19 and Resident Care

Facing the COVID-19 Winter: Ethical Lessons for Treating Older Adults.
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A. O. Giwa and P. B. Teaster.
J Am Geriatr Soc 2020 Dec 7
Approaching the winter of 2020, we ask, “Is society doing enough to protect older adults or contributing toward collective and systematic elder abuse?

Sources of Distress for Residents With Chronic Critical Illness and Ventilator Dependence in Long-Term Care.
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A. F. Howard, S. Crowe, L. Choroszewski, et al.
Qual Health Res 2020 Dec 8:1049732320976373
Limited understanding of the psychological challenges experienced by individuals with chronic critical illness hampers efforts to deliver quality care. We used an interpretive description approach to explore sources of distress for individuals with chronic critical illness in residential care, wherein we interviewed six residents, 11 family members, and 21 staff. Rather than discuss physical symptoms, sources of distress for residents were connected to feeling as though they were a patient receiving medical care as opposed to an individual living in their home. The tension between medical care and the unmet need for a sense of home was related to care beyond the physical being overlooked, being dependent on others but feeling neglected, frustration with limited choice and participation in decision making, and feeling sad and alone. Efforts to refine health care for individuals with chronic critical illness must foster a sense of home while ensuring individuals feel safe and supported to make decisions.

#MoreThanAVisitor: Families as “Essential” Care Partners During COVID-19.
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C. L. Kemp.
Gerontologist 2020 Dec 9
The public health response to the current Coronavirus pandemic in long-term care communities, including assisted living, encompasses prohibiting visitors. This ban, which includes family members, has been criticized for being unfair, unhealthy, and unsafe. Against this backdrop, I examine the roles family play in residents’ daily lives and care routines. I argue that classifying family as “visitors” rather than essential care partners overlooks their critical contributions and stems from taken-for-granted assumption about gender, families, and care work, and I demonstrate why families are more than visitors. Policies that ban family visits also reflect a narrow understanding of health that focuses on mitigating infection risk, but neglects overall health and well-being. This policy further stems from a limited comprehension of care relations. Research shows that banning family visits has negative consequences for residents, but also families themselves, and direct care workers. I argue that identifying ways to better understand and support family involvement is essential and demonstrate the utility of the Convoys of Care model for guiding the reconceptualization of family in long-term care research, policy, and practice during and beyond the pandemic.

Weight Loss in COVID-19 Positive Nursing Home Residents.

Michelle Martinchek, Kimberly J. Beiting, Jacob Walker, et al.
Journal of the American Medical Directors Association 2020/12.
COVID-19 positive residents of a skilled nursing facility experienced significantly more weight loss than COVID-19 negative residents during a COVID-19 outbreak, although both groups experienced weight loss during facility-wide infection control restrictions.

Should we Prescribe Antibiotics in Older Patients Presenting COVID-19 Pneumonia?

G. Odille, N. Girard, S. Sanchez, et al.
Journal of the American Medical Directors Association 2020/12
In this observational study of 124 older comorbid inpatients presenting COVID-19 pneumonia, a third of patients were dead at one month of follow-up. After adjustment on prognostic factors, mortality was similar in patients with or without antibiotics.; In this observational study of 124 older comorbid inpatients presenting COVID-19 pneumonia, a third of patients were dead at one month of follow-up. After adjustment on prognostic factors, mortality was similar in patients with or without antibiotics.

Increased Prescribing of Psychotropic Medications to Ontario Nursing Home Residents during the COVID-19 Pandemic.

Nathan M. Stall, Jonathan S. Zipursky, Jagadish Rangrej, et al.
medRxiv 2020
In this population-based study of all Ontario nursing home residents, we found increased prescribing of psychotropic drugs at the onset of the COVID-19 pandemic that persisted through September 2020. Increases in prescribing were out of proportion to expected secular trends, and distinct from observed prescribing changes in other drugs during the pandemic. Our findings underscore the urgency of balancing infection prevention and control measures in nursing homes with the mental wellbeing of residents.Competing Interest StatementThe authors have declared no competing interest.Funding StatementThis study was not funded. Dr. Stall is supported by the University of Toronto Department of Medicine{\textquoteright}s Eliot Phillipson Clinician-Scientist Training Program and the Vanier Canada Graduate Scholarship.Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:The study was approved by the University of Toronto{\textquoteright}s research ethics board.All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesStudy protocol and statistical code: The study protocol and underlying analytic code are available from the authors on request (e-mail, nathan.stall@mail.utoronto.ca), with the understanding that the computer programs may rely on coding templates or macros that are unique to the Ontario Ministry of Health and therefore either are inaccessible or may require modification. Data set: The data used for this study are not publicly available.

Clinical Suspicion of COVID-19 in Nursing Home Residents: Symptoms and Mortality Risk Factors.
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J. J. S. Rutten, A. M. van Loon, J. van Kooten, et al.
J Am Med Dir Assoc 2020 Dec;21(12):1791-1797.e1
To describe the symptomatology, mortality, and risk factors for mortality in a large group of Dutch nursing home (NH) residents with clinically suspected COVID-19 who were tested with a reverse transcription-polymerase chain reaction (RT-PCR) test. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: Residents of Dutch NHs with clinically suspected COVID-19 and who received RT-PCR test. METHODS: We collected data of NH residents with clinically suspected COVID-19 via electronic health records between March 18 and May 13, 2020. Registration was performed on diagnostic status [confirmed (COVID-19+)/ruled out (COVID-19-)] and symptomatology (typical and atypical symptoms). Information on mortality and risk factors for mortality were extracted from usual care data. RESULTS: In our sample of residents with clinically suspected COVID-19 (N = 4007), COVID-19 was confirmed in 1538 residents (38%). Although symptomatology overlapped between residents with COVID-19+ and COVID-19-, those with COVID-19+ were 3 times more likely to die within 30 days [hazard ratio (HR), 3.1, 95% confidence interval (CI) 2.7-3.6]. Within this group, mortality was higher for men than for women (HR 1.8, 95% CI 1.5-2.2), and we observed a higher mortality for residents with dementia, reduced kidney function, and Parkinson’s disease, even when corrected for age, gender, and comorbidities. CONCLUSIONS AND IMPLICATIONS: About 40% of the residents with clinically suspected COVID-19 actually had COVID-19, based on the RT-PCR test. Despite an overlap in symptomatology, mortality rate was 3 times higher for residents with COVID-19+. This emphasizes the importance of using low-threshold testing in NH residents, which is an essential prerequisite to using limited personal protective equipment and isolation measures efficiently.

Poor feeding due to visitor restrictions in long-term care facilities during the coronavirus disease 2019 pandemic.
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C. K. Shum, Y. F. Shea, M. Tang, W. H. Wan and M. M. K. Chan.
Psychogeriatrics 2020 Nov;20(6):929-930
Behavioural eating problems negatively affect patients with advanced dementia. However, these patients may be willing to be fed by close relatives. Unfortunately, during the coronavirus disease 2019 (COVID‐19) pandemic, visitor restrictions were imposed in long‐term care facilities (LTCFs) to limit the spread of infection among the most vulnerable LTCF residents. This reduced contact between patients and their relatives may have contributed to behavioural eating problems.

Clinical features and medical care factors associated with mortality in French nursing homes during COVID-19 outbreak.
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P. Tarteret, A. Strazzulla, M. Rouyer, et al.
Int J Infect Dis 2020 Dec 7
The aim of this study is to identify demographic, clinical and medical care factors associated with mortality in three nursing homes. METHODS: Two nursing homes were hospital-dependent, had connections with infection prevention and control departments, and had permanent physicians. Third nursing home had no direct connection with general hospital, no infection control practitioner, and no permanent physician. The main outcome was death. RESULTS: During first 3 months of the outbreak, 224/375 (59.7%) residents were classified “COVID-19 cases” and 57/375 (15.2%) died. Hospital dependent nursing homes had lower COVID-19 case fatality rates in comparison to non-hospital dependent nursing home (15 [6.6%] vs 38 [25.8%], OR 0.20 [0.11-0.38], p = 0.001). During first 3 weeks of the outbreak, mortality in COVID-19 patients decreased if they had daily clinical examination (aOR: 0.09 [0.03-0.35], p = 0.01), 3 vital signs measurements per day (OR: 0.06 [0.01-0.30], p = 0.001) and prophylactic anticoagulation (OR: 0 [0.00-0.24], p = 0.001). CONCLUSIONS: This study suggests that high mortality rates in some nursing homes during COVID-19 outbreak might be favoured by a lack of medical care management. Increasing human and material resources, encouraging presence of nursing home physicians and establishing connection with general hospitals should be consider to deal with present and future health disasters in nursing homes.

Clinical characteristics and predictors of mortality associated with COVID-19 in elderly patients from a long-term care facility.
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E. M. Trecarichi, M. Mazzitelli, F. Serapide, et al.
Sci Rep 2020 Nov 30;10(1):20834-020-77641-7
Since December 2019, coronavirus disease 2019 (COVID-19) pandemic has spread from China all over the world and many COVID-19 outbreaks have been reported in long-term care facilities (LCTF). However, data on clinical characteristics and prognostic factors in such settings are scarce. We conducted a retrospective, observational cohort study to assess clinical characteristics and baseline predictors of mortality of COVID-19 patients hospitalized after an outbreak of SARS-CoV-2 infection in a LTCF. A total of 50 patients were included. Mean age was 80 years (SD, 12 years), and 24/50 (57.1%) patients were males. The overall in-hospital mortality rate was 32%. At Cox regression analysis, significant predictors of in-hospital mortality were: hypernatremia (HR 9.12), lymphocyte count < 1000 cells/µL (HR 7.45), cardiovascular diseases other than hypertension (HR 6.41), and higher levels of serum interleukin-6 (IL-6, pg/mL) (HR 1.005). Our study shows a high in-hospital mortality rate in a cohort of elderly patients with COVID-19 and hypernatremia, lymphopenia, CVD other than hypertension, and higher IL-6 serum levels were identified as independent predictors of in-hospital mortality. Given the small population size as major limitation of our study, further investigations are necessary to better understand and confirm our findings in elderly patients.

Family Presence in Long-Term Care During the COVID-19 Pandemic: Call to Action for Policy, Practice, and Research.
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S. M. Tupper, H. Ward and J. Parmar.
Can Geriatr J 2020 Dec 1;23(4):335-339
The purpose of this commentary is to review the impact of restriction of family presence on residents, families, and LTC staff, and provide a resident/family-oriented perspective on policy, practice, and research implications to challenge the outdated notion of “one-size-fits-all” visitation restrictions during a pandemic.

Quality Improvement

COVID-19 and residential aged care: priorities for optimising preparation and management of outbreaks.
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G. E. Aitken, A. L. Holmes and J. E. Ibrahim.
Med J Aust 2020 Dec 9
The recommendations we describe in this perspective are informed by a short and rapid consultation with our colleagues in senior aged care medical and nursing professional roles within Victoria, Australia. We focus on identifying the priorities for preparation and the emergency management response to widespread outbreaks. Of the multiple priorities that emerged, three were prominent: outbreak management plans, training of staff, and maintaining an adequate workforce.

Medical strategies in nursing homes during the COVID-19 pandemic: A Brazilian experience.
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P. G. Blasco, M. A. C. de Benedetto, M. R. Levites, G. Moreto and E. P. Fernandes.
Aust J Gen Pract 2020 Nov 30;49:10.31128/AJGP-COVID-41
The difference in the quality of care provided in nursing home facilities in Brazil proved to be important for facing the COVID-19 pandemic.

Supervised Exercise (Vivifrail) Protects Institutionalized Older Adults Against Severe Functional Decline After 14 Weeks of COVID Confinement.
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J. Courel-Ibáñez, J. G. Pallarés, S. García-Conesa, Á. Buendía-Romero, A. Martínez-Cava and M. Izquierdo.
J Am Med Dir Assoc 2020 Dec 6
Spain experienced a Coronavirus Disease 2019 (COVID-19)–related confinement for 14 weeks (March 14 to June 21, 2020) affecting all citizens irrespective of age, interrupting any kind of supervised physical activity programs for the older adults. This physical inactivity period could lead, among other complications, to disuse atrophy, functional decline, muscle wasting, and disability, which are all associated with longer hospitalization periods and a worse rehabilitation. More so than ever, implementing structured and supervised exercise programs for older adults is critical to improve/maintain the health status of patients at risk of COVID-19 and alleviate the consequences of this pandemic.

COVID-19 among nursing home residents: results of an urgent pre-hospital intervention by a multidisciplinary task force.
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F. Dolveck, A. Strazzulla, C. Noel, et al.
Braz J Infect Dis 2020 Dec 5
The current coronavirus disease-2019 (COVID-19) pandemic caused 10,541 deaths among nursing home residents in France, by July 17th, 2020. This study reported the results of an urgent pre-hospital intervention in eight French nursing homes. A retrospective study was conducted from March 26th to May 7th, 2020, before and after the intervention of a task force which took action from April 9th to April 11th, 2020. The task force included nurses and specialists of the county general hospital. The intervention had four steps: i) daily notification of deaths; ii) audit by infectious diseases and hygiene specialists focused on nursing team reinforcing, tracking of suspected cases, patients’ cohorting, review of preventive and protective measures, hydration, thromboembolism prevention; iii) intervention of an emergency team which urgently performed procedures suggested; and iv) relay with a geriatric team. There were a total of 770 residents distributed in eight facilities with capacity varying from 53 to 145 residents. The number of deaths peaked at 139 in week 2 and the trough at 0 occurred in weeks 6-7. Comparison between periods (before vs after intervention) showed a significant decrease in number of new deaths (83/770; 11% vs 35/687; 5%, p = 0.0001) and new COVID-19 cases (348/770; 45% vs 123/422; 29%, p < 0.001). The urgent pre-hospital intervention by a multidisciplinary task force achieved mortality reduction during COVID-19 outbreak in nursing homes. Pre-hospital intervention is a valid alternative to hospitalization in case of hospital saturation.

Research Needed: Better Quantitative Studies to Identify Causes of COVID-19 Nursing Home Disparities.

Jennifer Gaudet Hefele.
Journal of the American Medical Directors Association 2020/12.
This letter identifies gaps in quantitative analyses conducted to identify and explain nursing home racial and ethnic disparities in COVID-19 outcomes and offers strategies for studies needed to fill those gaps

Crisis Standards of Care for the COVID-19 Pandemic: An Essential Resource for the PALTC Community.
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J. Wright.
J Am Med Dir Assoc 2020 Dec 7
This editorial introduces the first Crisis Standards of Care (CSC) document written for the PALTC community during the COVID-19 Pandemic. Readers are introduced to the concept of CSC, the workgroup as well as its covered topics.

Impact on Health Care Workers

Health Care Workers’ Mental Health and Quality of Life During COVID-19: Results From a Mid-Pandemic, National Survey.
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K. P. Young, D. L. Kolcz, D. M. O’Sullivan, J. Ferrand, J. Fried and K. Robinson.
Psychiatr Serv 2020 Dec 3:appips202000424
The authors sought to quantify the rates of psychological distress among health care workers (HCWs) during the COVID-19 pandemic and to identify job-related and personal risk and protective factors. METHODS: From April 1 to April 28, 2020, the authors conducted a national survey advertised via e-mail lists, social media, and direct e-mail. Participants were self-selecting, U.S.-based volunteers. Scores on the Patient Health Questionnaire-9, General Anxiety Disorder-7, Primary Care Posttraumatic Stress Disorder Screen, and Alcohol Use Disorders Identification Test-C were used. The relationships between personal resilience and risk factors, work culture and stressors and supports, and COVID-19-related events were examined. RESULTS: Of 1,685 participants (76% female, 88% White), 31% (404 of 1,311) endorsed mild anxiety, and 33% (427 of 1,311) clinically meaningful anxiety; 29% (393 of 1,341) reported mild depressive symptoms, and 17% (233 of 1,341) moderate to severe depressive symptoms; 5% (64 of 1,326) endorsed suicidal ideation; and 14% (184 of 1,300) screened positive for posttraumatic stress disorder. Pediatric HCWs reported greater anxiety than did others. HCWs’ mental health history increased risk for anxiety (odds ratio [OR]=2.78, 95% confidence interval [CI]=2.09-3.70) and depression (OR=3.49, 95% CI=2.47-4.94), as did barriers to working, which were associated with moderate to severe anxiety (OR=2.50, 95% CI=1.80-3.48) and moderate depressive symptoms (OR=2.15, 95% CI=1.45-3.21) (p<0.001 for all comparisons). CONCLUSIONS: Nearly half of the HCWs reported serious psychiatric symptoms, including suicidal ideation, during the COVID-19 pandemic. Perceived workplace culture and supports contributed to symptom severity, as did personal factors.

Prevalence of Mental Health Problems During Virus Epidemics in the General Public, Health Care Workers and Survivors: A Rapid Review of the Evidence.
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S. J. Zürcher, P. Kerksieck, C. Adamus, et al.
Front Public Health 2020 Nov 11;8:560389
The swift spread of SARS-CoV-2 provides a challenge worldwide. As a consequence of restrictive public health measures like isolation, quarantine, and community containment, the provision of mental health services is a major challenge. Evidence from past virus epidemics and the current SARS-CoV-2 outbreak indicate high prevalence rates of mental health problems (MHP) as short- and long-term consequences. However, a broader picture of MHP among different populations is still lacking. Methods: We conducted a rapid review on MHP prevalence rates published since 2000, during and after epidemics, including the general public, health care workers, and survivors. Any quantitative articles reporting on MHP rates were included. Out of 2,855 articles screened, a total of 74 were included in this review. Results: Most original studies on MHP were conducted in China in the context of SARS-CoV-1, and reported on anxiety, depression, post-traumatic stress symptoms/disorder, general psychiatric morbidity, and psychological symptoms. The MHP rates across studies, populations, and epidemics vary substantially. While some studies show high and persistent rates of MHP in populations directly affected by isolation, quarantine, threat of infection, infection, or life-threatening symptoms (e.g., health care workers), other studies report minor effects. Furthermore, even less affected populations (e.g., distant to epidemic epicenter, no contact history with suspected or confirmed cases) can show high rates of MHP. Discussion: MHP vary largely across countries and risk-groups in reviewed studies. The results call attention to potentially high MHP during epidemics. Individuals affected directly by an epidemic might be at a higher risk of short or even long-term mental health impairments. This study delivers insights stemming from a wide range of psychiatric instruments and questionnaires. The results call for the use of validated and standardized instruments, reference norms, and pre-post measurements to better understand the magnitude of the MHP during and after the epidemics. Nevertheless, emerging MHP should be considered during epidemics including the provision of access to mental health care to mitigate potential mental impairments.

Infection and mortality of healthcare workers worldwide from COVID-19: a systematic review.
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S. Bandyopadhyay, R. E. Baticulon, M. Kadhum, et al.
BMJ Glob Health 2020 Dec;5(12):e003097. doi: 10.1136/bmjgh-2020-003097
To estimate COVID-19 infections and deaths in healthcare workers (HCWs) from a global perspective during the early phases of the pandemic. DESIGN: Systematic review. METHODS: Two parallel searches of academic bibliographic databases and grey literature were undertaken until 8 May 2020. Governments were also contacted for further information where possible. There were no restrictions on language, information sources used, publication status and types of sources of evidence. The AACODS checklist or the National Institutes of Health study quality assessment tools were used to appraise each source of evidence. OUTCOME MEASURES: Publication characteristics, country-specific data points, COVID-19-specific data, demographics of affected HCWs and public health measures employed. RESULTS: A total of 152 888 infections and 1413 deaths were reported. Infections were mainly in women (71.6%, n=14 058) and nurses (38.6%, n=10 706), but deaths were mainly in men (70.8%, n=550) and doctors (51.4%, n=525). Limited data suggested that general practitioners and mental health nurses were the highest risk specialities for deaths. There were 37.2 deaths reported per 100 infections for HCWs aged over 70 years. Europe had the highest absolute numbers of reported infections (119 628) and deaths (712), but the Eastern Mediterranean region had the highest number of reported deaths per 100 infections (5.7). CONCLUSIONS: COVID-19 infections and deaths among HCWs follow that of the general population around the world. The reasons for gender and specialty differences require further exploration, as do the low rates reported in Africa and India. Although physicians working in certain specialities may be considered high risk due to exposure to oronasal secretions, the risk to other specialities must not be underestimated. Elderly HCWs may require assigning to less risky settings such as telemedicine or administrative positions. Our pragmatic approach provides general trends, and highlights the need for universal guidelines for testing and reporting of infections in HCWs.

Investigating the Psychological Impact of COVID-19 among Healthcare Workers: A Meta-Analysis.
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K. Batra, T. P. Singh, M. Sharma, R. Batra and N. Schvaneveldt.
Int J Environ Res Public Health 2020 Dec 5;17(23):9096. doi: 10.3390/ijerph17239096
Previous meta-analyses were conducted during the initial phases of the COVID-19 pandemic, which utilized a smaller pool of data. The current meta-analysis aims to provide additional (and updated) evidence related to the psychological impact among healthcare workers. The search strategy was developed by a medical librarian and bibliographical databases, including Medline, Embase, CINAHL, PsycINFO, and Scopus were searched for studies examining the impact of the COVID-19 pandemic on the psychological health of healthcare workers. Articles were screened by three reviewers. Heterogeneity among studies was assessed by I(2) statistic. The random-effects model was utilized to obtain the pooled prevalence. A subgroup analysis by region, gender, quality of study, assessment methods, healthcare profession, and exposure was performed. Publication bias was assessed by Funnel plot and Egger linear regression test. Sixty-five studies met the inclusion criteria and the total sample constituted 79,437 participants. The pooled prevalence of anxiety, depression, stress, post-traumatic stress syndrome, insomnia, psychological distress, and burnout was 34.4%, 31.8%, 40.3%, 11.4%, 27.8%, 46.1%, and 37.4% respectively. The subgroup analysis indicated higher anxiety and depression prevalence among females, nurses, and frontline responders than males, doctors, and second-line healthcare workers. This study highlights the need for designing a targeted intervention to improve resilience and foster post-traumatic growth among frontline responders.

Mount Sinai’s Center for Stress, Resilience and Personal Growth as a model for responding to the impact of COVID-19 on health care workers.
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J. DePierro, C. L. Katz, D. Marin, et al.
Psychiatry Res 2020 Nov;293:113426
The COVID-19 pandemic is anticipated to have a prolonged adverse mental health impact on health care workers (HCWs). The supportive services implemented by the Mount Sinai Hospital System in New York for its workers culminated in the founding of the Mount Sinai Center for Stress, Resilience, and Personal Growth (CSRPG). CSRPG is an innovative mental health and resilience-building service that includes strong community engagement, self- and clinician-administered screening, peer co-led resilience training workshops, and care matching. The long-term sustainability of similar programs across the United States will require federal funding.

Emotional freedom techniques on nurses’ stress, anxiety, and burnout levels during the COVID-19 pandemic: A randomized controlled trial.
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B. Dincer and D. Inangil.
Explore (NY) 2020 Dec 3
Infectious disease outbreaks pose psychological challenges to the general population, and especially to healthcare workers. Nurses who work wtih COVID-19 patients are particularly vulnerable to emotions such as fear and anxiety, due to fatigue, discomfort, and helplessness related to their high intensity work. This study aims to investigate the efficacy of a brief online form the Emotional Freedom Techniques (EFT) in the prevention of stress, anxiety, and burnout in nurses involved in the treatment of COVID patients. METHODS: The study is a randomized controlled trial. It complies with the guidelines prescribed by the Consolidated Standards of Reporting Trials (CONSORT) checklist. It was conducted in a COVID-19 department at a university hospital in Turkey. We recruited nurses who care for patients infected with COVID-19 and randomly allocated them into an intervention group (n = 35) and a no-treatment control group (n = 37). The intervention group received one guided online group EFT session. RESULTS: Reductions in stress (p .05). CONCLUSIONS: A single online group EFT session reduced stress, anxiety, and burnout levels in nurses treating COVID-19.

Burnout among Portuguese healthcare workers during the COVID-19 pandemic.
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I. Duarte, A. Teixeira, L. Castro, et al.
BMC Public Health 2020 Dec 7;20(1):1885-020-09980-z
During COVID-19 pandemic, healthcare workers (HCWs) have had high workload and have been exposed to multiple psychosocial stressors. The aim of this study was to evaluate HCWs in terms of the relative contributions of socio-demographic and mental health variables on three burnout dimensions: personal, work-related, and client-related burnout. METHODS: A cross-sectional study was performed using an online questionnaire spread via social networks. A snowball technique supported by health care institutions and professional organizations was applied. RESULTS: A total of 2008 subjects completed the survey. Gender, parental status, marriage status, and salary reduction were found to be significant factors for personal burnout. Health problems and direct contact with infected people were significantly associated with more susceptibility to high personal and work-related burnout. Frontline working positions were associated with all three dimensions. Higher levels of stress and depression in HCWs were significantly associated with increased levels of all burnout dimensions. Higher levels of satisfaction with life and resilience were significantly associated with lower levels of all burnout dimensions. CONCLUSIONS: All three burnout dimensions were associated with a specific set of covariates. Consideration of these three dimensions is important when designing future burnout prevention programs for HCWs.

Mental health and risk perception among Italian healthcare workers during the second month of the Covid-19 pandemic.
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A. Gorini, E. Fiabane, M. Sommaruga, et al.
Arch Psychiatr Nurs 2020 Dec;34(6):537-544
A multicentre cross-sectional study was conducted to assess perceived risk and fear of contagion, as well as mental health outcomes among 650 Italian healthcare workers during the COVID-19 outbreak. A relevant proportion of the sample reported symptoms of anxiety, depression, and distress. Female sex, nursing profession, fear of being infected, as well as the time of exposure to the COVID-19 spread and the fact of directly attending infected patients were the main risk factors for developing mental health disturbances. Tailored interventions need to be implemented to reduce psychological burden in healthcare workers, with a particular attention to nurses.

The “Wounded Healer” – Anxiety and Sleep Disturbance Amongst Healthcare Workers Facing COVID-19 Pandemic in India: A Cross-sectional Online Survey.
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B. Gupta, V. Sharma, N. Kumar and A. Mahajan.
JMIR Public Health Surveill 2020 Dec 5
The pandemic of novel coronavirus (COVID-19) infection caused by SARS-CoV-2 has become a serious concern in the medical community and has resulted in an unprecedented psychological impact on health care workers (HCWs), already working under high stress levels. The viral infection expanded internationally and World Health Organization announced a Public Health Emergency of International Concern. OBJECTIVE: We aimed to identify and measure the effects of this pandemic on anxiety levels and sleep disturbance and the availability of personal protective equipment (PPE) among the HCWs in India. METHODS: We conducted an online cross-sectional study using piloted structured questionnaires with self-reported responses from 368 volunteer males and females HCWs from India. Study participants were identified through social networking sites: Facebook and WhatsApp. The degree of symptoms of anxiety, sleep quality and the availability of PPE was assessed by the 7-item Generalized Anxiety Disorder (GAD) scale, Single Sleep Quality scale and questions on availability of PPE. RESULTS: Majority of the study subjects were in the age group 45-60 years and 52.2% were doctors. Severe anxiety scores (GAD>10) were observed in 7.3%; moderate, mild and minimal anxiety was observed in 12.5%, 29.3% and 50.8% HCWs respectively, and 31.5% had poor to fair sleep scores (<6). Univariate analysis showed female gender and inadequate availability of PPE significantly associated with higher anxiety levels (P= 0.01 and 0.01). Sleep disturbance was significantly associated with age<30 years (P=0.04) and inadequate PPE (P<0.001). Multivariable analysis showed that poorer quality of sleep was associated with higher anxiety levels (P<0.001). CONCLUSIONS: COVID-19 pandemic has potentially caused a significant level of anxiety and sleep disturbance amongst HCWs, associated with female gender, younger age group, and availability of inadequate PPE, which puts HCWs at constant risk of contracting the infection themselves or transmitting it to their families. Early detection of at-risk HCWs and institution of situation-tailored mitigation measures will enable alleviation of the risk of long term, serious psychological sequelae as well as reduce HCWs’ current anxiety.

Self-efficacy and fatigue among non-frontline health care workers during COVID-19 outbreak: A moderated mediation model of posttraumatic stress disorder symptoms and negative coping.
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T. Hou, R. Zhang, X. Song, et al.
PLoS One 2020 Dec 10;15(12):e0243884
Since a considerable number of health care workers (HCWs) were sent to Wuhan to aid COVID-19 control during the epidemic, non-frontline HCWs who stayed in local hospitals had to work overload to provide daily health care services for other health issues, which makes them more vulnerable to experience fatigue. Self-efficacy is suggested as a protective factor for fatigue. Nonetheless, less is known regarding the underlying mechanisms. This research aimed to explore the prevalence of fatigue among non-frontline HCWs during the pandemic, investigate the mediating effect of posttraumatic stress disorder (PTSD) symptoms and moderating effect of negative coping in the association between self-efficacy and fatigue. METHODS: General Self-Efficacy Scale, PTSD Checklist-Civilian Version, Simplified Coping Style Questionnaire and 14-item Fatigue Scale were administrated to 527 non-frontline HCWs from Anhui Province, China. The mediating effect was examined by Mackinnon’s four-step procedure, while Hayes PROCESS macro was used to test the moderated mediation model. RESULTS: The prevalence of fatigue among non-frontline HCWs was 56.7%. The effect of self-efficacy on fatigue was partially mediated by PTSD symptoms (ab = -0.146, SE = 0.030, 95% CI = [-0.207, -0.095]). Additionally, negative coping moderated both the direct effect of self-efficacy on fatigue (β = -0.158, P<0.001) and the mediating effect of PTSD symptoms (β = 0.077, P = 0.008). When the standard score of negative coping increased to 1.49 and over, the direct association between self-efficacy and fatigue became insignificant. Likewise, the effect of self-efficacy on PTSD symptoms had no statistical significance when the standard score of negative coping was -1.40 and lower. CONCLUSIONS: More than half non-frontline HCWs suffered from fatigue during COVID-19. For those who tend to use negative coping, it might be crucial to design programs combining the enhancement of self-efficacy, preventions for PTSD symptoms and interventions for fatigue.

Predictors of stress among emergency medical personnel during the COVID-19 pandemic.
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T. Ilczak, M. Rak, M. Ćwiertnia, et al.
Int J Occup Med Environ Health 2020 Dec 3
The COVID-19 pandemic has forced emergency services to implement new standards of practice around the world. The dynamic and unpredictable nature of many clinical situations has placed emergency service personnel in direct danger of contracting the disease. This work uses a validated survey developed for the study to assess the predictors of stress that paramedics, nurses and doctors experience in the face of the COVID-19 pandemic. MATERIAL AND METHODS: The study group included 955 medical staff, and the level of significance adopted for statistical analysis was p = 0.05. Non-parametric Mann-Whitney and Kruskal-Wallis tests were used to analyze the qualitative variables divided into groups. The selection of tests was carried out based on the distribution of variables, verified using the Shapiro-Wilk test. In order to determine the predictors that caused the feelings of stress, it was necessary to use the linear regression model. RESULTS: During the COVID-19 pandemic, stress among emergency medical personnel has increased considerably due to new factors that did not previously exist. The predictors of stress in the professional environment include the fear of contracting COVID-19, a decrease in the level of safety while conducting emergency medical procedures, and the marginalization of treatment for patients not suffering from COVID-19. Additional socio-demographic factors that increase stress among emergency medical personnel are being female and working in the nursing profession. Appropriate training, the supply of personal protective equipment and opinions on the preparedness of the system to deal with the outbreak of the pandemic did not affect the level of stress among health service personnel. CONCLUSIONS: The factors that can be considered to act as predictors of occupational stress include the fear of contracting COVID-19, a decrease in the level of safety and security while conducting emergency medical procedures, and the marginalization of patients not suffering from COVID-19.

South Korean Nurses’ Experiences with Patient Care at a COVID-19-Designated Hospital: Growth after the Frontline Battle against an Infectious Disease Pandemic.
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N. Lee and H. J. Lee.
Int J Environ Res Public Health 2020 Dec 3;17(23):9015. doi: 10.3390/ijerph17239015
COVID-19 is a respiratory disease caused by a novel coronavirus that quickly spread worldwide, resulting in a global pandemic. Healthcare professionals coming into close contact with COVID-19 patients experience mental health issues, including stress, depression, anxiety, post-traumatic stress disorder, and burnout. This study aimed to explore the experiences of COVID-19-designated hospital nurses in South Korea who provided care for patients based on their lived experiences. Eighteen nurses working in a COVID-19-designated hospital completed in-depth individual telephone interviews between July and September 2020, and the data were analyzed using Giorgi’s phenomenological methodology. The essential structure of the phenomenon was growth after the frontline battle against an infectious disease pandemic. Nine themes were identified: Pushed onto the Battlefield Without Any Preparation, Struggling on the Frontline, Altered Daily Life, Low Morale, Unexpectedly Long War, Ambivalence Toward Patients, Forces that Keep Me Going, Giving Meaning to My Work, and Taking Another Step in One’s Growth. The nurses who cared for patients with COVID-19 had both negative and positive experiences, including post-traumatic growth. These findings could be used as basic data for establishing hospital systems and policies to support frontline nurses coping with infectious disease control to increase their adaption and positive experiences.

Risk Perception and Worries among Health Care Workers in the COVID-19 Pandemic: Findings from an Italian Survey.
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M. V. Puci, G. Nosari, F. Loi, G. V. Puci, C. Montomoli and O. E. Ferraro.
Healthcare (Basel) 2020 Dec 3;8(4):E535. doi: 10.3390/healthcare8040535
The ongoing pandemic scenario, due to the coronavirus disease 2019 (COVID-19), has had a considerable impact on public health all over the world. Italy was one of the most affected countries, as the first European full-blown outbreak occurred there. The exposure of the Italian health care workers to COVID-19 may be an important risk factor for psychological distress. The aim of this cross-sectional study was to describe worries and risk perception of being infected among Italian Health Care Workers (HCWs) during the first wave of the pandemic. In total, 2078 HCWs participated in a web survey (78.8% were females). The highest percentage of respondents were physicians (40.75%) and nurses (32.15%), followed by medical (18.00%), health care support (4.50%) and administrative (4.60%) staff. In a score range between 0 (not worried) and 4 (very worried), our results showed that participants declared that they were worried about the Coronavirus infection with a median score of 3 (IQR 2-3) and for 59.19% the risk perception of being infected was very high. In addition, HCWs reported they suffered from sleep disturbances (63.43%). From the analysis of the psychological aspect, a possible divergence emerged between the perceived need for psychological support (83.85%) and the relative lack of this service among health care providers emerged (9.38%). Our findings highlight the importance of psychological and psychiatric support services not only during the COVID-19 pandemic, but also in other emerging infectious diseases (EIDs) scenarios. These services may be useful for health authorities and policymakers to ensure the psychological well-being of health care professionals and to promote precautionary behaviors among them.

Mental Health Concerns of Frontline Workers During the COVID-19 Pandemic: A Scoping Review.

Sritharan, Jeavana and Jegathesan, Thivia and Vimaleswaran, Dharshie and Sritharan, Ashvinie and others.
Global Journal of Health Science 2020;12(11):89-105
The current COVID-19 pandemic continues to have a significant impact on the mental health of frontline workers worldwide. Currently there are limited published studies addressing mental health issues in frontline workers. The objective of this scoping review is to examine the range of existing global literature on mental health issues reported in frontline workers during the COVID-19 pandemic and to understand what mitigating factors exist. METHODS: The scoping review was guided by the Levac Colquhoun and O’Brien’s adapted version of Arkey and O’Malley’s framework. We performed a comprehensive search of three databases, Pubmed, APA PsychINFO, and CINAHL, identifying 684 studies. In total, 16 original studies and 4 letters to editors were included in this review. RESULTS: Of the original studies, 13 were published in China, and the remaining 3 in Italy, Turkey, and Iraq; all letters to editors were published in China. Sources of stress reported in frontline workers across studies included direct contact with COVID-19 patients, isolation, putting loved ones at risk, facing life and death decision making with COVID-19 patients, uncertainty with COVID-19 disease control, limited personal protective equipment, time spent thinking about COVID-19, limited staff/resources/pay, burnout, and stigma. Mental health symptoms and outcomes reported in frontline workers were fear, stress, anxiety, depression, insomnia, burnout, and psychological distress. CONCLUSION: Findings demonstrate the immediate need to increase mental health awareness and resources at an individual and system wide level. Mental health programs need to be catered towards each unique workplace to provide the necessary resources for frontline workers.

Impacts and interactions of COVID-19 response involvement, health-related behaviours, health literacy on anxiety, depression and health-related quality of life among healthcare workers: a cross-sectional study.
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T. V. Tran, H. C. Nguyen, L. V. Pham, et al.
BMJ Open 2020 Dec 7;10(12):e041394-2020-041394
We examined impacts and interactions of COVID-19 response involvement, health-related behaviours and health literacy (HL) on anxiety, depression, and health-related quality of life (HRQoL) among healthcare workers (HCWs). DESIGN: A cross-sectional study was conducted. Data were collected 6 April to 19 April 2020 using online-based, self-administered questionnaires. SETTING: 19 hospitals and health centres in Vietnam. PARTICIPANTS: 7 124 HCWs aged 21-60 years. RESULTS: The COVID-19 response-involved HCWs had higher anxiety likelihood (OR (95% CI)=4.41 (3.53 to 5.51)), higher depression likelihood (OR(95% CI)=3.31 (2.71 to 4.05)) and lower HRQoL score (coefficient, b(95% CI)=-2.14 (-2.89 to -1.38)), compared with uninvolved HCWs. Overall, HCWs who smoked or drank at unchanged/increased levels had higher likelihood of anxiety, depression and lower HRQoL scores; those with unchanged/healthier eating, unchanged/more physical activity and higher HL scores had lower likelihood of anxiety, depression and higher HRQoL scores. In comparison to uninvolved HCWs who smoked or drank at never/stopped/reduced levels, involved HCWs with unchanged/increased smoking or drinking had lower anxiety likelihood (OR(95% CI)=0.34 (0.14 to 0.83)) or (OR(95% CI)=0.26 (0.11 to 0.60)), and lower depression likelihood (OR(95% CI)=0.33 (0.15 to 0.74)) or (OR(95% CI)=0.24 (0.11 to 0.53)), respectively. In comparison with uninvolved HCWs who exercised at never/stopped/reduced levels, or with those in the lowest HL quartile, involved HCWs with unchanged/increased exercise or with one-quartile HL increment reported lower anxiety likelihood (OR(95% CI)=0.50 (0.31 to 0.81)) or (OR(95% CI)=0.57 (0.45 to 0.71)), lower depression likelihood (OR(95% CI)=0.40 (0.27 to 0.61)) or (OR(95% CI)=0.63 (0.52 to 0.76)), and higher HRQoL scores (b(95% CI)=2.08 (0.58 to 3.58)), or (b(95% CI)=1.10 (0.42 to 1.78)), respectively. CONCLUSIONS: Physical activity and higher HL were found to protect against anxiety and depression and were associated with higher HRQoL. Unexpectedly, smoking and drinking were also found to be coping behaviours. It is important to have strategic approaches that protect HCWs’ mental health and HRQoL.

COVID-19 is Having A Destructive Impact On Healthcare Workers’ Mental Wellbeing.
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K. Vanhaecht, D. Seys, L. Bruyneel, et al.
Int J Qual Health Care 2020 Dec 3
The coronavirus disease 2019 (COVID-19) may aggravate workplace conditions that impact healthcare workers’ mental health. However, it can also place other stresses on workers outside of their work. This study determines the effect of COVID-19 on symptoms of negative and positive mental health and the workforce’s experience with various sources of support. Effect modification by demographic variables was also studied. METHODS: A cross-sectional survey study, conducted between April 2nd and May 4th 2020 (2 waves), led to a convenience sample of 4509 healthcare workers in Flanders (Belgium), including paramedics (40.6%), nurses (33.4%), doctors (13.4%) and management staff (12.2%). About three in four were employed in university and acute hospitals (29.6%), primary care practices (25.7%), residential care centers (21.3%) or care sites for disabled and mental healthcare. In each of the two waves, participants were asked how frequently (on a scale of 0 to 10) they experienced positive and negative mental health symptoms during normal circumstances and during last week, referred to as before and during COVID-19, respectively. These symptoms were stress, hypervigilance, fatigue, difficulty sleeping, unable to relax, fear, irregular lifestyle, flashback, difficulty concentrating, feeling unhappy and dejected, failing to recognize their own emotional response, doubting knowledge and skills, and feeling uncomfortable within the team. Associations between COVID-19 and mental health symptoms were estimated by cumulative logit models and reported as odds ratios. The needed support was our secondary outcome and was reported as the degree to which healthcare workers relied on sources of support and how they experienced them. RESULTS: All symptoms were significantly more pronounced during versus before COVID-19. For hypervigilance there was a twelvefold odds (OR 12.24, 95% CI 11.11-13.49) during versus before COVID-19. Positive professional symptoms such as the feeling that one can make a difference were less frequently experienced. The association between COVID-19 and mental health was generally strongest for the age group 30-49 years, females, nurses, and residential care centers. Healthcare workers reported to rely on support from relatives and peers. A considerable proportion, respectively 18% and 27%, reported the need for professional guidance from psychologists and more support from their leadership. CONCLUSIONS: The toll of the crisis has been heavy on healthcare workers. Those who carry leadership positions at an organizational or system level should take this opportunity to develop targeted strategies to mitigate key stressors of healthcare workers’ mental wellbeing.

Mental health and well-being of healthcare workers during the COVID-19 pandemic in the UK: contrasting guidelines with experiences in practice.
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N. Vera San Juan, D. Aceituno, N. Djellouli, et al.
BJPsych Open 2020 Dec 10;7(1):e15
Substantial evidence has highlighted the importance of considering the mental health of healthcare workers during the COVID-19 pandemic, and several organisations have issued guidelines with recommendations. However, the definition of well-being and the evidence base behind such guidelines remain unclear. AIMS: The aims of the study are to assess the applicability of well-being guidelines in practice, identify unaddressed healthcare workers’ needs and provide recommendations for supporting front-line staff during the current and future pandemics. METHOD: This paper discusses the findings of a qualitative study based on interviews with front-line healthcare workers in the UK (n = 33), and examines them in relation to a rapid review of well-being guidelines developed in response to the COVID-19 pandemic (n = 14). RESULTS: The guidelines placed greater emphasis on individual mental health and psychological support, whereas healthcare workers placed greater emphasis on structural conditions at work, responsibilities outside the hospital and the invaluable support of the community. The well-being support interventions proposed in the guidelines did not always respond to the lived experiences of staff, as some reported not being able to participate in these interventions because of understaffing, exhaustion or clashing schedules. CONCLUSIONS: Healthcare workers expressed well-being needs that aligned with socio-ecological conceptualisations of well-being related to quality of life. This approach to well-being has been highlighted in literature on support of healthcare workers in previous health emergencies, but it has not been monitored during this pandemic. Well-being guidelines should explore the needs of healthcare workers, and contextual characteristics affecting the implementation of recommendations.

Health Care Administration and Organization

Better COVID-19 outcomes in community-based long-term care than in nursing homes.

Julie Robison, Noreen Shugrue, Deborah Migneault, et al.
Journal of the American Medical Directors Association 2020/12
Despite similar vulnerability, prevalence and deaths of institutional residents from COVID-19 greatly exceeded those of persons receiving long term services and supports in the community during the first 5 months of the pandemic.; Despite similar vulnerability, prevalence and deaths of institutional residents from COVID-19 greatly exceeded those of persons receiving long term services and supports in the community during the first 5 months of the pandemic.

Prevalence and Spread

All-cause mortality supports the COVID-19 mortality in Belgium and comparison with major fatal events of the last century.
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N. Bustos Sierra, N. Bossuyt, T. Braeye, et al.
Arch Public Health 2020 Nov 13;78(1):117-020-00496-x
The COVID-19 mortality rate in Belgium has been ranked among the highest in the world. To assess the appropriateness of the country’s COVID-19 mortality surveillance, that includes long-term care facilities deaths and deaths in possible cases, the number of COVID-19 deaths was compared with the number of deaths from all-cause mortality. Mortality during the COVID-19 pandemic was also compared with historical mortality rates from the last century including those of the Spanish influenza pandemic. METHODS: Excess mortality predictions and COVID-19 mortality data were analysed for the period March 10th to June 21st 2020. The number of COVID-19 deaths and the COVID-19 mortality rate per million were calculated for hospitals, nursing homes and other places of death, according to diagnostic status (confirmed/possible infection). To evaluate historical mortality, monthly mortality rates were calculated from January 1900 to June 2020. RESULTS: Nine thousand five hundred ninety-one COVID-19 deaths and 39,076 deaths from all-causes were recorded, with a correlation of 94% (Spearman’s rho, p < 0,01). During the period with statistically significant excess mortality (March 20th to April 28th; total excess mortality 64.7%), 7917 excess deaths were observed among the 20,159 deaths from all-causes. In the same period, 7576 COVID-19 deaths were notified, indicating that 96% of the excess mortality were likely attributable to COVID-19. The inclusion of deaths in nursing homes doubled the COVID-19 mortality rate, while adding deaths in possible cases increased it by 27%. Deaths in laboratory-confirmed cases accounted for 69% of total COVID-19-related deaths and 43% of in-hospital deaths. Although the number of deaths was historically high, the monthly mortality rate was lower in April 2020 compared to the major fatal events of the last century. CONCLUSIONS: Trends in all-cause mortality during the first wave of the epidemic was a key indicator to validate the Belgium’s high COVID-19 mortality figures. A COVID-19 mortality surveillance limited to deaths from hospitalised and selected laboratory-confirmed cases would have underestimated the magnitude of the epidemic. Excess mortality, daily and monthly number of deaths in Belgium were historically high classifying undeniably the first wave of the COVID-19 epidemic as a fatal event.

Dementia and outcomes from coronavirus disease 2019 (COVID-19) pneumonia: A systematic review and meta-analysis.
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T. I. Hariyanto, C. Putri, J. Arisa, R. F. V. Situmeang and A. Kurniawan.
Arch Gerontol Geriatr 2020 Nov 19;93:104299
The number of positive and death cases from coronavirus disease 2019 (COVID-19) is still increasing until now. One of the most prone individuals, even in normal situations is patients with dementia. Currently, no study provides clear evidence regarding the link between dementia and COVID-19. This study aims to analyze the relationship between dementia and poor outcomes of COVID-19 infection. MATERIALS AND METHODS: We systematically searched the PubMed and Europe PMC database using specific keywords related to our aims until October 25th, 2020. All articles published on COVID-19 and dementia were retrieved. The quality of the study was assessed using the Newcastle Ottawa Scale (NOS) tool for observational studies. Statistical analysis was done using Review Manager 5.4 software. RESULTS: A total of 24 studies with 46,391 dementia patients were included in this meta-analysis. This meta-analysis showed that dementia was associated with composite poor outcome [RR 2.67 (95% CI 2.06 – 3.47), p < 0.00001, I(2) = 99%, random-effect modeling] and its subgroup which comprised of risk of COVID-19 infection [RR 2.76 (95% CI 1.43 – 5.33), p = 0.003, I(2) = 99%, random-effect modeling], severe COVID-19 [RR 2.63 (95% CI 1.41 – 4.90), p = 0.002, I(2) = 89%, random-effect modeling], and mortality from COVID-19 infection [RR 2.62 (95% CI 2.04 – 3.36), p < 0.00001, I(2) = 96%, random-effect modeling]. CONCLUSIONS: Extra care and close monitoring should then be provided to patients with dementia to minimize the risk of infections, preventing the development of severe and mortality outcomes.

Development of Herd Immunity to COVID-19 in Louisiana nursing homes.
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Thomas A. Reilly.
Journal of the American Medical Directors Association 2020/12.
Covid in nursing homes is a natural experiment. In Louisiana the peak of infection is about 60% where herd immunity appears to be the limiting factor. Applied to the US the pandemic has hardly begun.

Optimizing COVID-19 surveillance in long-term care facilities: a modelling study.
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D. R. M. Smith, A. Duval, K. B. Pouwels, et al.
BMC Med 2020 Dec 8;18(1):386-020-01866-6
Long-term care facilities (LTCFs) are vulnerable to outbreaks of coronavirus disease 2019 (COVID-19). Timely epidemiological surveillance is essential for outbreak response, but is complicated by a high proportion of silent (non-symptomatic) infections and limited testing resources. METHODS: We used a stochastic, individual-based model to simulate transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) along detailed inter-individual contact networks describing patient-staff interactions in a real LTCF setting. We simulated distribution of nasopharyngeal swabs and reverse transcriptase polymerase chain reaction (RT-PCR) tests using clinical and demographic indications and evaluated the efficacy and resource-efficiency of a range of surveillance strategies, including group testing (sample pooling) and testing cascades, which couple (i) testing for multiple indications (symptoms, admission) with (ii) random daily testing. RESULTS: In the baseline scenario, randomly introducing a silent SARS-CoV-2 infection into a 170-bed LTCF led to large outbreaks, with a cumulative 86 (95% uncertainty interval 6-224) infections after 3 weeks of unmitigated transmission. Efficacy of symptom-based screening was limited by lags to symptom onset and silent asymptomatic and pre-symptomatic transmission. Across scenarios, testing upon admission detected just 34-66% of patients infected upon LTCF entry, and also missed potential introductions from staff. Random daily testing was more effective when targeting patients than staff, but was overall an inefficient use of limited resources. At high testing capacity (> 10 tests/100 beds/day), cascades were most effective, with a 19-36% probability of detecting outbreaks prior to any nosocomial transmission, and 26-46% prior to first onset of COVID-19 symptoms. Conversely, at low capacity (< 2 tests/100 beds/day), group testing strategies detected outbreaks earliest. Pooling randomly selected patients in a daily group test was most likely to detect outbreaks prior to first symptom onset (16-27%), while pooling patients and staff expressing any COVID-like symptoms was the most efficient means to improve surveillance given resource limitations, compared to the reference requiring only 6-9 additional tests and 11-28 additional swabs to detect outbreaks 1-6 days earlier, prior to an additional 11-22 infections. CONCLUSIONS: COVID-19 surveillance is challenged by delayed or absent clinical symptoms and imperfect diagnostic sensitivity of standard RT-PCR tests. In our analysis, group testing was the most effective and efficient COVID-19 surveillance strategy for resource-limited LTCFs. Testing cascades were even more effective given ample testing resources. Increasing testing capacity and updating surveillance protocols accordingly could facilitate earlier detection of emerging outbreaks, informing a need for urgent intervention in settings with ongoing nosocomial transmission.