COVID-19 and Long Term Care

Collection of articles on COVID and LTC is available here

COVID-19 and Resident Care

Prescriptions of antipsychotics dispensed in long-term care facilities during the COVID-19 pandemic
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Ali MM, Oliveira I, Blanco M.
General Hospital Psychiatry. 2022 May;
Residents of long-term care facilities (LTCFs), including nursing homes and assisted living facilities, were disproportionately affected by the COVID-19 pandemic. Since the start of the pandemic, 5% of total cases and 31% of total deaths have occurred in LTCFs, representing more than 186,000 deaths of residents and staff. The high COVID-19 related mortality in LTCFs reflects not only the challenges posed by the pandemic in congregate care settings, but also longstanding deficiencies in the quality of care in these facilities. Recent studies have reported on the increasing use of antipsychotics in LTCFs to help manage challenging behaviors of residents, a concerning trend even before the pandemic. However, little is known about trends in antipsychotic prescribing in LTCFs during the pandemic, especially after the first three quarters of 2020 [3]. We present trends in antipsychotic prescriptions dispensed in LTCFs between 2019 and 2021, including new prescriptions and refills.

COVID‐19 vaccine side effects among nursing home residents and staff
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Bhatnagar S, Jones K, Montoya A.
Journal of Medical Virology. 2022 Aug;94(8):3491–3.
In this prospective observational study, we examined the proportion of NH residents and staff who reported localized and systemic side effects after administration of the Moderna COVID-19 vaccine. Our study population included 193 individuals who received the first dose (124 residents and 69 staff) and 207 individuals who received the second dose (105 residents and 102 staff) in two NHs in Southeast Michigan between January 7 and February 6, 2021.

Short- and long-term mortality and mortality risk factors among nursing home patients after COVID-19 infection
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Booij JA, van de Haterd JCHQ, Huttjes SN, van Deijck RHPD, Koopmans RTCM.
Journal of the American Medical Directors Association. 2022 Jun.
Objective: To assess short- and long-term mortality and risk factors in nursing home patients with COVID-19 infection. Design: Retrospective two-center cohort study. Setting and participants: Dutch nursing home patients with clinically suspected COVID-19 infection confirmed by RT–PCR testing. Methods: Data were gathered between March 2020 and November 2020 using electronic medical records, including demographic characteristics, comorbidities, medical management and symptoms on the first day of suspected COVID-19 infection. Mortality at thirty days and six months was assessed using multivariate logistic regression models and Kaplan–Meier analysis. At six months, a subgroup analysis was performed to estimate the mortality risk between COVID-negative patients and patients who survived COVID-19. Risk factors for mortality were assessed through multivariate logistic regression models. Results: A total of 321 patients with suspected COVID-19 infection were included, of whom 134 tested positive. Sixty-two patients in the positive group died at thirty days, with a short- term mortality rate of 2.9 (95% CI 1.7–5.3). Risk factors were fatigue (OR 2.6, 95% CI 1.3– 6.2) and deoxygenation (OR 2.9, 95% CI 1.3–7.6). At six months, the mortality risk was 2.1 (95% CI 1.3–3.7). Risk factors for six-month mortality were shortness of breath (OR 2.7, 95% CI 1.3–7.0), deoxygenation (OR 2.5, 95% CI 1.1–6.5) and medical management (OR 4.5, 95% CI 1.7–25.8). However, among patients who survived COVID-19 infection, the long-term mortality risk was not sustained (OR 1.0, 95% CI 0.4–2.7). Conclusions and Implications: Overall, COVID-19 infection increases short- and long-term mortality risk among nursing home patients. However, this study shows that surviving COVID-19 infection does not lead to increased mortality in the long term within this population. Therefore advanced care planning should focus on quality of life among nursing home patients after COVID-19 infection.

It’s the worst thing I’ve ever been put through in my life”: the trauma experienced by essential family caregivers of loved ones in long-term care during the COVID-19 pandemic in Canada.
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Chu CH, Yee AV, Stamatopoulos V.
International journal of qualitative studies on health and well-being. 2022 Dec;17(1):2075532.
BACKGROUND: Essential family caregivers (EFCs) of relatives living in long-term care homes (LTCHs) experienced restricted access to their relatives due to COVID-19 visitation policies. Residents’ experiences of separation have been widely documented; yet, few have focused on EFCs’ traumatic experiences during the pandemic. Objective: This study aims to explore the EFCs’ trauma of being locked out of LTCHs and unable to visit their loved ones in-person during COVID-19. METHODS: Seven online focus groups with a total of 30 EFCs from Ontario and British Columbia, Canada were conducted as part of a larger mixed-method study. We used an inductive approach to thematic analysis to understand the lived experiences of trauma. RESULTS: Four trauma-related themes emerged: 1) trauma from prolonged separation from loved ones; 2) trauma from uncompassionate interactions with the LTCH’s staff and administrators; 3) trauma from the inability to provide care to loved ones, and 4) trauma from experiencing prolonged powerlessness and helplessness. DISCUSSION: The EFCs experienced a collective trauma that deeply impacted their relationships with their relatives as well as their perception of the LTC system. Experiences endured by EFCs highlighted policy and practice changes, including the need for trauma-centred approaches to repair relational damage and post-pandemic decision-making that collaborates with EFCs.

Disruptions in Relational Continuity: The Impact of Pandemic Public Health Measures on Families in Long-Term Care.
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Cooke HA, Wu SA, Bourbonnais A, Baumbusch J.
Journal of family nursing. 2022 Jun;10748407221102462.
Although the value of family caregivers’ involvement with relatives in long-term care (LTC) is well recognized, tensions remain regarding their role. Such tensions were exacerbated during the COVID-19 pandemic as strict public health measures restricted family access to LTC homes. Using interpretive description, we examined the impact of visitation restrictions on family caregivers’ experiences caring for a relative in LTC between March 2020 and June 2021. In-depth interviews were conducted with 14 family caregivers (five spouses and nine adult daughters) and two key themes were identified. The first theme, “seeking to maintain relational continuity,” illustrates how caregivers sought to sustain connections with residents prior to and during the pandemic. The second theme, “disrupted relational continuity,” highlights the impact of severed relational connections on caregivers’ sense of self and ongoing feelings of loss and anger. Findings call for a trauma-informed approach that recognizes the pervasiveness of trauma for family caregivers and the avoidance of re-traumatization.

The Experience of COVID-19 Visitor Restrictions among Families of People Living in Long-Term Residential Care Facilities during the First Wave of the Pandemic in Ireland.
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Cornally N, Kilty C, Buckley C, O’Caoimh R, O’Donovan MR, Monahan MP, et al.
International journal of environmental research and public health. 2022 May;19(11).
Public health responses to COVID-19 in long-term residential care facilities (LTRCFs) have restricted family engagement with residents. These restrictions impact on quality of care and the psychosocial and emotional well-being of family caregivers. Following a national cross-sectional web-based survey, respondents were invited to provide personal reflections on visitor restrictions. This study aims to describe the consequences of these restrictions for individuals living in LTRCF and their families during the first wave of the COVID-19 pandemic. Data from open-ended questions contained within the survey were analyzed using Braun and Clarke’s (2006) method of thematic analysis. Four themes were identified: 1. Altered Communication and Connection; 2. Emotional and Psychological Impact; 3. Protecting and Caring Role of Staff; 4. Family Role. Throughout the narrative accounts, it is evident that the visitor restrictions impacted on the emotional and mental well-being of families. Some respondents expressed frustration that they could not assist staff in essential care provision, reducing meaning and purpose in their own lives. COVID-19 LTRCF visitor restrictions made little distinction between those providing essential personal care and those who visit for social reasons. A partnership approach to care provision is important and should encompass strategies to maintain the psychosocial and emotional well-being of families and their relatives during times of self-isolating or restrictive measures.

Psychotropic Drug Prescription in Nursing Homes During the COVID-19 Pandemic.
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Ferro Uriguen A, Laso Lucas E, Sannino Menicucci C, Iturrioz Arrechea I, Alaba Trueba J, Echevarría Orella E, et al.
Drugs & aging. 2022 Jun;39(6):467–75.
BACKGROUND: To limit the introduction of coronavirus disease 2019 (COVID-19) into nursing homes, restrictive measures and social distancing were implemented; however, these caused an increase in affective disorders such as depression and anxiety and an alteration of the behavioral and psychological symptoms of dementia. Therefore, it is expected that prescription trends of psychotropic drugs in nursing homes during the pandemic may have changed significantly. OBJECTIVE: This study aims to compare patterns of prescribing psychotropic drugs in nursing homes during the COVID-19 pandemic to those of the pre-pandemic period. METHODS: This cross-sectional multicenter study was conducted in geriatric units and psychogeriatric units in seven nursing homes in Gipuzkoa, Spain. On 1 March, 2020, data regarding 511 residents in geriatric units and 163 in psychogeriatric units were recorded. This study examined utilization percentages for psychotropic drugs before the pandemic (April 2018-March 2020) and during the pandemic (April 2020-March 2021) in light of projected usage based on previous years. Following the Anatomical, Therapeutic, Chemical Classification System, four therapeutic groups were analyzed: antipsychotics (N05A), benzodiazepines (N05B and N05C), antidepressants (N06A), and antiepileptic drugs (N03A). RESULTS: In the case of geriatric units, a downward trend of prescription was reversed for antipsychotics (-0.41; 95% confidence interval [CI] -1.41, 0.60). Benzodiazepine use also decreased less than expected (-2.00; 95% CI -3.00, -1.00). Antidepressant use increased more than predicted (0.02; 95% CI -0.97, 1.01), as did antiepileptic drug use (2.93; 95% CI 2.27, 3.60). In the psychogeriatric units, the drop in antipsychotic utilization was less than expected (-2.31; 95% CI -3.68, -0.93). Although it was expected that the prescription of benzodiazepines would decrease, usage remained roughly the same (-0.28; 95% CI -2.40, 2.34). Utilization of antidepressants (8.57; 95% CI 6.89, 10.24) and antiepileptic drugs (6.10; 95% CI 3.20, 9.00) increased significantly, which was expected, based on the forecast. CONCLUSIONS: For all categories, usage of psychotropic drugs was higher than anticipated based on the forecast; this increase might be related to the worsening of emotional and behavioral disorders caused by the restrictive measures of the COVID-19 pandemic.

Depressive disorders among long-term care residents in the face of isolation due to COVID-19 pandemic.
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Górski M, Garbicz J, Buczkowska M, Marsik G, Grajek M, Ca\lyniuk B, et al.
Psychiatria polska. 2022 Feb;56(1):101–14.
OBJECTIVES: The main aim of this study was to assess the effects of social and familial isolation due to COVID-19 on the mental well-being of patients staying in a residential medical care facility and evaluation of the effectiveness of therapeutic measures. METHODS: The study was conducted among the patients of a residential medical care facility (58 patients). A short form of the Geriatric Depression Scale (GDS) was used to assess the severity of depressive disorders. The number of medical and psychological interventions during the individual months of isolation was also compared. RESULTS: In February 2020, when there was no isolation, 87.9% of the study group did not suffer from depression compared to 72.4% during the period of full isolation. After introducing controlled methods for contacting loved ones, the number of individuals with no depressive symptoms increased again. A mean of 1.76 medical and 0.23 psychological interventions per one patient were conducted during the period of full isolation. CONCLUSIONS: The number of medical and psychological interventions was higher during the period of full isolation compared to months without compulsory isolation due to COVID-19. After the introduction of full isolation, the scores in the GDS were significantly higher, which means that the residents were at a higher risk of depressive disorders than in the months without isolation.

Delirium after COVID‐19 vaccination in nursing home residents: A case series
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Mak W, Prempeh AA, Schmitt EM, Fong TG, Marcantonio ER, Inouye SK, et al.
Journal of the American Geriatrics Society. 2022 Jun;70(6):1648–51.
This study was conducted at a 514-bed NH in 2021 during 1–2 day initiatives to provide COVID-19 vaccinations to residents. It was ancillary to a larger study, the Better Assessment of Illness (BASIL) II study, designed to improve the assessment of delirium in older adults. Institutional Review Board approval was obtained at the NH and affiliated medical center.

Inadequate human resources, equipment and training: A qualitative assessment of the objectives of the NUHELP end-of-life care programme in the context of the COVID-19 pandemic.
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Mota Romero E, Puente Fernández D, Rodríguez Pertíñez C, Árbol Fernández G, Moreno Guerrero S, Montoya Juárez R.
Palliative medicine. 2022 Jun;2692163221103099.
BACKGROUND: The COVID-19 pandemic had a particularly severe impact on nursing homes, exposing numerous pre-existing deficiencies in end-of-life care. AIM: To describe how the COVID-19 pandemic affected nursing home and primary care professionals’ attempts to achieve the objectives of a pre-existing end-of-life programme and to explore their personal experiences of end-of-life care in these facilities. DESIGN: A qualitative descriptive study using thematic analysis. SETTING/PARTICIPANTS: Twenty semi-structured interviews were conducted from March to November 2020 with professionals from nursing homes and primary care facilities who participated in the development of the NUHELP programme. RESULTS: Six main themes were identified: (1) Comprehensive assessments of residents at the homes were not conducted due to excessive workload and high staff turnover. (2) New technologies and changes to professional roles were used to meet relatives’ needs for information. Residents only received information when they requested it. (3) Advance care planning was not carried out and was limited to potential hospital transfer. (4) Arrangements were made to allow relatives to spend time with residents during their final moments, but complicated grief among relatives and professionals is anticipated. (5) Management of complexity varied depending on the degree of coordination with primary care facilities. (6) Nursing home professionals felt abandoned, with a lack of human resources, equipment and training. CONCLUSIONS: The pandemic cast light on existing shortcomings in nursing homes in terms of comprehensive assessments, communication, decision making, grief management and palliative care complexity. Nursing homes need more human, material and training resources, as well as improved coordination with the public healthcare system.

Absence of negativization of nasal swab test and frailty as risk factors for mortality in elderly COVID-19 patients admitted in long-term care facilities.
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Pagliuca R, Cupido MG, Mantovani G, Bugada M, Matteucci G, Caffarelli A, et al.
European geriatric medicine. 2022 Jun;1–7.
METHODS: A limited amount of data is now available on prognostic factors and mortality among elderly people resident in Long-Term Care facilities and in post-acute units. These populations (in particular those with underlying chronic medical conditions) seem to have higher risk of morbidity and mortality related to COVID-19 disease, but further evidence is needed. The aim of our study is to investigate the impact of some well-known prognostic factors in elderly patients (≥ 65 years) with COVID-19 admitted in the Long-Term Care setting in AUSL Ferrara, Italy. We performed binary regression logistic analysis for some variables (demographic data, clinical data including nasal swab test (NST) at discharge and frailty assessments) to find potential predictors of mortality. We subsequently tested statistically significant variables using Kaplan-Meier curves and Cox-regression models to find survival outcomes and related hazard ratio. RESULTS: Risk factors associated with increased mortality resulted NST at discharge, infection, age and frailty. At a further secondary analysis carried out between NST at discharge, age and clinical frailty scale (CFS) < 5, we found a positive correlation between NST at discharge and CFS < 5. Kaplan-Meier curves showed a statistically significant difference regarding frailty and NST at discharge but not for age. CONCLUSION: Our study showed that absence of negativization of NST at discharge and frailty are strong predictors for mortality in elderly COVID-19 patients admitted in Long-Term Care facilities, while age and the comorbidity burden are less important.

Activities for Residents of Dutch Nursing Homes during the COVID-19 Pandemic: A Qualitative Study.
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Smeitink MMP, Smaling HJA, van Tol LS, Haaksma ML, Caljouw MAA, Achterberg WP.
International journal of environmental research and public health. 2022 Apr;19(9).
To protect nursing home residents from getting infected with COVID-19, several measures have been imposed. The aim of this study was to describe the impact of these measures on activities for Dutch nursing home residents, the conditions under which the activities could take place, and the considerations when making decisions about the (dis)continuation of activities. The study consisted of the data of the qualitative MINUTES-study. Textual units derived from documentation of an outbreak team (OT) meetings on activities, well-being, informal caregivers, and volunteers from 39 long-term care organizations were re-analyzed using a content analysis. The results shows that OTs more often discussed restarting and continuing activities than stopping activities during the COVID-19 pandemic. There were differences between time periods, but activities never completely stopped according to the minutes. Activities were offered in an adapted way, often under certain conditions, such as organizing activities at other locations (e.g., outside), with limited group size, and following specific guidelines. The main focus of the considerations made were the ability to adhere to the guidelines, the well-being of residents, ensuring safety, and balancing benefits versus risks given vaccination availability and coverage. Overall, the study showed that organizing activities for nursing home residents despite COVID-19 measures is possible.

#Morethanavisitor: Experiences of COVID-19 visitor restrictions in Canadian long-term care facilities
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Thirsk LM, Stahlke S, Perry B, Gordon B.
Family Relations [Internet]. 2022 Jun.
Abstract Objective The purpose of this study was to understand the experiences of families, residents, and staff around visitor restriction policies in long-term care during the COVID-19 pandemic in Canada. Background Beginning in March 2020, public health orders across Canada restricted visitors to long-term care facilities to curb the spread of the infection. This included family caregivers who provide significant support to residents to meet their physical, psychological, social, and safety needs. Method We collected data from publicly available news and social media. News articles, blogs, and tweets from Canada were collected from March 2020 to April 2021. In total, 40 news articles, eight blogs, and 23 tweets were analyzed using generic qualitative description. Results Reports from family members indicate that some residents may have died from malnutrition, dehydration, and isolation, rather than from COVID-19, because of the sudden and prolonged absence of family caregivers. There are long-term impacts on family suffering and long-term care worker burnout. Policy and structural issues were identified. Conclusion Experiences in long-term care reflected not only impacts of pandemic-related visitor restrictions, but also long-standing funding and workforce issues. Implications Involvement of family, and specifically family caregivers, is crucial in policy decisions, even in unusual circumstances, such as the pandemic.

Inequities in the incidence and mortality due to COVID-19 in nursing homes in Barcelona by characteristics of the nursing homes.
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Torres ML, Palma Díaz D, Oliver-Parra A, Millet JP, Cosialls D, Guillaumes M, et al.
PloS one. 2022;17(6):e0269639.
BACKGROUND: Residents of Nursing Homes (NHs) have suffered greater impacts from the COVID-19 pandemic. However, the rates of COVID-19 in these institutions are heterogeneously distributed. Describing and understanding the structural, functional, and socioeconomic differences between NHs is extremely important to avoid new outbreaks. OBJECTIVES: Analyze inequalities in the cumulative incidences (CIs) and in the mortality rates (MRs) due to COVID-19 in the NHs of Barcelona based on the characteristics of the NHs. METHODS: Exploratory ecological study of 232 NHs. The dependent variables were the cumulative incidence and mortality rate due to COVID-19 in NHs between March and June 2020. Structural variables of the NHs were evaluated such as neighborhood socioeconomic position (SEP), isolation and sectorization capacity, occupancy, overcrowding and ownership. RESULTS: The cumulative incidence and mortality rate were higher in the low SEP neighborhoods and lower in those of high SEP neighborhoods. Regarding the isolation and sectorization capacity, Type B NHs had a higher risk of becoming infected and dying, while Type C had a lower risk of dying than Type A. Greater overcrowding was associated with greater morbidity and mortality, and higher occupancy was associated with higher incidence. The risk of becoming infected and dying in public NHs was significantly higher than for-profit NH. CONCLUSIONS: The social components together with the functional and infrastructure characteristics of the NHs influence the cumulative incidence and the mortality rate by COVID-19. It is necessary to redefine the care model in the NHs to guarantee the health of the residents.

Severity of Omicron SARS-CoV-2 Infection in Vaccinated and Unvaccinated Residents of Long Term Care Homes
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Vanker A, de Waal L, McGeer A, Morgan M.
Infection Control & Hospital Epidemiology. 2022 May;1–5.
In Ontario, Canada, the initial impact of the COVID-19 pandemic on long term care (LTC) homes was devastating. LTC residents were thus prioritized for vaccination with mRNA vaccines (2 doses at 3-4 week intervals in January/February 2021), and offered a third dose in the fall of 2021 because of waning immunity and decreased protection against variants. Omicron was first detected in Ontario on November 28th, 2021; by week 51 (beginning December 19th) more than 90% of incident cases sequenced were Omicron. In Ontario, PCR testing for COVID-19 is recommended for all residents with any compatible symptom, or exposure to any infected person. To assess the severity of COVID-19 due to Omicron in Ontario LTC residents, we undertook a chart review of the first 100 residents of Ontario LTC homes owned or managed by Extendicare Ltd. who were diagnosed with COVID-19 after December 15, 2021. We collected data on resident demographics, body mass index, COVID-19 vaccinations, underlying illness, treatment, symptoms and outcomes (oxygen requirements, hospitalizations and deaths within 31 days of diagnosis). Two reviewers (AV, AM) adjudicated whether hospitalizations and deaths were attributable to COVID-19, with a third reviewer (MM) if consensus was not achieved. This chart review was designated a quality improvement project and exempt from research ethics review.

Tolerance and clinical outcomes of COVID‐19 antiviral therapy in long‐term care residents
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Vuppalanchi S, Weaver L, Box K, Pontones P.
Journal of the American Geriatrics Society [Internet]. 2022 Jun.
Oral antivirals, Paxlovid® (nirmatrelvir tablets; ritonavir tablets, Pfizer) and molnupiravir (Merck), were authorized recently to treat individuals with confirmed mild to moderate COVID-19 within 5 days of symptom onset and at risk for progression to severe disease.1, 2 Median ages in these medication trials were 46 and 43 years, respectively. Limited real-world data exist on tolerance and clinical outcomes on these antivirals, particularly in older individuals, such as long-term care facility (LTCF) residents. In early 2022, Indiana Department of Health (IDOH) established a call center (8 AM to 5 PM Monday to Friday and 10 AM to 2 PM on Saturday) to assist LTCFs to locate and secure antiviral medications for eligible residents. The establishment of the IDOH call center provided a unique opportunity to prospectively track the outcomes of these agents.

Beyond Compliance: A More Integrated Public Health Approach To Outbreaks In Nursing Homes And Other Disasters.
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Wasserman M, Konetzka RT.
Health affairs (Project Hope). 2022 Jun;41(6):831–7.
Nursing home residents are vulnerable to disproportionate harm during disasters and health emergencies, as evidenced by the recent impact of COVID-19 and extreme weather events. Evaluation of these disasters shows that the nursing homes in question were often in compliance with relevant regulations around emergency planning. However, advance planning for disasters cannot anticipate every contingency, leading to the need for flexibility and quick adaptation on the part of nursing home leaders. In addition, disasters often involve larger, regional problems and situations that individual providers cannot solve. We suggest that policy makers need to prioritize development and expectations around leadership skills in nursing home management and better integrate the long-term care sector into local, state, and federal public health planning for future pandemics and other disasters.

Barriers and Facilitators to Receiving the COVID-19 Vaccination and Development of Theoretically-Informed Implementation Strategies for the Public: Qualitative Study in Hong Kong.
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Wong CH, Zhong CC, Chung VC, Nilsen P, Wong EL, Yeoh EK.
Vaccines. 2022 May;10(5).
OBJECTIVES: enhancing uptake of COVID-19 vaccines is an important tool for managing the pandemic. However, in Hong Kong, the COVID-19 vaccination rate in the general population was unsatisfactory during the early phase of the vaccination program. This two-part study aimed to (i) identify barriers and facilitators to receiving vaccinations, and (ii) develop theoretically-informed implementation strategies for promoting uptake. METHODS: in part 1, 45 Hong Kong residents who differed in their willingness to vaccinate (willing (n = 15), were unwilling (n = 15), and were hesitant (n = 15)), were interviewed individually in February 2021. They were invited to express their perceptions of receiving the COVID-19 vaccination. The theoretical domains framework (TDF) was applied to guide the interviews and analyses. Behavioral diagnoses from these findings were then used to develop theoretically-informed implementation strategies in part 2, composed of behavior change techniques (BCTs) informed by the established BCT taxonomy. RESULTS: in part 1, the five main barriers were (i) concerns on severe and long-term side effects; (ii) low confidence in the safety and effectiveness due to concerns of their accelerated development; (iii) unclear information on logistical arrangements of the vaccination program; (iv) insufficient data on safety and effectiveness; and (v) perceived low protection ability conferred by the vaccines. The five main facilitators included (i) healthcare professionals’ recommendations; (ii) news from TV, radio, and newspapers as main sources of trustworthy information; (iii) vaccine-related health education delivered by healthcare professionals; (iv) expectations of resuming to a normal social life; and (v) perceived benefits outweighing risks of mild and short-term side effects. CONCLUSIONS: seven implementation strategies were developed in part 2 based on the results above, namely (i) providing trustworthy vaccine-related information and scaling up the promotion; (ii) encouraging healthcare professionals to recommend vaccinations; (iii) giving incentives; (iv) using social influence approaches; (v) allowing a selection of COVID-19 vaccine brands; (vi) increasing accessibility for vaccinations; and (vii) emphasizing social responsibility.

Administration and Organization

The Use of Garden Memorial Ritual for Survivors, Families, and Healthcare Workers as a Result of the COVID-19 Pandemic in Nursing Facilities.
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Hoffman ML.
Omega. 2022 Jun;302228221107979.
Over the course of the last year and a half, the Coronavirus has swept across the world causing death and devastation to our geriatric population residing in long term care facilities, also known as nursing homes. This paper explores the complicated grief responses exhibited by individuals who were affected by nursing home resident COVID-19 deaths. Nursing home resident survivors, families of the deceased residents, and healthcare workers in this situation have experienced a wide variety of complicated grief responses that need to be addressed. To address this need, an application will follow regarding the usage of a garden memorial ritual and ceremony to help these grievers in their first steps of mourning.

Is the Systemic Agency Capacity of Long-Term Care Organizations Enabling Person-Centered Care during the COVID-19 Pandemic? A Repeated Cross-Sectional Study of Organizational Resilience.
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Pfaff H, Pförtner TK, Banaszak-Holl J, Hu Y, Hower K.
International journal of environmental research and public health. 2022 Apr;19(9).
The COVID-19 pandemic has strained long-term care organization staff and placed new demands on them. This study examines the role of the general ability and power of a long-term care organization to act and react collectively as a social system, which is called systemic agency capacity, in safeguarding the provision of person-centered care during a crisis. The question of how the systemic agency capacity of long-term care organizations helps to ensure person-centered care during the pandemic is an open research question. We conducted a pooled cross-sectional study on long-term care organizations in Germany during the first and second waves of the pandemic (April 2020 and December 2020-January 2021). The sample consisted of 503 (first wave) and 294 leaders (second wave) of long-term care organizations. The top managers of these facilities were asked to report their perceptions of their facility’s agency capacity, measured by the AGIL scale, and the extent to which the facility provides person-centered care. We found a significant positive association between the leaders’ perceptions of systemic agency capacity and their perceptions of delivered person-centered care, which did not change over time. The results tentatively support the idea that fostering the systemic agency capacity of long-term care organizations facilitates their ability to provide quality routine care despite environmental shocks such as the COVID-19 pandemic.

Nursing Home COVID Relief Under QIP’s Performance-Based Formula: Does Performance Actually Matter, and Should It?
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Plummer E, Wempe WF.
Medical care research and review : MCRR. 2022 Jun;10775587221096260.
The Quality Incentive Program (QIP) distributed US$2 billion to nursing homes (NHs) that met performance goals primarily related to their COVID-19 infection rates. We examine how QIP affected 15,331 NHs with different facility and community attributes, and the extent to which QIP payments per resident-week (QIP$) were associated with NHs’ COVID-related attributes. We find that QIP$ was primarily determined by county (not facility) infection rates. QIP distributed US$2 billion to NHs for months in which they experienced virtually no COVID-19 cases; US$0 was distributed for months in which they experienced more than 300,000 cases. We find that QIP$ was larger for smaller, nonprofit NHs located in more rural and economically distressed communities. Regression analyses reveal that recipients of larger QIP$ maintained greater supplies of personal protective equipment, conducted more staff testing, and limited admissions of infected residents, and that greater staff testing and limited admissions are also associated with NHs’ sustained success in receiving QIP payments. Policymakers should consider whether performance-based payment systems are optimal for addressing public health emergencies.

Social Isolation and Nursing Leadership in Long-Term Care: Moving Forward After COVID-19.
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Woods DL, Navarro AE, LaBorde P, Dawson M, Shipway S.
The Nursing clinics of North America. 2022 Jun;57(2):273–86.
Nursing leaders have a responsibility to promote and facilitate social engagement and connectedness to mitigate social isolation in long-term care (LTC). The COVID-19 pandemic has emphasized longstanding problems in LTC facilities, such as staff mix, workload, and support. The pandemic has shed light on the severe deleterious effect of social isolation and the critical importance of maintaining social engagement and connectedness, especially in times of crisis or major change. Staff education and ongoing support cannot be overemphasized. Critical nursing leadership and interdisciplinary collaboration engaging all team members are essential in operationalizing nonpharmacological approaches that foster the well-being of residents with dementia.

Prevalence and Spread

The role of staff in transmission of SARS-CoV-2 in long-term care facilities.
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Adams C, Chamberlain A, Wang Y, Hazell M, Shah S, Holland DP, et al.
Epidemiology (Cambridge, Mass). 2022 May.
BACKGROUND: U.S. long-term care facilities have experienced a disproportionate burden of COVID-19 morbidity and mortality. METHODS: We examined SARS-CoV-2 transmission among residents and staff in 60 long-term care facilities in Fulton County, Georgia, from March 2020 to September 2021. Using the Wallinga-Teunis method to estimate the time-varying reproduction number, R(t), and linear mixed regression models, we examined associations between case characteristics and R(t). RESULTS: Case counts, outbreak size and duration, and R(t) declined rapidly and remained low after vaccines were first distributed to long-term care facilities in December 2020, despite increases in community incidence in summer 2021. Staff cases were more infectious than resident cases (average individual reproduction number, Ri = 0.6 [95%CI: 0.4-0.7] and 0.1 [95%CI: 0.1-0.2], respectively). Unvaccinated resident cases were more infectious than vaccinated resident cases (Ri = 0.5 [95%CI: 0.4-0.6] and 0.2 [95%CI: 0.0-0.8], respectively), but estimates were imprecise. CONCLUSIONS: COVID-19 vaccines slowed transmission and contributed to reduced caseload in long-term care facilities. However, due to data limitations, we were unable to determine whether breakthrough vaccinated cases were less infectious than unvaccinated cases. Staff cases were six times more infectious than resident cases, consistent with the hypothesis that staff were the primary drivers of SARS-CoV-2 transmission in long-term care facilities.

SARS-CoV-2 cases reported from long-term residential facilities (care homes) in South Africa: a retrospective cohort study.
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Arendse T, Cowper B, Cohen C, Masha M, Tempia S, Legodu C, et al.
BMC public health. 2022 May;22(1):1035.
BACKGROUND: Globally, long-term care facilities (LTCFs) experienced a large burden of deaths during the COVID-19 pandemic. The study aimed to describe the temporal trends as well as the characteristics and risk factors for mortality among residents and staff who tested positive for SARS-CoV-2 in selected LTCFs across South Africa. METHOD: We analysed data reported to the DATCOV sentinel surveillance system by 45 LTCFs. Outbreaks in LTCFs were defined as large if more than one-third of residents and staff had been infected or there were more than 20 epidemiologically linked cases. Multivariable logistic regression was used to assess risk factors for mortality amongst LTCF residents. RESULTS: A total of 2324 SARS-CoV-2 cases were reported from 5 March 2020 through 31 July 2021; 1504 (65%) were residents and 820 (35%) staff. Among LTCFs, 6 reported sporadic cases and 39 experienced outbreaks. Of those reporting outbreaks, 10 (26%) reported one and 29 (74%) reported more than one outbreak. There were 48 (66.7%) small outbreaks and 24 (33.3%) large outbreaks reported. There were 30 outbreaks reported in the first wave, 21 in the second wave and 15 in the third wave, with 6 outbreaks reporting between waves. There were 1259 cases during the first COVID-19 wave, 362 during the second wave, and 299 during the current third wave. The case fatality ratio was 9% (138/1504) among residents and 0.5% (4/820) among staff. On multivariable analysis, factors associated with SARS-CoV-2 mortality among LTCF residents were age 40-59 years, 60-79 years and ≥ 80 years compared to < 40 years and being a resident in a LTCF in Free State or Northern Cape compared to Western Cape. Compared to pre-wave 1, there was a decreased risk of mortality in wave 1, post-wave 1, wave 2, post-wave 2 and wave 3. CONCLUSION: The analysis of SARS-CoV-2 cases in sentinel LTCFs in South Africa points to an encouraging trend of decreasing numbers of outbreaks, cases and risk for mortality since the first wave. LTCFs are likely to have learnt from international experience and adopted national protocols, which include improved measures to limit transmission and administer early and appropriate clinical care.

COVID-19 in Long-Term Care: The Built Environment Impact on
Infection Control.

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Benbow WB.
HERD. 2022 Jun;19375867221101896.
PURPOSE: The purpose of this article is to review available literature for evidence-based impact of the built environment upon the prevention and management of COVID-19 with a view to emphasizing lessons learned for future infection control of pandemics. BACKGROUND: This is urgently needed given the devastation brought upon long-term care residents worldwide. Long-term care (LTC) facilities face a battle to protect their residents. Previous studies of infection control design issues have focused generally on Fomites: that is, contaminated objects and surfaces. As COVID-19 has been shown to be largely spread through the air, this article will broaden the focus to include engineering controls that effect this type of transmission. METHOD: A literature search was conducted using key words such as long-term care facilities, built environment, COVID-19, infection control, and nursing homes. RESULTS: Results were sorted using an engineering controls pyramid developed by the author to stratify approaches to LTC infrastructure. Basically, six elements were supported: ventilation, spatial separation, physical barriers, hand hygiene stations, resident room zones, and private rooms. IMPLICATIONS: Conclusions were that the built environment has a major impact on infection control that can be deleterious or beneficial. Substantial changes need to be made to protect the very vulnerable LTC population from future pandemics and infectious diseases.

COVID-19 vaccine booster dose needed to achieve Omicron-specific neutralisation in nursing home residents.
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Canaday DH, Oyebanji OA, White E, Keresztesy D, Payne M, Wilk D, et al.
EBioMedicine. 2022 Jun;80:104066.
BACKGROUND: Nursing home (NH) residents have borne a disproportionate share of SARS-CoV-2 morbidity and mortality. Vaccines have limited hospitalisation and death from earlier variants in this vulnerable population. With the rise of Omicron and future variants, it is vital to sustain and broaden vaccine-induced protection. We examined the effect of boosting with BNT162b2 mRNA vaccine on humoral immunity and Omicron-specific neutralising activity among NH residents and healthcare workers (HCWs). METHODS: We longitudinally enrolled 85 NH residents (median age 77) and 48 HCWs (median age 51), and sampled them after the initial vaccination series; and just before and 2 weeks after booster vaccination. Anti-spike, anti-receptor binding domain (RBD) and neutralisation titres to the original Wuhan strain and neutralisation to the Omicron strain were obtained. FINDINGS: Booster vaccination significantly increased vaccine-specific anti-spike, anti-RBD, and neutralisation levels above the pre-booster levels in NH residents and HCWs, both in those with and without prior SARS-CoV-2 infection. Omicron-specific neutralisation activity was low after the initial 2 dose series with only 28% of NH residents’ and 28% HCWs’ titres above the assay’s lower limit of detection. Omicron neutralising activity following the booster lifted 86% of NH residents and 93% of HCWs to the detectable range. INTERPRETATION: With boosting, the vast majority of HCWs and NH residents developed detectable Omicron-specific neutralising activity. These data provide immunologic evidence that strongly supports booster vaccination to broaden neutralising activity and counter waning immunity in the hope it will better protect this vulnerable, high-risk population against the Omicron variant. FUNDING: NIH AI129709-03S1, U01 CA260539-01, CDC 200-2016-91773, and VA BX005507-01.

COVID-19 Prevalence in UNIVI Group Nursing Homes and Multilevel Geriatric Hospitals: Epidemiological Study of Immunological Status with Rapid Serological Tests for Diagnostic Guidance and Follow Up.
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de Malherbe A, Verdun S, Brenière V, Luquel L, Jourdan M, Harboun M.
The journal of nutrition, health & aging. 2022;26(5):477–84.
BACKGROUND/OBJECTIVES: To date, data are lacking on the proportion of residents, and employees who have actually been exposed to SARS-Cov-2 in nursing homes and geriatric healthcare institutions, as well as the evolution of their serological status and the recurrence of Covid-19. The primary objective was to determine the prevalence of COVID-19 using NG Biotech rapid serological tests among caregivers and residents. The secondary objectives were to determine: prevalence according to RT PCR tests or clinical diagnosis; the risk factors (autonomy, arterial hypertension, diabetes mellitus) and clinical presentation (e.g. respiratory, abdominal or cutaneous symptoms, asthenia, fever) among residents; the risk factors (age, sex, profession, family situation) among caregivers; the evolution of the serological status at 1, 3 and 6 months using NG Biotech rapid serological tests; the symptomatic recurrence of Covid 19 at 1, 3 and 6 months. DESIGN: Multicentric prospective observational. SETTING: Study location: 27 nursing homes and 3 multilevel geriatric hospitals belonging to the UNIVI Group in France. PARTICIPANTS: 1334 professionals: 692 among multilevel geriatric hospitals (mean age: 43.6+/-11.8; 441 (82.4%) female) and 642 among nursing homes (mean age: 43.5+/-12.4; 685 (85.9%) female), and 1145 residents (mean age: 89+/-7.5; 898 (78.7%) female). MEASUREMENTS: Prevalence using NG Biotech rapid serological tests, medical diagnosis, RT-PCR tests.Risk factors among residents using the medical file and among caregivers using questionnaires.Clinical presentation in residents using the medical file. RESULTS: The prevalence using NG Biotech rapid serological test in residents was 14.4 % (168 of 1142 available diagnostics), the global prevalence (positive RT-PCR or positive serological test) was 22.7% (203 of 895 available diagnostics). The prevalence using NG Biotech rapid serological test in professionals was 12.8% (164 of 1315 available diagnostics), the global prevalence (positive RT-PCR test or positive serological test) was 23.8% (222 of 933 available diagnostics). The risk factors among residents were: living in an Alzheimer unit, and being a contact case. Being independent for activities of daily living was protective. The risk factor among caregivers was being a contact case. Another risk factor was the job; nurse assistants, nurses, and physicians were the most exposed. Residents had atypical clinical presentations including frequent geriatric syndromes (falls, delirium). 68.3% (71 of 104) of the initially positive residents still had a positive rapid serological test at 1 month follow up and 74 % (54 of 73) at 3 months follow up. 77.9% (88 of 113) of the initially positive employees still had a positive rapid serological test at 1 month follow up. Symptomatic reinfection was exceptional in caregivers or in residents during follow up. CONCLUSION: COVID 19 prevalence among caregivers and residents in nursing homes and geriatric health Institutions is underestimated when using only one method for diagnosis. Geriatric syndromes such as falls and delirium in residents should trigger further investigations on a COVID-19 cause. Immunity was persistent in ¾ of caregivers and residents during the 3 months follow up. The high prevalence of COVID 19 in geriatric institutions pleads in favor of the French vaccination policy, initially targeting as a priority the most vulnerable and dependent people, followed by staff members in healthcare institutions and nursing homes. More studies on the persistence of immunity and the perspective of Covid 19 mutations will help determine the long-term vaccine booster policy.

A Third Dose of mRNA COVID-19 Vaccine Significantly Enhances Anti–SARS-CoV-2 Spike IgG Response in Nursing Home Residents in Italy
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Fedele G, Palmieri A, Malara A, Damiano C, Di Lonardo A, Schiavoni I, et al.
Journal of the American Medical Directors Association. 2022 May.
A rapid development of effective vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their deployment has proved to be a highly successful strategy to reduce the impact of the COVID-19 pandemic. Several studies have suggested a waning of humoral responses after primary vaccination. A third dose of the mRNA vaccine was shown to increase neutralizing antibody levels and prevent severe outcomes. However, data on the response to third dose of SARS-CoV-2 vaccine in the frail and complex population in Nursing Homes (NHs) are still limited. In this context, we have assessed the trajectories of humoral immunity in a sample NH resident receiving a 3-dose SARS-CoV-2 vaccine schedule.

Antibody Seroprevalence, Infection and Surveillance for SARS-CoV-2 in Residents and Staff of New Jersey Long-Term Care Facilities.
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Friedman SM, Davidow AL, Gurumurthy M, Peymani R, Webb J, Desai K, et al.
Journal of community health. 2022 Jun.
Early in the pandemic, New Jersey (NJ) long-term care facilities (LTCFs) witnessed severe COVID-19 illness. With limited surveillance to characterize the scope of infection, we estimated the prevalence of antibody to the SARS-CoV-2 nucleocapsid protein among residents and staff, to describe the epidemiology, and to measure antibody distribution by prior PCR/antigen status and symptomatology. 10 NJ LTCFs of 20 solicited with diverse geography and bed-capacities were visited between October 2020 and March 2021. A single serum was tested for total N-antibody (ELISA) by the state laboratory. Residents’ demographics and clinical history were transcribed from the patient record. For staff, this information was solicited directly from employees, supplemented by prior PCR/antigen results from facilities. 62% of 332 residents and 46% of 661 staff tested N-antibody positive. In a multivariable logistic regression in residents, odds ratios for older age and admission prior before March 1, 2020 were significant. Among the staff, odds ratios for older age, ethnic-racial group, nursing-related job, and COVID-19 symptoms were significantly associated with N-antibody positivity. In a sub-analysis in five better record-keeping LTCFs, 90% of residents and 85% of staff with positive PCR/antigen results were seropositive for N-antibody, yet 25% of residents and 22% of staff were N-antibody positive but PCR/antigen and symptoms negative. The high rate of clinically unsuspected infections likely contributed to the spread. These findings argue for robust surveillance, regular screening of asymptomatic individuals, and vaccinating both residents and staff to abate the pandemic. The data also provide guidance to prevent future outbreaks.

Testing and vaccination to reduce the impact of COVID-19 in nursing homes: an agent-based approach.
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Gómez Vázquez JP, García YE, Schmidt AJ, Martínez-López B, Nuño M.
BMC infectious diseases. 2022 May;22(1):477.
BACKGROUND: Efforts to protect residents in nursing homes involve non-pharmaceutical interventions, testing, and vaccine. We sought to quantify the effect of testing and vaccine strategies on the attack rate, length of the epidemic, and hospitalization. METHODS: We developed an agent-based model to simulate the dynamics of SARS-CoV-2 transmission among resident and staff agents in a nursing home. Interactions between 172 residents and 170 staff based on data from a nursing home in Los Angeles, CA. Scenarios were simulated assuming different levels of non-pharmaceutical interventions, testing frequencies, and vaccine efficacy to reduce transmission. RESULTS: Under the hypothetical scenario of widespread SARS-CoV-2 in the community, 3-day testing frequency minimized the attack rate and the time to eradicate an outbreak. Prioritization of vaccine among staff or staff and residents minimized the cumulative number of infections and hospitalization, particularly in the scenario of high probability of an introduction. Reducing the probability of a viral introduction eased the demand on testing and vaccination rate to decrease infections and hospitalizations. CONCLUSIONS: Improving frequency of testing from 7-days to 3-days minimized the number of infections and hospitalizations, despite widespread community transmission. Vaccine prioritization of staff provides the best protection strategy when the risk of viral introduction is high.

Immune Response 5-7 Months after Vaccination against SARS-CoV-2 in Elderly Nursing Home Residents in the Czech Republic: Comparison of Three Vaccines.
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Martínek J, Tomášková H, Janošek J, Zelená H, Kloudová A, Mrázek J, et al.
Viruses. 2022 May;14(5).
BACKGROUND AND AIMS: Elderly nursing home residents are especially prone to a severe course of SARS-CoV-2 infection. In this study, we aimed to investigate the complex immune response after vaccination depending on the convalescence status and vaccine. METHODS: Sampling took place in September-October 2021. IgG antibodies against spike protein and nucleocapsid protein, the titer of virus neutralization antibodies against delta and (on a subset of patients) omicron, and cellular immunity (interferon-gamma release assay) were tested in nursing home residents vaccinated with Pfizer, Moderna (both 30-31 weeks after the completion of vaccination), or AstraZeneca (23 weeks) vaccines. The prevalence with 95% confidence intervals (CI) was evaluated in Stata version 17. RESULTS: 95.2% (95% CI: 92.5-97.1%) of the 375 participants had positive results of anti-S IgG, 92.8% (95% CI: 89.7-95.2%) were positive in virus neutralization assay against delta, and 89.0% (95% CI: 84.5-92.5%) in the interferon-gamma-releasing assay detecting cellular immunity. Results of the virus neutralization assay against omicron correlated with those against delta but the neutralization capacity was reduced by about half. As expected, the worst results were found for the AstraZeneca vaccine, although the vaccination-to-test period was the shortest for this vaccine. All immune parameters were significantly higher in convalescent residents than in naive residents after vaccination. No case of COVID-19 occurred during the vaccination-to-test period. CONCLUSIONS: A high immune response, especially among vaccinated convalescents (i.e., residents with hybrid immunity), was found in elderly nursing home residents 5-7 months after vaccination against SARS-CoV-2. In view of this, it appears that such residents are much better protected from COVID-19 than those who are only vaccinated and the matter of individual approach to the booster dose in such individuals should be further discussed.

Likely community transmission of COVID-19 infections between neighboring, persistent hotspots in Ontario, Canada.
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Mucaki EJ, Shirley BC, Rogan PK.
F1000Research. 2021;10:1312.
Introduction: This study aimed to produce community-level geo-spatial mapping of confirmed COVID-19 cases in Ontario Canada in near real-time to support decision-making. This was accomplished by area-to-area geostatistical analysis, space-time integration, and spatial interpolation of COVID-19 positive individuals. Methods: COVID-19 cases and locations were curated for geostatistical analyses from March 2020 through June 2021, corresponding to the first, second, and third waves of infections. Daily cases were aggregated according to designated forward sortation area (FSA), and postal codes (PC) in municipal regions Hamilton, Kitchener/Waterloo, London, Ottawa, Toronto, and Windsor/Essex county. Hotspots were identified with area-to-area tests including Getis-Ord Gi*, Global Moran’s I spatial autocorrelation, and Local Moran’s I asymmetric clustering and outlier analyses. Case counts were also interpolated across geographic regions by Empirical Bayesian Kriging, which localizes high concentrations of COVID-19 positive tests, independent of FSA or PC boundaries. The Geostatistical Disease Epidemiology Toolbox, which is freely-available software, automates the identification of these regions and produces digital maps for public health professionals to assist in pandemic management of contact tracing and distribution of other resources. Results: This study provided indicators in real-time of likely, community-level disease transmission through innovative geospatial analyses of COVID-19 incidence data. Municipal and provincial results were validated by comparisons with known outbreaks at long-term care and other high density residences and on farms. PC-level analyses revealed hotspots at higher geospatial resolution than public reports of FSAs, and often sooner. Results of different tests and kriging were compared to determine consistency among hotspot assignments. Concurrent or consecutive hotspots in close proximity suggested potential community transmission of COVID-19 from cluster and outlier analysis of neighboring PCs and by kriging. Results were also stratified by population based-categories (sex, age, and presence/absence of comorbidities). Conclusions: Earlier recognition of hotspots could reduce public health burdens of COVID-19 and expedite contact tracing.

Association of Receipt of the Fourth BNT162b2 Dose With Omicron Infection and COVID-19 Hospitalizations Among Residents of Long-term Care Facilities.
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Muhsen K, Maimon N, Mizrahi AY, Boltyansky B, Bodenheimer O, Diamant ZH, et al.
JAMA internal medicine. 2022 Jun.
The administration of a fourth BNT162b2 COVID-19 vaccine dose was approved in Israel in December 2021 for individuals 60 years or older who were vaccinated with a third dose 4 months previously or earlier to control the substantial surge of the SARS-CoV-2 Omicron variant. Nonetheless, the association between receipt of the fourth dose and protection against infection remains elusive. Objective: To determine the association of the fourth BNT162b2 dose with protection against SARS-CoV-2-related infections, hospitalizations, and deaths during the Omicron surge in long-term care facility (LTCF) residents. Design, setting, and participants: This prospective cohort study was conducted in Israel between January 10 and March 31, 2022 and included LTCF residents 60 years or older. Exposures: Vaccination with the fourth dose of BNT162b2 vs 3 doses that were administered 4 months previously or earlier. Main outcomes and measures: Cumulative incidences of SARS-CoV-2 infections, hospitalizations, and deaths during the Omicron surge. The follow-up was initiated more than 7 days after receipt of the fourth dose, which was matched to the follow-up initiation date of those who had received 3 doses of vaccine in each facility. We obtained hazard ratios and 95% confidence intervals from multivariable Cox regression models. Results: The data of 43 775 residents (mean [SD] age, 80.1 [9.4] years; 29 679 women [67.8%]) were analyzed, of whom 24 088 (55.0%) and 19 687 (45.0%) received the fourth and third dose (4 months previously or earlier), respectively. The median follow-up time was 73 days (4-dose group: IQR, 6 days; 3-dose group: IQR, 56 days). More than 7 days postvaccination with the fourth dose, SARS-CoV-2 infection was detected among 4058 fourth-dose vs 4370 third-dose recipients (cumulative incidence, 17.6% vs 24.9%). The corresponding incidences of hospitalizations for mild-to-moderate COVID-19, severe illness, and mortality were 0.9% and 2.8%, 0.5% and 1.5%, and 0.2% and 0.5%, respectively. The adjusted protections were 34% (95% CI, 30%-37%), 64% (95% CI, 56%-71%), and 67% (95% CI, 57%-75%) against overall infection, hospitalizations for mild-to-moderate illness, and severe illness, respectively, and 72% (95% CI, 57%-83%) against related deaths. Conclusions and relevance: The results of this cohort study suggest that receipt of a fourth BNT162b2 dose conferred high protection against COVID-19 hospitalizations and deaths among LTCF residents during a substantial Omicron variant surge, but protection was modest against infection. These findings are relevant to the control of COVID-19 pandemic globally, especially among the population of LTCFs.

A mixed-methods study of risk factors and experiences of healthcare workers tested for the novel coronavirus in Canada.
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Okpani AI, Barker S, Lockhart K, Grant J, Delgado-Ron JA, Zungu M, et al.
Journal of occupational and environmental medicine. 2022 Jun.
OBJECTIVE: To investigate occupational and non-work-related risk factors of COVID-19 among healthcare workers (HCWs) in Vancouver Coastal Health, British Columbia, Canada, and to examine how HCWs described their experiences. METHODS: Matched case-control study using data from online and phone questionnaires with optional open-ended questions completed by HCWs who sought SARS-CoV-2 testing between March 2020 and March 2021. Conditional logistic regression and thematic analysis were utilized. RESULTS: Providing direct care to COVID-19 patients during the intermediate cohort period (adjusted odds ratio -aOR- 1.90, 95% CI 1.04-3.46), and community exposure to a known case in the late cohort period (aOR 3.595% CI 1.86-6.83) were associated with higher infection odds. Suboptimal communication, mental stress, and situations perceived as unsafe were common sources of dissatisfaction. CONCLUSIONS: Varying levels of risk between occupational groups call for wider targeting of infection prevention measures. Strategies for mitigating community exposure and supporting HCW resilience are required.

Characteristics of nursing homes and early preventive measures associated with risk of infection from COVID-19 in Lazio region, Italy: a retrospective case-control study.
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Orlando S, Mazhari T, Abbondanzieri A, Cerone G, Ciccacci F, Liotta G, et al.
BMJ open. 2022 Jun;12(6):e061784.
OBJECTIVES: To understand which organisational-structural characteristics of nursing homes-also referred to as long-term care facilities (LTCFs)-and the preventative measures adopted in response to the pandemic are associated with the risk of a COVID-19 outbreak. SETTING: LTCFs in Lazio region in Italy. DESIGN: The study adopts a case-control design. PARTICIPANTS: We included 141 facilities and 100 provided information for the study. Cases were defined as facilities reporting a COVID-19 outbreak (two or more cases) in March-December 2020; controls were defined as LTCFs reporting one case or zero. The exposures include the structural-organisational characteristics of the LTCFs as reported by the facilities, preventative measures employed and relevant external factors. RESULTS: Twenty facilities reported an outbreak of COVID-19. In binary logistic regression models, facilities with more than 15 beds were five times more likely to experience an outbreak than facilities with less than 15 beds OR=5.60 (CI 1.61 to 25.12; p value 0.002); admitting new residents to facilities was associated with a substantially higher risk of an outbreak: 6.46 (CI 1.58 to 27.58, p value 0.004). In a multivariable analysis, facility size was the only variable that was significantly associated with a COVID-19 outbreak OR= 5.37 (CI 1.58 to 22.8; p value 0.012) for larger facilities (>15 beds) versus smaller (<15 beds). Other characteristics and measures were not associated with an outbreak. CONCLUSION: There was evidence of a higher risk of COVID-19 in larger facilities and when new patients were admitted during the pandemic. All other structural-organisational characteristics and preventative measures were not associated with an outbreak. This finding calls into question existing policies, especially where there is a risk of harm to residents. One such example is the restriction of visitor access to facilities, resulting in the social isolation of residents.

Effectiveness of BNT162b2 and ChAdOx-1 vaccines in residents of long-term care facilities in England using a time-varying proportional hazards model.
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Paranthaman K, Subbarao S, Andrews N, Kirsebom F, Gower C, Lopez-Bernal J, et al.
Age and ageing. 2022 May;51(5).
INTRODUCTION: residents of long-term care facilities (LTCFs) are at high risk of adverse outcomes from SARS-CoV-2. We aimed to estimate the vaccine effectiveness (VE) of one and two doses of BNT162b2 and ChAdOx-1 against SARS CoV-2 infection and COVID-19-related death in residents of LTCFs. METHODS: this observational study used testing, vaccination and mortality data for LTCF residents aged ≥ 65 years who were regularly tested regardless of symptoms from 8 December 2020 to 30 September 2021 in England. Adjusted VE, calculated as one minus adjusted hazard ratio, was estimated using time-varying Cox proportional hazards models for infection and death within 28 days of positive test result. Vaccine status was defined by receipt of one or two doses of vaccine and assessed over a range of intervals. RESULTS: of 197,885 LTCF residents, 47,087 (23.8%) had a positive test and 11,329 (5.8%) died within 28 days of a positive test during the study period. Relative to unvaccinated individuals, VE for infection was highest for ChAdOx-1 at 61% (40-74%) at 1-4 weeks and for BNT162b2 at 69% (52-80%) at 11-15 weeks following the second dose. Against death, VE was highest for ChAdOx-1 at 83% (58-94%) at 1-4 weeks and for BNT162b2 at 91% (75-97%) at 11-15 weeks following second dose. CONCLUSIONS: compared with unvaccinated residents, vaccination with one dose of BNT162b2 or ChAdOx-1 provided moderate protection against infection and death in residents of LTCFs. Protection against death improved after two doses. However, some waning of protection over time was noted.

Cross-Sectional Analysis of Risk Factors for Outbreak of COVID-19 in Nursing Homes for Older Adults in the Community of Madrid.
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San Román J, Candel FJ, Del Mar Carretero M, Sanz JC, Pérez-Abeledo M, Barreiro P, et al.
Gerontology. 2022 Jun.
INTRODUCTION: Nursing homes for older adults have been hot spots for SARS-CoV-2 infections and mortality. Factors that facilitate COVID-19 outbreaks in these settings need to be assessed. METHODS: A retrospective cross-sectional study of a cohort of residents and workers in nursing homes taking occasion of a point seroprevalence survey was done in the Community of Madrid. Factors related to outbreaks in these facilities were analyzed. RESULTS: A total of 369 nursing homes for older adults, making a population of 23,756 residents and 20,795 staff members, were followed from July to December 2020. There were 54.2% SARS-CoV-2 IgG+ results in residents and in 32.2% of workers. Sixty-two nursing homes (16.8%) had an outbreak during the follow-up. Nursing homes with outbreaks had more residents than those without (median number of 81 [IQR, 74] vs. 50 [IQR, 56], p < 0.001). Seropositivity for SARS-CoV-2 was lower in facilities with versus without outbreaks, for residents (42.2% [IQR, 55.7] vs. 58.7% [IQR, 43.4], p = 0.002) and for workers (23.9% [IQR, 26.4] vs. 32.8% [IQR, 26.3], p = 0.01). For both residents and staff, the number of infections in outbreaks was larger in centers with lower, as compared with intermediate or high seroprevalence. The size of the facility did not correlate with the number of cases in the outbreak. Taking the incidence of cases in the community as a time-dependent variable (p = 0.03), a Cox analysis (HR [95% CI], p) showed that intermediate or high seroprevalence among residents in the facility was related to a reduction of 55% (0.45 [0.25-0.80], p = 0.007) and 78% (0.22 [0.10-0.48], p < 0.001) in the risk of outbreaks, respectively, as compared with low sero-prevalence. Also, as compared with smaller, medium (1.91 [1.00-3.65], p = 0.05) or large centers (4.57 [2.38-8.75], p < 0.001) had more respective risk of outbreaks. CONCLUSIONS: The size of the facility and the seroprevalence among residents in nursing homes, and the incidence of infections in the community, are associated with the risk of outbreaks of COVID-19. Facilities with greater proportion of seropositives had smaller number of cases. Monitoring of immunity in nursing homes may help detect those at a greater risk of future cases.

SARS-CoV-2 Omicron BA.1 variant breakthrough infections in nursing home residents after an homologous third dose of the Comirnaty® COVID-19 vaccine: Looking for correlates of protection.
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Torres I, Giménez E, Albert E, Zulaica J, Álvarez-Rodríguez B, Burgos JS, et al.
Journal of medical virology. 2022 May.
We investigated whether peripheral blood levels of SARS-CoV-2 Spike (S) receptor binding domain antibodies (anti-RBD), neutralizing antibodies (NtAb) targeting Omicron S, and S-reactive-interferon (IFN)-γ-producing CD4(+) and CD8(+) T cells measured after a homologous booster dose (3D) with the Comirnaty® vaccine was associated with the likelihood of subsequent breakthrough infections due to the Omicron variant. An observational study including 146 nursing home residents (median age, 80 years; range, 66-99; 109 female) evaluated for an immunological response after 3D (at a median of 16 days). Anti-RBD total antibodies were measured by chemiluminescent immunoassay. NtAb were quantified by an Omicron S pseudotyped virus neutralization assay. SARS-CoV-2-S specific-IFNγ-producing CD4(+) and CD8(+) T cells were enumerated by whole-blood flow cytometry for intracellular cytokine staining. In total, 33/146 participants contracted breakthrough Omicron infection (symptomatic in 30/33) within 4 months after 3D. Anti-RBD antibody levels were comparable in infected and uninfected participants (21 123 vs. 24 723 BAU/ml; p = 0.34). Likewise, NtAb titers (reciprocal IC(50) titer, 157 vs. 95; p = 0.32) and frequency of virus-reactive CD4(+) (p = 0.82) and CD8(+) (p = 0.91) T cells were similar across participants in both groups. anti-RBD antibody levels and NtAb titers estimated at around the time of infection were also comparable (3445 vs. 4345 BAU/ml; p = 0.59 and 188.5 vs. 88.9; p = 0.70, respectively). Having detectable NtAb against Omicron or SARS-CoV-2-S-reactive-IFNγ-producing CD4(+) or CD8(+) T cells after 3D was not correlated with increased protection from breakthrough infection (OR, 1.50; p = 0.54; OR, 0.0; p = 0.99 and OR 3.70; p = 0.23, respectively). None of the immune parameters evaluated herein, including NtAb titers against the Omicron variant, may reliably predict at the individual level the risk of contracting COVID-19 due to the Omicron variant in nursing home residents.

The role of airborne transmission in a large single source outbreak of SARS-CoV-2 in a Belgian nursing home in 2020.
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Vuylsteke B, Cuypers L, Baele G, Stranger M, Paralovo SL, André E, et al.
Epidemics. 2022 Jun;40:100589.
OBJECTIVES: To better understand the conditions which have led to one of the largest COVID-19 outbreaks in Belgian nursing homes in 2020. SETTING: A nursing home in Flanders, Belgium, which experienced a massive outbreak of COVID-19 after a cultural event. An external volunteer who dressed as a legendary figure visited consecutively the 4 living units on December, 4th and tested positive for SARS-CoV-2 the next day. Within days, residents started to display symptoms and the outbreak spread rapidly within the nursing home. METHODS: We interviewed key informants and collected standardized data from all residents retrospectively. A batch of 115 positive samples with a Ct value of < 37 by qRT-PCR were analyzed using whole-genome sequencing. Six months after the outbreak, ventilation assessment of gathering rooms in the nursing home was done using a tracer gas test with calibrated CO(2) sensors. RESULTS: Timeline of diagnoses and symptom onsets clearly pointed to the cultural event as the start of the outbreak, with the volunteer as index case. The genotyping of positive samples depicted the presence of one large cluster, suggesting a single source outbreak. By the end of December, a total of 127 residents and 40 staff were diagnosed with SARS-CoV-2 since the beginning of the outbreak. The attack rate among residents was 77 % and significantly associated with presence at the event but not with close contact or mask wearing. The ventilation assessment showed a high background average CO(2) level in four main rooms varying from 657 ppm to 846 ppm. CONCLUSIONS: Our investigation shows a rapid and widespread single source outbreak of SARS-CoV-2 in a nursing home, in which airborne transmission was the most plausible explanation for the massive intra-facility spread. Our results underscore the importance of ventilation and air quality for the prevention of future outbreaks in closed facilities.

Spread of COVID-19 Infection in Long-Term Care Facilities of Trieste (Italy) during the Pre-Vaccination Era, Integrating Findings of 41 Forensic Autopsies with Geriatric Comorbidity Index as a Valid Option for the Assessment of Strength of Causation.
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Zanon M, Peruch M, Concato M, Moreschi C, Pizzolitto S, Radaelli D, et al.
Vaccines. 2022 May;10(5).
BACKGROUND: in 2020, a new form of coronavirus spread around the world starting from China. The older people were the population most affected by the virus worldwide, in particular in Italy where more than 90% of deaths were people over 65 years. In these people, the definition of the cause of death is tricky due to the presence of numerous comorbidities. OBJECTIVE: to determine whether COVID-19 was the cause of death in a series of older adults residents of nursing care homes. METHODS: 41 autopsies were performed from May to June 2020. External examination, swabs, and macroscopic and microscopic examination were performed. RESULTS: the case series consisted of nursing home guests; 15 men and 26 women, with a mean age of 87 years. The average number of comorbidities was 4. Based only on the autopsy results, the defined cause of death was acute respiratory failure due to diffuse alveolar damage (8%) or (31%) bronchopneumonia with one or more positive swabs for SARS-CoV-2. Acute cardiac failure with one or more positive swabs for SARS-CoV-2 was indicated as the cause of death in in symptomatic (37%) and asymptomatic (10%) patients. Few patients died for septic shock (three cases), malignant neoplastic diseases (two cases), and massive digestive bleeding (one case). CONCLUSIONS: Data from post-mortem investigation were integrated with previously generated Geriatric Index of Comorbidity (GIC), resulting in four different degrees of probabilities: high (12%), intermediate (10%), low (59%), and none (19%), which define the level of strength of causation and the role of COVID-19 disease in determining death.

Modeling the effectiveness of healthcare personnel reactive testing and screening for the SARS-CoV-2 Omicron variant within nursing homes.
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Zipfel CM, Paul P, Gowler CD, Reddy SC, Stone ND, Jacobs Slifka K, et al.
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2022 Jun.
The SARS-CoV-2 Omicron variant has been hypothesized to exhibit faster clearance (time from peak viral concentration to clearance of acute infection), decreased sensitivity of antigen tests, and increased immune escape (the ability of the variant to evade immunity conferred by past infection or vaccination) compared to prior variants. These factors necessitate re-evaluation of prevention and control strategies-particularly in high-risk, congregate settings like nursing homes that have been heavily impacted by other COVID-19 variants. We used a simple model representing individual-level viral shedding dynamics to estimate the optimal strategy for testing nursing home healthcare personnel and quantify potential reduction in transmission of COVID-19. This provides a framework for prospectively evaluating testing strategies in emerging variant scenarios when data are limited. We find that case-initiated testing prevents 38% of transmission within a facility if implemented within a day of an index case testing positive, and screening testing strategies could prevent 30-78% of transmission within a facility if implemented daily, depending on test sensitivity.

Quality Improvement

The residential healthcare for the elderly in Italy: some considerations for post-COVID-19 policies.
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Cepparulo A, Giuriato L.
The European journal of health economics : HEPAC : health economics in prevention and care. 2022 Jun;23(4):671–85.
In Italy, the COVID-19 pandemic and the death of many elderly people have put in evidence the uneven territorial distribution of nursing homes, which have amplified the spread and severity of the pandemic. By applying a pooled OLS model to the Italian regions, over the 2010-18 period, we investigate the demand factors, market forces and institutional drivers of the spatial distribution of residential healthcare for the elderly. Using a fine-grained approach that considers specific regional and age-related elements and the market environment, which can reduce or increase the pressure on regional governments to provide formal assistance, we find that the financial resources and the availability of unemployed women as potential caregivers explain the distribution of expenditure better than the health needs of the elderly. As a result, the expenditure is concentrated in richer and more financially autonomous regions and it is not congruent with the distribution of chronicity, health and frailty factors or income among the elderly. These critical issues of the care services for frail elderly people, related to a highly decentralized governance and resulting in fragmented, market-driven provision, could be attacked only by a national reform.

A Clinical Response Team Providing Support to Long-Term Care Homes with COVID-19 Outbreaks in Eastern Ontario-a Cohort Study.
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Downar J, Boese K, Lalumiere G, Bercier G, Leduc S, Rice J, et al.
Canadian geriatrics journal : CGJ. 2022 Jun;25(2):171–4.
BACKGROUND: The greatest impact of the COVID-19 pandemic in Canada has been on long-term care facilities which have accounted for a large majority of the mortality seen in this country. We developed a clinical response team to perform mass assessment and provide support to long-term care facilities in Eastern Ontario with large outbreaks in the hope of reducing the impact of the outbreaks. METHODS: This is a retrospective cohort study of all residents of LTC facilities supported by our multidisciplinary clinical response team. We collected data about the timing of the outbreak and our deployment, as well as the total number of COVID-19 cases and deaths, and measured the correlation between the timing of our deployment and the observed mortality rate. RESULTS: Our clinical team was deployed to 14 long-term care facilities, representing 719 cases and 243 deaths (mean ± standard error of mortality 34% ± 4%). Our team was deployed a mean ± standard error of 16 ± 2 days after the declaration of an outbreak. There was a significant correlation between an earlier deployment of our clinical team and a lower mortality rate for that outbreak (Pearson’s r = 0.70, p < .01). INTERPRETATION: This retrospective, uncontrolled study of a non-standardized intervention has many potential limitations. However, the data suggest that timely deployment of our clinical response team may improve outcomes in the event of a large outbreak. This clinical team may be useful in future pandemics.

Assessing facilitating conditions and barriers for innovation implementation in Canadian long-term care homes: a research protocol.
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Hardy MS, Sasseville M, Attieh R, Bergeron-Drolet LA, Sanchez RHB, Gallani MC, et al.
Implementation science communications. 2022 Jun;3(1):61.
BACKGROUND: The COVID-19 pandemic has profoundly affected the health and care of older adults, with particularly negative consequences for those residing in long-term care homes (LTCH) and retirement homes (RH). To inform the implementation of interventions with the most potential for impact, Healthcare Excellence Canada identified six promising practices and policy options that can be introduced to ensure that LTCH and RH are better prepared for potential future outbreaks. A total of 22 implementation science teams (ISTs) were funded to support LTCH and RH across Canada in their implementation of these practices. This study aims to identify the enablers and barriers to the successful implementation of evidence-based practices and the impact of intervention in LTCH and RH across Canada. METHODS: A survey-based longitudinal correlational design will be used. The Organizational Readiness for Knowledge Translation (OR4KT) tool will be used to assess the readiness of LTCH and RH to implement the selected practice. The OR4KT includes 59 questions and takes about 15 min to complete. Five to ten respondents per organization, holding different job positions, will be invited by the ISTs to complete the OR4KT in 91 LTCH or RH across Canada at the beginning of the project (T1) and 6 months after the first measurement (T2). DISCUSSION: The study will provide a benchmark for assessing the readiness of LTCH and RH to implement evidence-based practices. It will also inform decision-makers about barriers and facilitators that influence the integration of promising practices in these organizations.

Distancing Measures and Challenges Discussed by COVID-19 Outbreak Teams of Dutch Nursing Homes: The COVID-19 MINUTES Study.
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van Tol LS, Smaling HJA, Meester W, Janus SIM, Zuidema SU, de Waal MWM, et al.
International journal of environmental research and public health. 2022 May;19(11).
The most severe COVID-19 infections and highest mortality rates are seen among long-term care residents. To reduce the risk of infection, physical distancing is important. This study investigates what physical distancing measures were discussed by COVID-19 outbreak teams of Dutch long-term care organizations and what challenges they encountered. The COVID-19 MINUTES study is a qualitative multi-center study (n = 41) that collected minutes of COVID-19 outbreak teams from March 2020 to October 2021. Textual units about distancing measures were selected and analyzed using manifest content analysis for the first wave: early March-early May 2020; the intermediate period of 2020: mid-May-mid-September 2020; and the second wave: late September 2020-mid-June 2021. During all periods, COVID-19 outbreak teams often discussed distancing visitors from residents. Moreover, during the first wave they often discussed isolation measures, during the intermediate period they often discussed distancing staff and volunteers from residents, and during both the intermediate period and the second wave they often discussed distancing among residents. During all periods, less often admission measures were discussed. Challenges persisted and included unrest among and conflicts between visitors and staff, visitors violating measures, resident non-adherence to measures, and staffing issues. The discussed distancing measures and corresponding challenges may guide local long-term care and (inter)national policymakers during the further course of the COVID-19 pandemic, outbreaks of other infectious diseases, and long-term care innovations.

Impact on Long Term Care Workers

Fear of COVID-19, emotional exhaustion, and care quality experience in nursing home staff during the COVID-19 pandemic.
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Altintas E, Boudoukha AH, Karaca Y, Lizio A, Luyat M, Gallouj K, et al.
Archives of gerontology and geriatrics. 2022 Jun;102:104745.
BACKGROUND: Nursing home staff have been adversely impacted throughout the COVID-19 pandemic, facing difficulties in providing patient care. The aim of this study was to explore health workers’ perception regarding their own care quality experience in nursing homes during the COVID-19 pandemic. Amidst the second wave of the pandemic, we investigated the relationships between fear of COVID-19 and care quality experiences in nursing homes with emotional exhaustion (EE) as a mediating role. We hypothesized that EE is associated with fear of COVID-19 and care quality experience among nursing home staff. Furthermore, we predicted that EE would mediate the relationships between fear of COVID-19 and care quality experience. METHODS: During the second wave of COVID-19 (October to December 2020), we administered surveys to a large sample of 129 French nursing home staff with a mean age of 38.47 ± 10.31 who were directly and repeatedly exposed to COVID-19. We assessed their emotional exhaustion (EE) and care quality experience in the workplace via subjective indicators using self-reported scales. RESULTS: In the context of COVID-19, low to severe emotional exhaustion levels were found among nursing home staff, and these levels were associated with care quality experience as well as fear of COVID-19. The groups with low and severe levels of EE reported the highest levels of fear of COVID-19. The groups with moderate and severe levels of EE reported the lowest levels of care quality experience. Lastly, the relationships between fear of COVID-19 and care quality experience were mediated by EE. CONCLUSIONS: The findings made by the present study focused on the role of emotional coping responses to COVID-19. EE was associated positively with fear of COVID-19 and negatively with care quality experience. Furthermore, EE was found to mediate the relationship between fear of COVID-19 and care quality experience. We discuss these findings as they relate to palliative care issues in nursing homes and the manner in which emotional exhaustion ought to be addressed among nursing home staff.

Caring and Working during the COVID-19 Pandemic: Perspective of Portuguese Residential Care Facility Workers.
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Barbosa MM, Teixeira L, Paúl C, Yanguas J, Afonso RM.
International journal of environmental research and public health. 2022 May;19(10).
Residential care facilities (RCF) for older people are facing high demands due to the COVID-19 pandemic. The aim of this study was to explore the workers’ perspectives on the changes in work and care dynamics amidst the first wave of the pandemic at Portuguese RCF. This is a descriptive, quantitative, and cross-sectional study. An online questionnaire about pandemic-induced changes in work and care dynamics was sent to 2325 RCF. These entities were then asked to share it with their workers. The participants (n = 784) were mostly women (92.7%) and mostly composed of technical directors (41.6%) and direct-care workers (17.1%). The respondents reported that during the first wave of the pandemic, when compared to the pre-pandemic period, there were greater difficulties in providing care related to the basic necessities of older people (52.7%); direct-care workers were required to work more consecutive hours in each shift (69.95%); direct-care workers had to live at RCF (14.8%), and there were changes concerning the possibility of promoting person-centered care (PCC) practices. It also revealed that focusing on disease prevention and sanitary measures alone facilitates practices that reinforce the traditional model of procedure-centered care and have negative consequences on the rights and well-being of those living and working at RCF, exposing and accentuating preexisting vulnerabilities. This study considers the pandemic’s serious implications and alarming questions about basic care, dignity, living, and working conditions at Portuguese RCF. These notions reinforce the need for change through redefining care policies and practices in Portuguese RCF beyond the pandemic. The current situation provides an opportunity to adopt a formal PCC model.

Work-Related Stress among a Cohort of Italian Long-Term Care Workers during the COVID-19 Pandemic: An Observational Study.
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Conti A, Russotto S, Opizzi A, Ratti M, Nicolini D, Vanhaecht K, et al.
International journal of environmental research and public health. 2022 May;19(10).
Despite long-term care (LTC) workers having been identified as particularly subject to chronic stress, only a few studies evaluated the impact of the COVID-19 pandemic on stress in this population. As far as the authors know, no studies have investigated the relationship between work-related stress and chronic stress in the LTC setting. This retrospective observational study aimed to assess the level of chronic stress in LTC workers, to identify some possible predictors and vulnerability factors, and to measure the impact of the COVID-19 pandemic on work-related stress. The study was based on the information gathered from two different questionnaires administered before and one year after the beginning of the pandemic, to a cohort of Italian LTC workers. We found that chronic stress was associated with lower resilience to stress scores (57.42 vs. 60.66) and with higher work-related stress scores (30.48 vs. 20.83). Interestingly, the overall level of work-related stress did not differ between the two questionnaires (27.84 vs. 29.08). However, the main components of the questionnaires changed; fatigue and burnout symptoms became more relevant after the pandemic. Results of this study suggests deepening knowledge of the components of stress to develop and implement effective stress mitigation interventions.

Psychological distress and resilience among italian healthcare workers of geriatric services during the COVID-19 pandemic.
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Mangialavori S, Riva F, Froldi M, Carabelli S, Caimi B, Rossi P, et al.
Geriatric nursing (New York, NY). 2022 May;46:132–6.
The COVID-19 pandemic exposed healthcare workers (HW) to heavy workload and psychological distress. This study was aimed to investigate distress levels among Italian physicians, nurses, rehabilitation professionals and healthcare assistants working in geriatric and long-term care services, and to explore the potential role of resilience as a protective resource. The General Health Questionnaire-12, the Connor-Davidson Resilience Scale, and a demographic survey were completed by 708 Italian HWs. Distress and resilience levels were compared between professionals through ANOVA; the contribution of sex, age, professional role, and resilience to distress was explored through regression analyses. Physicians reported significantly higher resilience and distress levels than rehabilitation professionals and healthcare assistants respectively. Women, HWs aged above 45, physicians, and participants reporting low resilience levels were at higher risk for distress. Findings suggest the importance of supporting HW’s resilience to counterbalance the pandemic related distress.

Mental Health Outcomes in Australian Healthcare and Aged-Care Workers during the Second Year of the COVID-19 Pandemic.
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McGuinness SL, Johnson J, Eades O, Cameron PA, Forbes A, Fisher J, et al.
International journal of environmental research and public health. 2022 Apr;19(9).
OBJECTIVE: the COVID-19 pandemic has incurred psychological risks for healthcare workers (HCWs). We established a Victorian HCW cohort (the Coronavirus in Victorian Healthcare and Aged-Care Workers (COVIC-HA) cohort study) to examine COVID-19 impacts on HCWs and assess organisational responses over time. METHODS: mixed-methods cohort study, with baseline data collected via an online survey (7 May-18 July 2021) across four healthcare settings: ambulance, hospitals, primary care, and residential aged-care. Outcomes included self-reported symptoms of depression, anxiety, post-traumatic stress (PTS), wellbeing, burnout, and resilience, measured using validated tools. Work and home-related COVID-19 impacts and perceptions of workplace responses were also captured. RESULTS: among 984 HCWs, symptoms of clinically significant depression, anxiety, and PTS were reported by 22.5%, 14.0%, and 20.4%, respectively, highest among paramedics and nurses. Emotional exhaustion reflecting moderate-severe burnout was reported by 65.1%. Concerns about contracting COVID-19 at work and transmitting COVID-19 were common, but 91.2% felt well-informed on workplace changes and 78.3% reported that support services were available. CONCLUSIONS: Australian HCWs employed during 2021 experienced adverse mental health outcomes, with prevalence differences observed according to occupation. Longitudinal evidence is needed to inform workplace strategies that support the physical and mental wellbeing of HCWs at organisational and state policy levels.

Care home managers’ views on the media coverage of COVID-19 outbreaks in care homes for older adults: A case study in Stockholm.
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Morath LP, Burström B, Liljas AEM.
International journal of older people nursing. 2022 Jun;e12483.
The COVID-19 pandemic has particularly affected older adults and resulted in high rates of infections and deaths in care homes. We have conducted a case study in which three managers of care homes for older adults in central Stockholm have shared their thoughts on the media coverage of care homes for older adults during the COVID-19 pandemic. We analysed the data using conventional content analysis and identified three themes and five categories. The results show that the managers experienced the media coverage of care homes during the pandemic to be negative and incomplete, causing feelings of sadness and shame amongst themselves and their staff. The negative media coverage further generated added workload as they had to arrange for discussions to answer questions by staff and close relatives of the residents. Informants also thought that there is a lack of knowledge about the role of care homes and subsequently what to expect of them. Finally, informants reported that the pandemic might create an opportunity for system-level policy changes. In light of this, we discuss possible victim blaming of staff and how greater public awareness of the care home sector could facilitate for a debate on policy changes and the low social status of caring for older adults.

Factors associated with satisfaction and depressed mood among nursing home workers during the covid-19 pandemic.
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Navarro-Prados AB, García-Tizón SJ, Meléndez JC, López J.
Journal of clinical nursing. 2022 Jun.
AIMS AND OBJECTIVES: This paper aims to examine the satisfaction and depressed mood experienced by nursing home workers during the COVID-19 pandemic and associated variables. Specifically, to analyse the factors that may contribute to nursing home workers developing adaptive behaviours that promote satisfaction or, on the contrary, show characteristics associated with a negative mood. BACKGROUND: Nursing homes have faced unprecedented pressures to provide appropriately skills to meet the demands of the coronavirus outbreak. DESIGN: A cross-sectional survey design using the STROBE checklist. METHODS: Professionals working in nursing homes (n = 165) completed an online survey measuring sociodemographic and professional characteristics, burnout, resilience, experiential avoidance, satisfaction with life and depression. Data were collected online from April to July 2021, the time in which Spain was experiencing its fifth wave of COVID-19. Two multiple linear regression models were performed to identify salient variables associated with depressive mood and satisfaction. RESULTS: Resilience, personal accomplishment and satisfaction had a significant and negative relationship with depression and emotional exhaustion, depersonalisation and experiential avoidance had a positive relationship with depression. However, emotional exhaustion, depersonalisation and experiential avoidance had a negative and significant relationship with satisfaction and personal accomplishment, and resilience had a positive and significant relationship with satisfaction. In addition, it was found that accepting thoughts and emotions when they occur is beneficial for developing positive outcomes such as satisfaction. CONCLUSIONS: Experiential avoidance was an important predictor of the effects that the COVID-19 pandemic can have on nursing home workers. RELEVANCE TO CLINICAL PRACTICE: Interventions focusing on resources that represent personal strengths, such as acceptance, resilience and personal accomplishment, should be developed. NO PATIENT OR PUBLIC CONTRIBUTION: The complex and unpredictable circumstances of COVID’s strict confinement in the nursing home prohibited access to the centres for external personnel and family members. Contact with the professionals involved could not be made in person but exclusively through online systems. However, professionals related to the work environment have subsequently valued this research positively as it analyses ‘How they felt during this complicated process’.

Mental Health of Caregivers Working in Nursing Homes during the COVID-19 Pandemic.
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Takahashi T, Ekoyama S, Tachikawa H, Midorikawa H, Shiratori Y, Ota M, et al.
Dementia and geriatric cognitive disorders. 2022 Jun.
INTRODUCTION: There have been numerous reports of cluster outbreaks of coronavirus disease 2019 (COVID-19) in hospitals and nursing homes. Healthcare workers fighting COVID-19 experience mental health issues. Caregivers in nursing homes experienced increased psychological distress and concern about deterioration of their mental health. We conducted a large-scale web-based survey exploring mental health among caregivers working in nursing homes during the COVID-19 pandemic with the aim of identifying their support needs. METHODS: Survey participants were caregivers working at 284 nursing homes in Ibaraki prefecture, Japan. The survey period was from September 2020 to March 2021. Participants responded to a questionnaire covering gender, age, occupation, infections at facilities, infection protection, changes in nursing home users, cooperation with other medical institutions, and prejudice/discrimination. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate participants’ depression and anxiety. RESULTS: In total, 676 participants completed the survey; 350 (52.5%) were with anxiety symptoms and 378 (56.7%) were with depressive symptoms (scores exceeding the HADS cut-off points). The risk for anxiety was associated with being care worker or social worker. The risk of anxiety or depression was high when family caregivers’ mental state changed. DISCUSSION/CONCLUSION: This study found that caregivers working in nursing homes were exposed to high levels of stress during the COVID-19 pandemic and were at high risk for developing depression and anxiety.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021
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Tunalilar O.
Journal of the American Medical Directors Association. 2022 Jun.
The impact of the COVID-19 pandemic on residents and staff of assisted living and residential care (AL/RC) facilities has been sizable, yet little is known about how the pandemic affected their administrators and their job stability. Considering the crucial role that administrators play in the delivery of high-quality care and staffing in residential long-term settings, this research letter describes the turnover experience among Oregon AL/RC administrators and its organizational and structural correlates during the first year of the COVID-19 pandemic (March 2020–February 2021).

Impact on Health Care Workers

The mental health impact of the COVID-19 pandemic on Canadian critical care nurses.
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Crowe S, Fuchsia Howard A, Vanderspank B.
Intensive & critical care nursing. 2022 Aug;71:103241.
OBJECTIVE: Focusing on Canadian critical care nurses (CCNs), the study objectives were to examine the impact of the COVID-19 pandemic on: mental health, quality of work life, and intent to stay in their current positions. RESEARCH DESIGN: Mixed-methods study using an online cross-sectional survey and integration of closed- and open-ended survey data. SETTING: Canadian CCNs working in an intensive care unit, high acuity unit, or intensive care step-down unit during the COVID-19 pandemic between May 2021 to June 2021. MAIN OUTCOME MEASURES: The survey consisted of four instruments: (1) the impact of event scale – revised, (2) the depression, anxiety, and stress scale, (3) the professional quality of life scale, and (4) intent to turnover tool, as well as one optional open-ended question. RESULTS: From across Canada, 425 CCNs responded. The large majority reported symptoms of post traumatic stress disorder (74%), depression (70%), anxiety (57%), and stress (61%). All (100%) reported moderate to high burnout, 87% were suffering from signs of secondary traumatic stress, and 22% intended to quit their current employment. Qualitative analysis of written comments submitted by 147 (34.5%) of the respondents depicted an immense mental health toll on CCNs that stemmed from 1) failed leadership and 2) the traumatic nature of the work environment, that led to 3) a sense of disillusionment, defeat, and an intent to leave. CONCLUSION: The mental health toll of the pandemic has been significant for Canadian CCNs and highlights the urgent need for individual supports and systems level changes.

You can’t walk through water without getting wet’ UK nurses’ distress and psychological health needs during the Covid-19 pandemic: A longitudinal interview study.
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Maben J, Conolly A, Abrams R, Rowland E, Harris R, Kelly D, et al. “
International journal of nursing studies. Impact of Covid On Nurses (ICON) Survey Research Group; 2022. p. 104242.
BACKGROUND: Pre-COVID-19 research highlighted the nursing profession worldwide as being at high risk from symptoms of burnout, post-traumatic stress disorder (PTSD) and suicide. The World Health Organization declared a pandemic on 11th March 2020 due to the sustained risk of further global spread of COVID-19. The high healthcare burden associated with COVID-19 has increased nurses’ trauma and workload, thereby exacerbating pressure on an already strained workforce and causing additional psychological distress for staff. OBJECTIVES: The Impact of COVID-19 on Nurses (ICON) interview study examined the impacts of the pandemic on frontline nursing staff’s psychosocial and emotional wellbeing. DESIGN: Longitudinal qualitative interview study. SETTINGS: Nurses who had completed time 1 and 2 of the ICON survey were sampled to include a range of UK work settings including acute, primary and community care and care homes. Interviewees were purposively sampled for maximum variation to cover a broad range of personal and professional factors, and experiences during the COVID-19 pandemic, including redeployment. METHODS: Nurses participated in qualitative in-depth narrative interviews after the first wave of COVID-19 in July 2020 (n = 27) and again at the beginning of the second wave in December 2020 (n = 25) via video and audio platform software. Rigorous qualitative narrative analysis was undertaken both cross-sectionally (within wave) and longitudinally (cross wave) to explore issues of consistency and change. RESULTS: The terms moral distress, compassion fatigue, burnout and PTSD describe the emotional states reported by the majority of interviewees leading many to consider leaving the profession. Causes of this identified included care delivery challenges; insufficient staff and training; PPE challenges and frustrations. Four themes were identified: (1) ‘Deathscapes’ and impoverished care (2) Systemic challenges and self-preservation (3) Emotional exhaustion and (4) (Un)helpful support. CONCLUSIONS: Nurses have been deeply affected by what they have experienced and report being forever altered with the impacts of COVID-19 persisting and deeply felt. There is an urgent need to tackle stigma to create a psychologically safe working environment and for a national COVID-19 nursing workforce recovery strategy to help restore nurse’s well-being and demonstrate a valuing of the nursing workforce and therefore support retention.