COVID-19 and Long Term Care

Collection of articles on COVID and LTC is available here

COVID-19 and Resident Care

Technology Recommendations to Support Person-Centered Care in Long-Term Care Homes during the COVID-19 Pandemic and Beyond.
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Chu CH, Ronquillo C, Khan S, Hung L, Boscart V.
J Aging Soc Policy 2021;33(4-5):539-554.
The COVID-19 pandemic has exposed persistent inequities in the long-term care sector and brought strict social/physical distancing distancing and public health quarantine guidelines that inadvertently put long-term care residents at risk for social isolation and loneliness. Virtual communication and technologies have come to the forefront as the primary mode for residents to maintain connections with their loved ones and the outside world; yet, many long-term care homes do not have the technological capabilities to support modern day technologies. There is an urgent need to replace antiquated technological infrastructures to enable person-centered care and prevent potentially irreversible cognitive and psychological declines by ensuring residents are able to maintain important relationships with their family and friends. To this end, we provide five technological recommendations to support the ethos of person-centered care in residential long-term care homes during the pandemic and in a post-COVID-19 pandemic world.

Absence of COVID-19 Disease Among Chronically Ventilated Nursing Home Patients.
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Gomolin IH, Krichmar G, Siskind D, Divers J, Polsky B.
Journal of the American Medical Directors Association 2021 oct.
Objective To describe the experience of COVID-19 disease among chronically ventilated and non-ventilated nursing home patients living in three separate nursing homes.

Comorbidity-adjusted NEWS predicts mortality in suspected patients with COVID-19 from nursing homes: Multicentre retrospective cohort study.
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Martin-Rodriguez F, Sanz-Garcia A, Melero Guijarro Laura, Ortega GJ, Gomez-Escolar Perez Marta, Castro Villamor Miguel A, et al.
J Adv Nurs 2021 sep.
AIMS: To assess the prognostic accuracy of comorbidity-adjusted National Early Warning Score in suspected Coronavirus disease 2019 patients transferred from nursing homes by the Emergency Department. DESIGN: Multicentre retrospective cohort study. METHODS: Patients transferred by high-priority ambulances from nursing homes to Emergency Departments with suspected severe acute respiratory syndrome coronavirus 2 infection, from March 12 to July 31 2020, were considered. Included variables were: clinical covariates (respiratory rate, oxygen saturation, systolic blood pressure, heart rate, temperature, level of consciousness and supplemental oxygen use), the presence of comorbidities and confirmatory analytical diagnosis of severe acute respiratory syndrome coronavirus 2 infection. The primary outcome was a 2-day mortality rate. The discriminatory capability of the National Early Warning Score was assessed by the area under the receiver operating characteristic curve in two different cohorts, the validation and the revalidation, which were randomly selected from the main cohort. RESULTS: A total of 337 nursing homes, 10 advanced life support units, 51 basic life support units and 8 hospitals in Spain entailing 1,324 patients (median age 87 years) was involved in this study. Two-day mortality was 11.5% (152 cases), with a positivity rate of severe acute respiratory syndrome coronavirus 2 of 51.2%, 77.7% of hospitalization from whom 1% was of intensive care unit admission. The National Early Warning Score results for the revalidation cohort presented an AUC of 0.771, and of 0.885, 0.778 and 0.730 for the low-, medium- and high-level groups of comorbidities. CONCLUSION: The comorbidity-adjusted National Early Warning Score provides a good short-term prognostic criterion, information that can help in the decision-making process to guide the best strategy for each older adult, under the current pandemic. IMPACT: What problem did the study address? Under the current coronavirus disease 2019 pandemic, targeting older adults at high risk of deterioration in nursing homes remains challenging. What were the main findings? Comorbidity-adjusted National Early Warning Score helps to forecast the risk of clinical deterioration more accurately. Where and on whom will the research have impact? A high NEWS, with a low level of comorbidity is associated with optimal predictive performance, making these older adults likely to benefit from continued follow up and potentially hospital referral under the current coronavirus disease 2019 pandemic.

We Are Saving Their Bodies and Destroying Their Souls.”: Family Caregivers’ Experiences of Formal Care Setting Visitation Restrictions during the COVID-19 Pandemic.
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Nash WA, Harris LM, Heller KE, Mitchell BD.
J Aging Soc Policy 2021;33(4-5):398-413.
This study aims to explore the experiences of family caregivers during the COVID-19 pandemic-imposed visitation restrictions at formal care settings (FCS) such as assisted living centers and traditional nursing homes. Participants (N = 512) were recruited from an international caregiving social media site that was developed at the beginning of the COVID-19 pandemic. Descriptive data was collected on the family caregivers, the care recipient and facility. Respondents also provided a single feeling word describing their experience and an open-ended question allowed for further exploration. Caregivers were predominantly daughters (n = 375). The most common reported feeling words were sadness (n = 200), trauma (n = 108), anger (n = 65), frustration (n = 56), helplessness (n = 50), and anxiety (n = 36). Thematic analysis revealed four overarching themes: 1) isolation 2) rapid decline 3) inhumane care and 4) lack of oversight. This study highlights the importance of addressing the mental, emotional and physical needs of both care recipient and family caregiver during this challenging time. Caregiver visitation policy reform that includes the care recipient and family caregiver is also discussed.

Management of COVID-19 in a French Nursing Home: Experiences from a Multidisciplinary Mobile Team.
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Poupin P, N’Diaye D, Chaumier F, Lemaignen A, Bernard L, Foug\`ere B.
The Journal of frailty & aging 2021;10(4):363-366.
BACKGROUND: Long-term residential care facilities and nursing homes are known to be particularly vulnerable to viral respiratory diseases and have expressed the need for multidisciplinary collaboration to help manage outbreaks when they occur. METHOD: In April 2020, Tours University Medical Center created a multidisciplinary mobile team to help local nursing homes deal with outbreaks of coronavirus disease 2019 (COVID-19). The team included a geriatrician, infectious disease experts, and palliative care specialists. RESULTS: On April 8th, 2020, the first intervention took place in a 100 residents nursing home with a total of 18 confirmed cases among 26 symptomatic residents and five deaths. The nursing home staffs’ main requests were a multidisciplinary approach, consensus decision-making, and the dissemination of information on disease management. CONCLUSION: Three lessons emerged from this collaboration: (i) intensify collaborations between hospitals and nursing homes, (ii) limit disease transmission through the use of appropriate hygiene measures, broad screening, and the isolation of sick residents and sick employees, and (iii) provide sufficient human resources.

Rapid Changes in the Provision of Rehabilitation Care in Post-Acute and Long-Term Care Settings During the COVID-19 Pandemic.
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Reddy A, Resnik L, Freburger J, Ciolek DE, Gifford DR, Whitten MJ, et al.
Journal of the American Medical Directors Association 2021 aug.
OBJECTIVES: Little is known about how the COVID-19 pandemic has affected rehabilitation care in post-acute and long-term care. As part of a process to assess research priorities, we surveyed professionals in these settings to assess the impact of the pandemic and related research needs. DESIGN: Qualitative analysis of open-ended survey results. SETTING AND PARTICIPANTS: 30 clinical and administrative staff working in post-acute and long-term care. METHODS: From June 24 through July 10, 2020, we used professional connections to disseminate an electronic survey to a convenience sample of clinical and administrative staff. We conducted an inductive thematic analysis of the data. RESULTS: We identified 4 themes, related to (1) rapid changes in care delivery, (2) negative impact on patients’ motivation and physical function, (3) new access barriers and increased costs, and (4) uncertainty about sustaining changes in delivery and payment. Rapid changes: Respondents described how infection control policies and practices shifted rehabilitation from group sessions and communal gyms to the bedside and telehealth. Negative impact: Respondents felt that patients’ isolation, particularly in residential care settings, affected their motivation for rehabilitation and their physical function. Access and costs: Respondents expressed concerns about increased costs (eg, for personal protective equipment) and decreased patient volume, as well as access issues. Uncertainty: At the same time, respondents described how telehealth and Medicare waivers enabled new ways to connect with patients and wondered whether waivers would be extended after the public health emergency. CONCLUSIONS AND IMPLICATIONS: Survey results highlight rapid changes to rehabilitation in post-acute and long-term care during the height of the COVID-19 pandemic. Because staff vaccine coverage remains low and patients vulnerable in residential care settings, changes such as infection precautions are likely to persist. Future research should evaluate the impact on care, outcomes, and costs.

Dementia and Parkinson’s Disease: Risk Factors for 30-Day Mortality in Nursing Home Residents with COVID-19.
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Rutten JJS, van Kooten J, van Loon AM, van Buul LW, Joling KJ, Smalbrugge M, et al.
Journal of Alzheimer’s disease : JAD 2021 sep.
BACKGROUND: The COVID-19 pandemic has led to high mortality rates in nursing homes (NHs) in Europe. For adequate risk management and good prognostications, it is essential to identify mortality risk factors. OBJECTIVE: This study aimed to determine whether previously identified risk factors for 30-day mortality in Dutch NH residents with COVID-19 are unique to COVID-19. METHODS: In this cohort study, we included 1,294 NH residents with COVID-19 (cases) and 17,999 NH residents without COVID-19 (controls, from the pre-COVID-19 period). We used descriptive statistics and Cox proportional hazard models to compare mortality rates in residents with and without COVID-19, categorized by risk factors. RESULTS: Cases had a more than 18 times higher hazard of death within 30 days compared to controls (HR 18, 95%CI: 16-20). For residents with COVID-19, being male, having dementia, and having Parkinson’s disease (PD) were all associated with a higher 30-day mortality (HR 1.8 versus 1.3 versus 1.7). Being male was also associated with a higher mortality (HR 1.7) in the control group, whereas having dementia and PD were not. COVID-19 symptomatology was very similar for residents with and without dementia or PD, except for delirium and malaise which was more frequent in residents with dementia. CONCLUSION: Dementia and PD were significant additional risk factors for mortality in Dutch NH residents with COVID-19, whereas male gender was not unique to residents with COVID-19. The frailty of PD and dementia in NH residents with COVID-19 are relevant to consider in prognostication, communication, and care planning with residents and their families.

Quality Improvement

COVID-19 Vaccine Uptake Among Residents and Staff Members of Assisted Living and Residential Care Communities-Pharmacy Partnership for Long-Term Care Program, December 2020-April 2021.
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Gharpure R, Yi SH, Li R, Jacobs Slifka Kara M, Tippins A, Jaffe A, et al.
Journal of the American Medical Directors Association 2021 oct;22(10):2016-2020.e2.
OBJECTIVES: In December 2020, CDC launched the Pharmacy Partnership for Long-Term Care Program to facilitate COVID-19 vaccination of residents and staff in long-term care facilities (LTCFs), including assisted living (AL) and other residential care (RC) communities. We aimed to assess vaccine uptake in these communities and identify characteristics that might impact uptake. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: AL/RC communities in the Pharmacy Partnership for Long-Term Care Program that had ≥1 on-site vaccination clinic during December 18, 2020-April 21, 2021. METHODS: We estimated uptake using the cumulative number of doses of COVID-19 vaccine administered and normalizing by the number of AL/RC community beds. We estimated the percentage of residents vaccinated in 3 states using AL census counts. We linked community vaccine administration data with county-level social vulnerability index (SVI) measures to calculate median vaccine uptake by SVI tertile. RESULTS: In AL communities, a median of 67 residents [interquartile range (IQR): 48-90] and 32 staff members (IQR: 15-60) per 100 beds received a first dose of COVID-19 vaccine at the first on-site clinic; in RC, a median of 8 residents (IQR: 5-10) and 5 staff members (IQR: 2-12) per 10 beds received a first dose. Among 3 states with available AL resident census data, median resident first-dose uptake at the first clinic was 93% (IQR: 85-108) in Connecticut, 85% in Georgia (IQR: 70-102), and 78% (IQR: 56-91) in Tennessee. Among both residents and staff, cumulative first-dose vaccine uptake increased with increasing social vulnerability related to housing type and transportation. CONCLUSIONS AND IMPLICATIONS: COVID-19 vaccination of residents and staff in LTCFs is a public health priority. On-site clinics may help to increase vaccine uptake, particularly when transportation may be a barrier. Ensuring steady access to COVID-19 vaccine in LTCFs following the conclusion of the Pharmacy Partnership is critical to maintaining high vaccination coverage among residents and staff.

The promise of transformed long-term care homes: Evidence
from the pandemic.

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Power GA, Carson J.
Healthcare management forum 2021 sep:8404704211037794.
A combination of factors during the SARS-CoV-2 pandemic led to a disproportionately high mortality rate among residents of long-term care homes in Canada and around the globe. Retrospectively, some of these factors could have been avoided or minimized. Many infection control approaches recommended by public health experts and regulators, while well intended to keep people safe from disease exposure, threatened other vital aspects of health and well-being. Furthermore, focusing narrowly on infection control practices does not address longstanding operational and infrastructural factors that contributed significantly to the pandemic toll. In this article, we review traditional (ie institutional) long-term care practices that were associated with increased risk during the pandemic and highlight one transformational model (the Green House Project) that worked well to protect the lives and livelihood of people within congregate care settings. Drawing on this evidence, we identify specific strategies for necessary and overdue improvements in long-term care homes.

Prevalence and Spread

Care-home outbreaks of COVID-19 in Scotland March to May 2020: National linked data cohort analysis.
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Burton JK, McMinn M, Vaughan JE, Fleuriot J, Guthrie B.
Age Ageing 2021 sep;50(5):1482-1492.

BACKGROUND: understanding care-home outbreaks of COVID-19 is a key public health priority in the ongoing pandemic to help protect vulnerable residents. OBJECTIVE: to describe all outbreaks of COVID-19 infection in Scottish care-homes for older people between 01/03/2020 and 31/03/2020, with follow-up to 30/06/2020. DESIGN AND SETTING: National linked data cohort analysis of Scottish care-homes for older people. METHODS: data linkage was used to identify outbreaks of COVID-19 in care-homes. Care-home characteristics associated with the presence of an outbreak were examined using logistic regression. Size of outbreaks was modelled using negative binomial regression. RESULTS: 334 (41%) Scottish care-homes for older people experienced an outbreak, with heterogeneity in outbreak size (1-63 cases; median = 6) and duration (1-94 days, median = 31.5 days). Four distinct patterns of outbreak were identified: ‘typical’ (38% of outbreaks, mean 11.2 cases and 48 days duration), severe (11%, mean 29.7 cases and 60 days), contained (37%, mean 3.5 cases and 13 days) and late-onset (14%, mean 5.4 cases and 17 days). Risk of a COVID-19 outbreak increased with increasing care-home size (for ≥90 beds vs <20, adjusted OR = 55.4, 95% CI 15.0-251.7) and rising community prevalence (OR = 1.2 [1.0-1.4] per 100 cases/100,000 population increase). No routinely available care-home characteristic was associated with outbreak size. CONCLUSIONS: reducing community prevalence of COVID-19 infection is essential to protect those living in care-homes. More systematic national data collection to understand care-home residents and the homes in which they live is a priority in ensuring we can respond more effectively in future.


Investigation of an Outbreak of COVID-19 in a French Nursing Home With Most Residents Vaccinated.
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Burugorri-Pierre C, Lafuente-Lafuente C, Oasi C, Lecorche E, Pariel S, Donadio C, et al.
JAMA network open 2021 sep;4(9):e2125294.
This cohort study investigates an outbreak of COVID-19 among residents and health care professionals in a French nursing home in which most residents were fully vaccinated against COVID-19.

Trends in COVID‐19 death rates by racial composition of nursing homes
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Gilman M, Bassett MT.
J Am Geriatr Soc 2021 sep;69(9):2442-2444.
Coronavirus disease 2019 (COVID-19) has taken a severe toll on US nursing homes, which accounted for more than one-third of all COVID-19 deaths in the United States in 2020. Nursing homes with low proportions of white residents accounted for a disproportionate share of these deaths through mid-September 2020. We examine trends in COVID-19 death rates by racial composition of nursing homes through mid-April 2021.

Analysis of social interactions and risk factors relevant to the spread of infectious diseases at hospitals and nursing homes.
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Huttel FB, Iversen A, Bo Hansen Marco, Kjaer Ersboll Bjarne, Ellermann-Eriksen S, Lundtorp Olsen Niels.
PloS one 2021;16(9):e0257684.
Ensuring the safety of healthcare workers is vital to overcome the ongoing COVID-19 pandemic. We here present an analysis of the social interactions between the healthcare workers at hospitals and nursing homes. Using data from an automated hand hygiene system, we inferred social interactions between healthcare workers to identify transmission paths of infection in hospitals and nursing homes. A majority of social interactions occurred in medication rooms and kitchens emphasising that health-care workers should be especially aware of following the infection prevention guidelines in these places. Using epidemiology simulations of disease at the locations, we found no need to quarantine all healthcare workers at work with a contagious colleague. Only 14.1% and 24.2% of the health-care workers in the hospitals and nursing homes are potentially infected when we disregard hand sanitization and assume the disease is very infectious. Based on our simulations, we observe a 41% and 26% reduction in the number of infected healthcare workers at the hospital and nursing home, when we assume that hand sanitization reduces the spread by 20% from people to people and 99% from people to objects. The analysis and results presented here forms a basis for future research to explore the potential of a fully automated contact tracing systems.

Beta SARS-CoV-2 variant and BNT162b2 vaccine effectiveness in long-term care facilities in France
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Lefevre B, Tondeur L, Madec Y, Grant R, Lina B, van der Werf S, et al.
The Lancet Healthy Longevity 2021 sep.
Variants of SARS-CoV-2 have emerged that are more transmissible than the original virus or that exhibit some properties of immune escape, or both. The beta (B.1.351) variant has shown abrogated neutralising capacity1 and has circulated widely in eastern France in the first months of 2021. As residents of long-term care facilities are at high risk of severe COVID-19, we did a retrospective cohort study from Jan 15 to May 19, 2021, in eastern France to assess the association between BNT162b2 mRNA vaccination (Pfizer-BioNTech) and incidence of infection with the beta variant among residents of long-term care facilities.

Comparison of antigen- and RT-PCR-based testing strategies for detection of SARS-CoV-2 in two high-exposure settings.
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Love J, Wimmer MT, Toth DJA, Chandran A, Makhija D, Cooper CK, et al.
PloS one 2021;16(9):e0253407.
Surveillance testing for infectious disease is an important tool to combat disease transmission at the population level. During the SARS-CoV-2 pandemic, RT-PCR tests have been considered the gold standard due to their high sensitivity and specificity. However, RT-PCR tests for SARS-CoV-2 have been shown to return positive results when performed to individuals who are past the infectious stage of the disease. Meanwhile, antigen-based tests are often treated as a less accurate substitute for RT-PCR, however, new evidence suggests they may better reflect infectiousness. Consequently, the two test types may each be most optimally deployed in different settings. Here, we present an epidemiological model with surveillance testing and coordinated isolation in two congregate living settings (a nursing home and a university dormitory system) that considers test metrics with respect to viral culture, a proxy for infectiousness. Simulations show that antigen-based surveillance testing coupled with isolation greatly reduces disease burden and carries a lower economic cost than RT-PCR-based strategies. Antigen and RT-PCR tests perform different functions toward the goal of reducing infectious disease burden and should be used accordingly.

Aerosol SARS-CoV-2 in hospitals and long-term care homes during the COVID-19 pandemic.
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Mallach G, Kasloff SB, Kovesi T, Kumar A, Kulka R, Krishnan J, et al.
PloS one 2021;16(9):e0258151.
BACKGROUND: Few studies have quantified aerosol concentrations of SARS-CoV-2 in hospitals and long-term care homes, and fewer still have examined samples for viability. This information is needed to clarify transmission risks beyond close contact. METHODS: We deployed particulate air samplers in rooms with COVID-19 positive patients in hospital ward and ICU rooms, rooms in long-term care homes experiencing outbreaks, and a correctional facility experiencing an outbreak. Samplers were placed between 2 and 3 meters from the patient. Aerosol (small liquid particles suspended in air) samples were collected onto gelatin filters by Ultrasonic Personal Air Samplers (UPAS) fitted with <2.5μm (micrometer) and <10 μm size-selective inlets operated for 16 hours (total 1.92m3), and with a Coriolis Biosampler over 10 minutes (total 1.5m3). Samples were assayed for viable SARS-CoV-2 virus and for the viral genome by multiplex PCR using the E and N protein target sequences. We validated the sampling methods by inoculating gelatin filters with viable vesicular stomatitis virus (VSV), and with three concentrations of viable SARS-CoV-2, operating personal samplers for 16hrs, and quantifying viable virus recovery by TCID50 assay. RESULTS: In total, 138 samples were collected from 99 rooms. RNA samples were positive in 9.1% (6/66) of samples obtained with the UPAS 2.5μm samplers, 13.5% (7/52) with the UPAS 10μm samplers, and 10.0% (2/20) samples obtained with the Coriolis samplers. Culturable virus was not recovered in any samples. Viral RNA was detected in 15.1% of the rooms sampled. There was no significant difference in viral RNA recovery between the different room locations or samplers. Method development experiments indicated minimal loss of SARS-CoV-2 viability via the personal air sampler operation.

Single Dose of an mRNA Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Cov-2) Vaccine Is Associated With Lower Nasopharyngeal Viral Load Among Nursing Home Residents With Asymptomatic Coronavirus Disease 2019 (COVID-19).
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McEllistrem MC, Clancy CJ, Buehrle DJ, Lucas A, Decker BK.
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2021 sep;73(6):e1365-e1367.
In nursing home residents with asymptomatic COVID-19 diagnosed through twice-weekly surveillance testing, single-dose BNT162b2 vaccination (Pfizer-BioNTech) was associated with -2.4 mean log10 lower nasopharyngeal viral load than detected in absence of vaccination (P = .004). Since viral load is linked to transmission, single-dose mRNA SARS-CoV-2 vaccination may help control outbreaks.

Association of Nursing Home Characteristics With Staff and Resident COVID-19 Vaccination Coverage.
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McGarry BE, Shen K, Barnett ML, Grabowski DC, Gandhi AD.
JAMA internal medicine 2021 sep.
This cross-sectional study examines associations of nursing home characteristics with COVID-19 vaccination rates among nursing home staff and residents.

Comparison of Dried Blood Spots and Venous Blood for the Detection of SARS-CoV-2 Antibodies in a Population of Nursing Home Residents.
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Meyers E, Heytens S, Formukong A, Vercruysse H, De Sutter An, Geens T, et al.
Microbiology spectrum 2021 sep:e0017821.
In the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, testing for SARS-CoV-2-specific antibodies is paramount for monitoring immune responses in postauthorization vaccination and seroepidemiological studies. However, large-scale and iterative serological testing by venipuncture in older persons can be challenging. Capillary blood sampling using a finger prick and collection on protein saver cards, i.e., dried blood spots (DBSs), has already proven to be a promising alternative. However, elderly persons have reduced cutaneous microvasculature, which may affect DBS-based antibody testing. Therefore, we aimed to evaluate the performance of DBS tests for the detection of SARS-CoV-2 antibodies among nursing homes residents. We collected paired venous blood and DBS samples on two types of protein saver cards (Whatman and EUROIMMUN) from nursing home residents, as well as from staff members as a reference population. Venous blood samples were analyzed for the presence of SARS-CoV-2 IgG antibodies using the Abbott chemiluminescent microparticle immunoassay (CMIA). DBS samples were analyzed by the EUROIMMUN enzyme-linked immunosorbent assay (ELISA) for SARS-CoV-2 IgG antibodies. We performed a statistical assessment to optimize the ELISA cutoff value for the DBS testing using Youden’s J index. A total of 273 paired DBS-serum samples were analyzed, of which 129 were positive, as assessed by the reference test. The sensitivities and specificities of DBS testing ranged from 95.0% to 97.1% and from 97.1% to 98.8%, respectively, depending on the population (residents or staff members) and the DBS card type. Therefore, we found that DBS sampling is a valid alternative to venipuncture for the detection of SARS-CoV-2 antibodies among elderly subjects. IMPORTANCE Since the implementation of newly developed SARS-CoV-2 vaccines in the general population, serological tests are of increasing importance. Because DBS samples can be obtained with a finger prick and can be shipped and stored at room temperature, they are optimal for use in large-scale SARS-CoV-2 serosurveillance or postauthorization vaccination studies, even in an elderly study population.

Neutralizing antibodies directed against SARS‐CoV‐2 in a population residing in a nursing home and a long‐term care unit
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Moyet J, Helle F, Bourdenet G, Joseph C, Gubler B, Brochot E, et al.
Geriatrics & Gerontology International 2021 oct.
Following the first COVID-19 outbreak, in June 2020, a French university hospital organized a screening campaign at the heart of its (NHs) and (LTCUs). This campaign consisted of testing using Reverse Transcription – Polymerase Chain Reaction (RT-PCR) nasopharyngeal tests and ELISA (enzyme-linked-immuno-sorbent-assay) serological techniques that involved qualitative serological tests that detected antibodies against the SARS-CoV-2 nucleocapsid (Abbott Alinity SARS-Cov-2 IgG assay) and against the spike protein (Wantai SARS-CoV-2 Ab ELISA). Among the 221 patients screened, 147 (66.5%) showed seroconversion against SARS-CoV-2. A disparity between the two structure was found, with 88.7% seroconversion in the NH versus 45.6% seroconversion in the LTCU (P < 0.001).

Outbreaks of COVID-19 in Nursing Homes: A Cross-Sectional Survey of 74 Nursing Homes in a French Area.
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Piet E, Maillard A, Mallaval FO, Dusseau JY, Galas-Haddad M, Ducki S, et al.
Journal of clinical medicine 2021 sep;10(18).
In this multi-centric cross-sectional survey conducted in nursing homes of the French Alps, from 1 March to 31 May 2020, we analyze the relationship between the occurrence of an outbreak of COVID 19 among residents and staff members. Out of 225 eligible nursing homes, 74 (32.8%) completed the survey. Among 5891 residents, the incidence of confirmed or probable COVID-19 was 8.2% (95CI, 7.5% to 8.9%), and 22 (29.7%) facilities had an outbreak with at least 3 cases. Among the 4652 staff members, the incidence of confirmed or probable COVID-19 was 6.3% (95CI, 5.6% to 7.1%). A strong positive correlation existed between residents and staff members for both numbers of cases (r(2) = 0.77, p < 0.001) and the incidence (r(2) = 0.76, p < 0.001). In univariate analyses, cases among the staff were the only factor associated with the occurrence of an outbreak among residents (OR = 11.2 (95CI, 2.25 to 53.6)). In bivariate analysis, this relationship was not influenced by any nursing home characteristics, nor the action they implemented to mitigate the COVID-19 crisis. Staff members were, therefore, likely to be a source of contamination and spread of COVID-19 among nursing home residents during the first wave of the pandemic.

Impact on Long Term Care Workers

Analysis of COVID-19 in Professionals Working in Geriatric Environment: Multicenter Prospective Study.
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Mihai A, Barben J, Dipanda M, Vovelle J, Nuss V, Baudin-Senegas C, et al.
International journal of environmental research and public health 2021 sep;18(18).
Healthcare workers (HCWs) are exposed to a higher risk of coronavirus disease (COVID-19) contamination. This prospective multicenter study describes the characteristics of HCWs tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) while working in a geriatric environment. We also compared HCWs with a positive reverse transcription polymerase chain reaction (RTPCR) assay (RTPCR+ group) and those with a negative test result (RTPCR- group). Between 15/5/2020 and 15/9/2020, 258 HCWs, employed in the acute geriatric unit (AGU), geriatric rehabilitation unit (GRU) or nursing home of three hospitals in Burgundy (France) were invited to complete an online survey. Among the 171 respondents, 83 participants, with mean age 42 years and 87.9% female, were tested for SARS-CoV-2 infection. Among these 83 participants, COVID-19 was confirmed in 38 cases (RTPCR+ group) of which 36 were symptomatic, and the RTPCR assay was negative in 45 cases (RTPCR- group) of which 20 participants were symptomatic. A total of 22.9% (of 83) had comorbidities, 21.7% were active smokers, and 65.1% had received the flu vaccine. A total of 37.3% worked in AGU, 19.3% in GRU and 16.9% in nursing homes. The most common symptom described was headache (23.2%), followed by fatigue or cough (12.5% each), and fever or myalgia (10.7% each). There were more participants with normal body mass index (p = 0.03) in the RTPCR+ group. In contrast, there were more users of non-steroidal anti-inflammatory drugs (p = 0.01), active smokers (p = 0.03) and flu vaccinated (p = 0.01) in the RTPCR- group. No difference was found between the two groups for the type of work (p = 0.20 for physicians and p = 0.18 for nurses). However, acquiring COVID-19 was significantly associated with working in AGU (p < 0.001) and nursing homes (p = 0.001). There were significantly more users of surgical masks (p = 0.035) in the RTPCR+ group and more filtering facepiece-2 mask users (p = 0.016) in the RTPCR- group. Our results reflect the first six months of the COVID-19 pandemic in France. Further studies are needed to evaluate and track the risks and consequences of COVID-19 in HCWs.

Assessing the impact of COVID-19 on healthcare staff at a combined elderly care and specialist palliative care facility: A cross-sectional study.
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Nestor S, O’ Tuathaigh Colm, O’ Brien Tony.
Palliat Med 2021 sep;35(8):1492-1501.
BACKGROUND: In the pre-COVID-19 era, healthcare professionals experienced stress and burnout. The international literature confirms that COVID-19 placed significant additional burdens on healthcare workers. AIM: To describe and characterise the magnitude and variety of ways in which the COVID-19 pandemic affected the personal, social and professional lives of healthcare workers representing several multidisciplinary specialties in a fully-integrated palliative and elderly care service. DESIGN: All staff were invited to complete an anonymised standardised questionnaire evaluating the impact of COVID-19 across a diverse range of domains. The study was conducted over a 6-week period commencing 11 September 2020. SETTING: The setting incorporates two distinct but integrated services operating under a single management structure in Ireland: (i) Specialist palliative care across hospice (44 beds), community and hospitals and (ii) Elderly Care Service (long-term and respite care) delivered in a 63-bed inpatient unit. RESULTS: 250 respondents (69.8%) completed the questionnaire. Nurses and healthcare assistants comprised the majority of respondents (60%) and other disciplines were represented proportionately. 230 participants (92%) agreed that their personal workload had changed significantly in response to COVID-19 and 182 (72.8%) agreed that their responsibilities had increased. 196 (78.4%) reported greater work-related stress. Highest-rated sources of stress included fear of contracting COVID-19 or transmitting it to friends/family, interacting with isolated frail/dying patients, changes to workplace protocols and reduced social interaction with colleagues. CONCLUSIONS: This study demonstrates the profound impact of COVID-19 on personal and professional wellbeing of staff. The greatest burden was carried by those providing prolonged, direct and intimate patient care.

Impact on Health Care Workers

Posttraumatic growth among health care workers on the frontlines of the COVID-19 pandemic.
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Feingold JH, Hurtado A, Feder A, Peccoralo L, Southwick SM, Ripp J, et al.
J Affect Disord 2021 sep;296:35-40.
BACKGROUND: The COVID-19 pandemic has led to significant mental health consequences for frontline health care workers (FHCWs). However, no known study has examined the prevalence, determinants, or correlates of posttraumatic growth (PTG) in this population. METHODS: Data were analyzed from a prospective cohort of FHCWs at an urban tertiary care hospital in New York City (NYC). Assessments were conducted during the spring 2020 pandemic peak (Wave 1) and seven months later (Wave 2). Multivariable logistic regression analyses were conducted to identify Wave 1 sociodemographic, occupational, and psychosocial factors associated with PTG at Wave 2, and the association between aspects of PTG with burnout and pandemic-related PTSD symptoms at Wave 2. RESULTS: A total 76.8% of FHCWs endorsed moderate or greater PTG; the most prevalent domains were increased appreciation of life (67.0%), improved relationships (48.7%), and greater personal strength (44.1%). Non-White race/ethnicity, greater levels of positive emotions, pandemic-related PTSD symptoms, dispositional gratitude, and feelings of inspiration were independently associated with PTG. At Wave 2, endorsement of spiritual growth during the pandemic was associated with 52% and 44% lower odds of screening positive for pandemic-related PTSD symptoms and burnout, respectively; greater improvement in relationships was associated with 36% lower odds of screening positive for burnout. LIMITATIONS: Single institution study and use of self-report instruments. CONCLUSIONS: Nearly 4-of-5 FHCWs report pandemic-related PTG, driven largely by salutogenic factors assessed during the pandemic surge. Interventions to bolster these factors may help promote PTG and mitigate risk for burnout and pandemic-related PTSD symptoms in this population.

If I die, they do not care”: U.K. National Health Service staff experiences of betrayal-based moral injury during COVID-19.
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French L, Hanna P, Huckle C.
Psychological trauma : theory, research, practice and policy 2021 sep.
OBJECTIVE: The COVID-19 pandemic brought unparalleled pressure, stress, and a dramatic change in practice to health care systems across the world. National Health Service (NHS) staff have reported higher levels of burnout, stress, and other mental health issues that they relate directly to the impact of the pandemic. Burnout is often used as a “catch-all” term for psychological distress in the workplace, and it has been suggested that, during the pandemic, experience of “burnout” may be influenced by “moral injury”: the distress that can arise from actions, or lack of action, that are seen to violate one’s ethical code. This study investigates NHS staff experiences of burnout and betrayal-based moral injury, in which a trusted authority betrays “what is right.” METHOD: Sixteen NHS staff members were interviewed in relation to their experiences during the COVID-19 pandemic, and data were thematically analyzed. RESULTS: Three themes were identified: abandonment as betrayal; dishonesty and lack of accountability; and fractured relationship to management or the NHS. CONCLUSIONS: This analysis concludes that self-identified “burnout” in NHS staff may include a significant moral component, and that failure to engage in moral repair following betrayal-based moral injury may relate to a long-term loss of trust or fractured relationship with the organization. In addition to traditional trauma-informed psychological support, leadership at all levels should be trained to be aware of betrayal-based moral injury and to engage in moral repair to reduce staff intent to leave and encourage mutual trust. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Moral Injury and Burnout in Health Care Professionals During the COVID-19 Pandemic.
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Mantri S, Song YK, Lawson JM, Berger EJ, Koenig HG.
J Nerv Ment Dis 2021 oct;209(10):720-726.
The coronavirus pandemic (COVID-19) is predicted to increase burnout in health professionals (HPs), but little is known about moral injury (MI) in this context. We administered the Moral Injury Symptoms Scale for Health Professionals (MISS-HP) and the abbreviated Maslach Burnout Inventory via online survey to a global sample of 1831 HPs in April and October 2020. Mean MISS-HP increased from 27.4 (SD, 11.6) in April to 36.4 (SD, 13.8) in October (p < 0.001), with an accompanying increase in personal accomplishment (April: 4.7; SD, 3.1; October: 9.3; SD, 3.1; p < 0.001) and no change in other burnout subscales. In April, 26.7% of respondents reported at least moderate functional impairment from MI, increasing to 45.7% in October (p < 0.001). Predictors of MISS-HP included younger age and being a nurse. Odds of functional impairment were higher in respondents who were widowed, divorced, never married, or had direct experience caring for patients with COVID-19. COVID-19 has increased MI but not burnout in HPs; younger or unmarried individuals, nurses, and frontline workers may benefit from targeted outreach to reduce downstream effects of MI, depression, and/or posttraumatic stress disorder.

Nursing Moral Distress and Intent to Leave Employment During the COVID-19 Pandemic.
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Sheppard KN, Runk BG, Maduro RS, Fancher M, Mayo AN, Wilmoth DD, et al.
J Nurs Care Qual 2021 sep.
BACKGROUND: Complexity in nursing practice creates an intense and stressful environment that may lead to moral distress (MD) and registered nurses (RNs) seeking other employment. LOCAL PROBLEM: In 2020, the RN turnover rate was 8%, with postpandemic turnover projected to reach 13%. METHODS: The Measure of Moral Distress for Health Care Professionals (MMD-HP) was used to measure the frequency and level of RNs’ MD. RESULTS: t tests showed significant differences for 16 of 27 MMD-HP items in RN intent to leave. RNs had 2.9 times the odds of intent to leave (P = .019) due to perceived issues with patient quality and safety and 9.1 times the odds of intent to leave (P < .001) due to perceived issues with the work environment. Results explained 40.3% of outcome variance. CONCLUSIONS: MD related to work environment or patient quality and safety were significant factors in RN intent to leave their position.