Workers May Spread COVID-19 in Nursing Homes

Laird Harrison

July 24, 2020

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COVID-19 infections in long-term-care facilities in Ontario, Canada, appear to have started with workers, researchers say.

"A lot of the work in these facilities is low paying, and you have folks working in multiple facilities," David Fisman, MD, MPH, a professor of epidemiology at the University of Toronto in Ontario, Canada, told Medscape Medical News. "It effectively links the facilities together and allows the virus to spread."

The study by Fisman and colleagues was published online July 22 in JAMA Network Open.

The virus has hit long-term-care facilities around the world particularly hard. In Canada, more than 80% of the people who have died from the virus lived in these institutions, a government investigation found.

Frail people living in close quarters are vulnerable to many communicable diseases, and it comes as no surprise that workers might bring the virus with them from the outside, Fisman said. The data show the scale of the problem and point to policy changes that could help control the pandemic.

To understand the course of outbreaks at long-term-care facilities, the researchers analyzed data from the Ontario Ministry of Health and Long-term Care from March 29 to April 7, 2020.

The data indicate that in almost half (43.4%) of the 627 long-term-care facilities in the province, there were confirmed or suspected cases of COVID-19 among staff or residents.

Of 1,732,315 people older than 69 years in Ontario during the study period, 229 died of COVID-19. By contrast, of the 79,498 residents in long-term-care facilities, 83 died.

The researchers calculated that a long-term-care resident was 13 times more likely to die of the virus than someone older than 69 years living in the community during those 10 days (incident rate ratio [IRR], 13.1).

The difference in risk increased during the study period, the researchers found. "This is Ebola-level stuff in this population," Fisman said.

The deaths of so many elders have devastated families, many of whom never had an opportunity to say goodbye, Fisman said. To prevent the trend from continuing, policymakers should focus on staff, he suggested.

In facilities in which a staff member was diagnosed with the infection, the risk for death among residents increased by 20% during the next 2 days (IRR, 1.20). In the 6 days after the diagnosis of a staff member, the risk for death increased 17% (IRR, 1.17).

By contrast, residents appeared much less likely to infect each other. There was no statistically significant increase in deaths among other residents after the first day on which a resident was diagnosed. On that day, the increased risk for death was 8% (IRR, 1.08).

"To keep this out, you have to keep the testing focus on long-term-care workers," Fisman said.

Another measure is to employ staff full time with living wages, so they would not need to work at multiple facilities, he suggested.

Inadequate staffing may also play a role, he said. Anecdotal reports suggest that some nursing home residents died when workers stopped showing up because of fear of contracting the disease. "The long-term-care facility situation was so out of control that the military was called to backstop some of the human resources issues," he explained. "They found quality-of-care issues in terms of the way residents were being treated."

To prevent this from happening, staff should receive adequate personal protective equipment and danger pay, Fisman said. By employing such measures, British Columbia was able to better protect its long-term-care residents, he added.

The study shows that Ontario long-term-care facilities were unprepared to resist the pandemic, said Nathan Stall, MD, a geriatrician at the University of Toronto.

Compared with long-term-care residents in the United States, those in Canada may be more vulnerable to COVID-19 because the Canadian facilities don't include relatively healthy people who are recovering from surgery, Stall said. Still, the finding that staff are transmitting the virus is likely to apply to both countries, he said.

"It has shined a light on the plight of long-term-care workers," he told Medscape Medical News. "In many cases, they had a lack of proper training and preparedness to care for residents with COVID-19."

In his own research, published in CMAJ, he found that the risk for death from COVID-19 in for-profit long-term-care facilities was 78% higher than in nonprofit facilities in Ontario (relative risk, 1.78).

That finding, too, parallels research conducted in the United States, he said.

Fisman and Stall have disclosed no relevant financial relationships.

JAMA Netw Open. Published online July 22, 2020. Full text

Laird Harrison writes about science, health and culture. His work has appeared in magazines, newspapers , and online publications. He is at work on a novel about alternate realities in physics. Harrison has taught writing at San Francisco State University, UC Berkeley Extension and the Writers Grotto. Visit him at lairdharrison.comor follow him on Twitter: @LairdH.

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