key: cord-0830172-po0rhyqr authors: Frazer, K.; Mitchell, L.; Stokes, D.; Lacey, E.; Crowley, E.; Kelleher, C. C. title: A rapid systematic review of measures to protect older people in long term care facilities from COVID-19 date: 2020-11-03 journal: nan DOI: 10.1101/2020.10.29.20222182 sha: d92365ffe9458804528f9a22f1577fc73f709b48 doc_id: 830172 cord_uid: po0rhyqr The global COVID-19 pandemic produced large-scale health and economic complications. Older people and those with comorbidities are particularly vulnerable to this virus, with nursing homes and long term care facilities experiencing significant morbidity and mortality associated with COVID-19 outbreaks. The aim of this rapid systematic review was to investigate measures implemented in long term care facilities to reduce transmission of COVID-19 and their effect on morbidity and mortality of residents, staff, and visitors. Databases (including MedRXiv pre-published repository) were systematically searched to identify studies reporting assessment of interventions to reduce transmission of COVID-19 in nursing homes among residents, staff, or visitors. Outcome measures include facility characteristics, morbidity data, case fatalities, and transmission rates. Due to study quality and heterogeneity, no meta-analysis was conducted. The search yielded 1414 articles, with 38 studies included. Reported interventions include mass testing, use of personal protective equipment, symptom screening, visitor restrictions, hand hygiene and droplet/contact precautions, and resident cohorting. Prevalence rates ranged from 1.2-85.4% in residents and 0.6-62.6% in staff. Mortality rates ranged from 5.3-55.3% in residents. Novel evidence in this review details the impact of facility size, availability of staff and practices of operating between multiple facilities, and for-profit status of facilities as factors contributing to the size and number of COVID-19 outbreaks. No causative relationships can be determined; however, this review provides evidence of interventions that reduce transmission of COVID-19 in long term care facilities. Facilities Residents noted to share rooms, walk throughout the facility and spent time in shared areas (e.g., gym, dining rooms, and recreational rooms). Because all case-patients had visited the gym at the facility for recreation or physical therapy before becoming ill, environmental cleaning of this area was performed. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. Morbidity and mortality results from included studies are presented for residents (Table 3a) , staff (Table 3b) , and visitors ( death rate in residents who tested positive for the SARS virus. 47 A study examining the mortality risk in Ontario LTCF reported a death rate of 0.1% across all residents. 42 Across the three studies which presented mortality results in COVID-19 positive staff, mortality rates were 0%. 28, 34, 45 One study presenting mortality rates in a nursing home following a SARS outbreak reported one death of a All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. ; member of staff. 47 Mortality rates reported in visitors in two studies was 0% 47 and 6.2%, 28 respectively. Numerous facility-specific characteristics were linked with risk of COVID-19 cases (Table 2 ). These include size of LTCF; 16 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. ; https://doi.org/10.1101/2020.10.29.20222182 doi: medRxiv preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. 40 Facility characteristics 1532 COVID-19 Highest correlation of increased All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. 25 Facility characteristics 7 staff COVID-19 positive prior to intervention 0 further staff positive after intervention implemented Heung et al. (2006) 46 Hand hygiene, contact precautions 1 staff member SARS-CoV positive during outbreak (a domestic worker) 0/26 staff positive for SARS-CoV antibodies All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. The quality ratings of included studies are presented in Supplementary Table 2 . Overall quality of evidence in this review is considered low based on MMAT assessment criteria. The facility size/number of beds was significantly associated with the probability of having a COVID-19 case, and the resulting size of an outbreak. For example, in a sample of 30 US nursing homes, the probability of having a COVID -19 case was increased in medium and large facilities compared with All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. ; https://doi.org/10.1101/2020.10.29.20222182 doi: medRxiv preprint small facilities, 16 while in 121 UK homes reporting an outbreak, facilities with ≥ 70 beds had 80% greater infection rates than facilities with <35 beds. 38 A sample of 623 Canadian nursing homes demonstrated facilities with a high crowding index had more infections and deaths than those with a low crowding index. Simulations conducted suggested nearly 20% of infections and deaths may have been averted by converting all 4-bed rooms into 2-bed rooms. 41 Similarly, facilities with a greater number of staff, staff who work in multiple facilities, and greater number of infected staff, were also more likely to experience a COVID -19 outbreak. 36, 39, 50 However, facilities where staff receive sick leave were shown to be less likely to have positive cases. 39 Reduced availability of PPE predicted the spread and increase in case number in facilities, 36 while for-profit status of facilities was commonly identified as increasing the odds of case outbreaks relative to non-profit status. 16, 31, 35, 42, 43 Quality review The quality of evidence in this review is technically low, primarily reported from observational studies, expert opinion, reporting of outbreaks and describing the process and management (Supplementary Table 2 ). Factors associated with lower quality of evidence includes the reliance of self-reporting of symptoms, recall bias, use of datasets which may be incomplete, and use of convenience sampling. However, confirmation of COVID-19 in the majority of studies was via laboratory testing. We did not remove any study following our review of quality and the evidence is consistent with real time reporting of data to learn from outbreaks. The Institute of Medicine (2004) 54 advocates for early detection of epidemics, effective communication to the public, and promotion of research and development for strategic planning. A key strength of this review is that it addresses a knowledge gap and has collated evidence from a broad methodological base to report the measures to reduce transmission of COVID-19 in LTFC and reports characteristics of facilities. Due to the heterogeneity of studies, meta-analysis was not performed, while the descriptive nature of studies prevents identification of a causative relationship between measures and outcomes. Despite All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. ; https://doi.org/10.1101/2020.10.29.20222182 doi: medRxiv preprint this, the systematic approach to this review has identified the scope of interventions implemented in LTFC to reduce COVID -19 transmission. Publication bias was minimized with inclusion of pre-published evidence, follow up contacts with authors for early reporting, and through the inclusion of observational study designs. Most studies reported are in English, we translated papers from German and Spanish as part of the assessment and review. Outbreak reports include convenience samples or smaller cohorts of residents in LTCF with limited data reported in brief reports and letters. However, real time reporting of outbreaks provides immediate evidence and shared understanding advocated by the Institute of Medicine. 54 While the present review builds on a review by Salcher-Konrad, Jhass, Naci, Tan, El-Tawil, Comas-Herrera 55 , a recent report from WHO, 56 and from an Irish review report, 57 data on the role of facilities in the transmission of COVID-19 are reported. This novel, rapid review summarises the evidence base to date identifying specific factors for consideration as part of preparedness plans to reduce transmission of COVID-19 outbreaks in LTCF. Future research should incorporate methodologically robust study designs with longer follow up to assess the impact on reducing transmission. Authors declare no funds were provided for the production of this review. CK, KF, and LM designed the study; KF and DS developed the search strategy; DS conducted the literature search; KF and LM screened titles and full texts to select studies, and extracted data; LM, EL, KF, and CK conducted quality ratings; all authors interpreted and synthesised data; all authors were involved in writing. All authors have approved the final version of the manuscript. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. ; https://doi.org/10.1101/2020.10.29.20222182 doi: medRxiv preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 3, 2020. ; European Centre for Disease Prevention and Control (ECDC) World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report -94 Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review Risk assessment: Outbreak of acute respiratory syndrome associated with a novel coronavirus Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) COVID-19 and anosmia: A review based on up-to-date knowledge COVID-19 situation update 10. United Nations. Policy Brief: The Impact of COVID-19 on older persons World Health Organization. Policy Brief: The Impact of COVID-19 on older persons Systematic review of measures to protect older people in long term care facilities from COVID 19. PROSPERO: International prospective register of systematic reviews Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Education for Information Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline Characteristics of U.S. Nursing Homes with COVID-19 Cases Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility An Illustration of SARS-CoV-2 Dissemination Within a Skilled Nursing Facility Using Heat Maps Universal and Serial Laboratory Testing for SARS-CoV-2 at a Long-Term Care Skilled Nursing Facility for Veterans Hospital affiliated long term care facility COVID-19 containment strategy by using prevalence testing and infection control best practices High Proportion of Asymptomatic SARS-CoV-2 Infections in 9 Long-Term Care Facilities SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 23 Rapid Telehealth-Centered Response to COVID-19 Outbreaks in Postacute and Long-Term Care Facilities MMWR Morbidity and mortality weekly report Comparison of viral levels in individuals with or without symptoms at time of COVID-19 testing among 32,480 residents and staff of nursing homes and assisted living facilities in Massachusetts. medRxiv Lessons from Mass-Testing for COVID-19 in Long Term Care Facilities for the Elderly in San Francisco Epidemiology of covid-19 in a long-term care Asymptomatic SARS-CoV-2 Infection and COVID-19 Mortality During an Outbreak Investigation in a Skilled Nursing Facility Longitudinal Surveillance for SARS-CoV-2 RNA Among Asymptomatic Staff in Five Colorado Skilled Nursing Facilities: Epidemiologic, Virologic and Sequence Analysis COVID-19 Preparedness in Nursing Homes in the Midst of the Pandemic Mass Screening for SARS-CoV-2 Infection among Residents and Staff in Twenty-eight Long-term Care Facilities in Fulton County Nursing Home Characteristics Associated With COVID-19 Deaths in Connecticut Introduction to and spread of COVID-19 in care homes in Norfolk Evolution and impact of COVID-19 outbreaks in care homes: population analysis in 189 care homes in one geographic region Covid-19 infection and attributable mortality in UK Long Term Care Facilities: Cohort study using active surveillance and electronic records National Early Warning Scores (NEWS / NEWS2) and COVID-19 deaths in care homes: a longitudinal ecological study Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario Risk Factors Associated With Mortality Among Residents With Coronavirus Disease 2019 (COVID-19) in Long-term Care Facilities in Ontario, Canada COVID-19 in seniors: Findings and lessons from mass screening in a nursing home Prevalence of subclinical infection and transmission of severe acute respiratory syndrome (SARS) in a residential care home for the elderly An outbreak of severe acute respiratory syndrome in a nursing home Asymptomatic SARS-CoV-2 infection in Belgian long-term care facilities. The Lancet Infectious Diseases Der erste COVID-19-Hotspot in einer Hamburger Senioreneinrichtung Asymptomatic carriage rates and case-fatality of SARS-CoV-2 infection in residents and staff in Irish nursing homes. medRxiv Clusters of COVID-19 in long-term care hospitals and facilities in Japan from 16 Improving Preparedness for and Response to Long-Term Care Hospitals in the Korea. Infect Chemother Emerging Infectious Disease journal The authors declare no conflicts of interest. CK was a member of an expert panel investigating COVID-19 in nursing homes in Ireland.