key: cord-0316973-13o0h9u9 authors: Egunsola, O.; Hofmeister, M.; Dowsett, L. E.; Noseworthy, T.; Clement, F. title: Preventing the Transmission of COVID-19 in Older Adults Aged 60 Years and Above Living in Long-Term Care: Rapid Review Update date: 2021-11-08 journal: nan DOI: 10.1101/2021.11.05.21265759 sha: 5e882e89fcb3e4c82e209b935e894af0cd724e5f doc_id: 316973 cord_uid: 13o0h9u9 Objectives: The objective of this study was to examine the effect of measures of control and management of COVID-19, Middle East Respiratory Syndrome (MERS), and severe acute respiratory syndrome (SARS) in adults 60 years or above living in long-term care facilities. This is an update of previous work done by Rios et al. Methods: A rapid review was conducted in accordance with the Rapid Review Guide for Health Policy and Systems Research. Literature search of databases MEDLINE, Cochrane library, and pre-print servers (biorxiv/medrxiv) was conducted from July 31, 2020 to October 9, 2020. EMBASE was searched from July 31, 2020 until October 18, 2020. Titles and abstracts from public archives were identified for screening using Gordon V. Cormack and Maura R. Grossmans Continuous Active Learning (CAL) tool, which uses supervised machine learning. Results: Five observational studies and one clinical practice guideline were identified. Infection prevention measures identified in this rapid review included: social distancing and isolation, personal protective equipment (PPE) use and hygiene practices, screening, training and staffing policies. The use of PPE, laboratory screening tests, sick pay to staff, self-confinement of staff within the LTCFs for 7 or more days, maintaining maximum resident occupancy, training and social distancing significantly reduced the prevalence of COVID-19 infection among residents and/or staff of LTCFs (p<0.05). Practices such as hiring of temporary staff, not assigning staff to care separately for infected and uninfected residents, inability to isolate sick residents and infrequent cleaning of communal areas significantly increased the prevalence of infection among residents and/or staff of LTCFs (p<0.05). Conclusion: The available studies are limited to only three countries despite the global nature of the disease. The majority of these studies showed that infection control measures such as favourable staffing policies, training, screening, social distancing, isolation and use of PPE significantly improved residents and staff related outcomes. More studies exploring the effects infection prevention and control practices in long term care facilities are required.  Practices such as hiring of temporary staff, not assigning staff to care separately for infected and uninfected residents, inability to isolate sick residents and infrequent cleaning of communal areas significantly increased the prevalence of infection among residents and/or staff of LTCFs (p<0.05). . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint As compared to other segments of the population, older adults living in long-term care facilities have a higher risk of infection and death as a result of coronavirus 2019 (COVID-19). 1 The overall objective of this rapid review was to examine the control and management of COVID-19, SARS, or MERS in adults 60 years or above living in long-term care facilities. This is an update of a previous work done by Rios et al. 2 The specific research questions were: 1. What are the infection prevention and control practices for preventing or reducing the transmission of COVID-19, Middle East Respiratory Syndrome (MERS), and Severe Acute Respiratory Syndrome (SARS) in older adults aged 60 years and above living in long-term care facilities? 2. Do the infection prevention and control practices for adults aged 60 years and above living in long-term care with severe comorbidities or frailty differ as compared to those without such severe comorbidities/frailty? 3. What are the employment and remuneration policies of care providers that may have contributed to the COVID-19 outbreaks in adults aged 60 years and above living in long-term care facilities? A rapid review was conducted in accordance with the Rapid Review Guide for Health Policy and Systems Research. 3 A combination of comprehensive literature searches and automated search and citation screening was used to search MEDLINE, EMBASE, Cochrane library, and pre-print servers (biorxiv/medrxiv). Grey literature was searched via international clinical trial registries (e.g., clinical trials.gov, WHO international clinical trials register), COVID-19 focused evidence gathering services (e.g., EPPI Mapper, COVID-END), as well as guideline producers/repositories (e.g., NICE guidance, ECRI). The search for all sources for the previous review was conducted from inception up to July 31, 2020. 2 The literature search for this update, for all sources except EMBASE, was conducted on October 9, 2020. Titles and abstracts from public archives were identified for screening using Gordon V. Cormack and Maura R. Grossman's Continuous Active Learning® ("CAL®") tool, which uses supervised machine learning. 4 For archives that could be retrieved in their entirety (e.g., Medline), the entire archive was processed and searched using CAL®. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint For those archives that could only be accessed using keywords (e.g. clinicaltrials.gov), relevant search terms were applied (e.g., COVID-19, long-term care). The CAL® tool identifies the titles and abstracts most likely to meet specific inclusion criteria, based on the screening results that have been previously identified and reviewed. This process continues iteratively, until none of the identified articles meet the inclusion criteria. The EMBASE search was carried out from July 31, 2020 until October 18, 2020. The search strategy is available in Appendix 1. This rapid review is registered in the International Prospective Register of Systematic Reviews (CRD42020181993). The eligibility criteria followed the PICOST framework outlined in Table 1 . No other limitations were imposed. Both peer-reviewed and non-peer-reviewed papers were eligible for inclusion, as were papers written in languages other than English. In order to meet the requested timeline, an automated approach to initial screening was used to identify the most relevant citations, the full-text of which were subsequently screened. Prior to full-text screening, calibration was conducted on five consecutive studies. Full-text screening was completed by two reviewers using Microsoft Excel. All included studies were verified by a second reviewer. A screening form based on the eligibility criteria was utilized and studies were excluded if they failed to meet the inclusion criteria as stated below. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint Items for data extraction included: title of the article, author, year of publication, country of publication, study design, inclusion criteria, total population sample, group sample sizes, number of LTCF, infection control methods and outcomes. For the clinical practice guidelines, the recommendations and level of evidence for reach recommendation was abstracted. Included studies were abstracted by a single reviewer. Risk of bias appraisal was carried out by a single reviewer using the AGREE-II tool 5 for clinical practice guidelines and the Newcastle Ottawa Scale (NOS) 6 for cohort and case-control studies. For the NOS scale, each study was assessed across three categories: selection, comparability, and outcome. The cross-sectional studies were assessed with the Joanna Briggs Institute (JBI) checklist. 7 The infection control interventions were classified into five broad categories: staffing policy, isolation and social distancing, personal protective equipment and hygiene, screening, and education. A narrative synthesis of the included studies was conducted. The search strategy yielded 457 unique citations; 376 were excluded after abstract review. Eighty-one studies proceeded to full-text review ( Figure 1 ). Seventy-five studies were excluded for the following reasons: study design not of interest (n=35); no intervention of interest (n=33); duplicate (n=3); not retrievable (n=3); and one was an older published version of this rapid review. A total of 6 relevant studies were included in the final dataset. [8] [9] [10] [11] [12] [13] Two of the included studies were cohort studies, 10,11 two were cross-sectional studies 8, 9 and one was a case-control study. 12 One clinical practice guideline was identified. 13 A total of 14,830 long term care facilities and 864,434 residents were involved in these studies. Two studies were conducted in France 8,10 and the United States 11,12 , respectively and one was . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint conducted in the United Kingdom. 9 The only included clinical practice guideline was developed for nursing homes in Canada 13 (Table 2 ). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The two included cohort studies were truly representative of the general population and the non-exposed cohorts were from the same community as the intervention groups. In both studies, outcomes were not present at the start of the study, the cohorts were comparable, outcomes were assessed independently, with sufficient and complete follow-up. However, in one study, exposure was ascertained by self-report, thus earning no star; 11 while exposure in the other was ascertained by structured interview. 10 Overall, one study earned seven of eight stars 11 while the other earned eight stars 10 ( Table 3) . The case-control study was judged to be representative of the general population; the control group was from the community and had no prior history of disease. Both cases and control were comparable and the methods of ascertainment of exposure between them were comparable. There was no description of the method of ascertainment of exposure and no designation for non-response rate. Overall, this study had six of eight stars (Table 3) . 12 The two cross-sectional studies had clearly defined inclusion criteria, properly defined participants and setting, and reported objective standard for measuring COVID-19 cases. Both studies did not demonstrate the validity or reliability of the questionnaires used for exposure measurement. Both studies identified confounding factors and stated strategies to deal with them. Appropriate statistics were used in both studies 8, 9 (Table 3) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Two studies evaluated the effect of different staffing policies on COVID-19 outcomes. 8, 9 Shallcross et al. reported an almost two-fold increase in the prevalence of COVID-19 infection among residents of LTCFs employing temporary staff on most days compared with those that never employed temporary staff (p<0.001). They also found that LTCFs were about two times more likely to report a case of COVID-19 or a large outbreak of the disease if they hired temporary staff (p<0.001). 9 Similarly, COVID-19 infection was significantly more prevalent among the staff of LTCFs that hired temporary staff than those that did not (p<0.001). 9 However, Rolland et al. did not show any significant relationship between the proportion of LTCFs with a reported case of COVID-19 and the use of temporary staff (p=0.26). 8 The study showed that staff compartmentalization i.e. organization of the work so that the team works in small groups in one area of the LTCF with no physical connection with the other members of the team, statistically significantly lowered the risk of COVID-19 cases in LTCFs (p=0.01). 8 Finally, Shallcross et al. showed that providing sick pay to LTCF staff statistically significantly lowered the prevalence of infection among residents and staff (p<0.001) 9 (Table 4 , Appendix 3 ). In a study of LTCFs in Fulton county, USA, social distancing and maintaining maximum occupancy limit in the facilities were statistically significantly associated with lower is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint When compared with using PPE all the time, Shallcross et al. found that PPE use only during contact with all or infected residents was associated with a statistically significantly lower prevalence of infection among residents and staff 9 ( Table 4 ). The study also showed that cleaning of communal areas less than twice daily was significantly associated with higher prevalence of COVID-19 infection among residents and staff. 9 Similarly, Telford et al. , found that nursing homes that use PPE and had bathrooms and sinks in the residents' rooms had significantly lower infection rates (p<0.001 and p=0.04 respectively) than those that did not. They however did not find any significant relationship between cleaning and hand hygiene, and the prevalence of COVID-19 infection . 12 Rolland et al. also did not find any significant association between PPE supply and use or the availability of hydro-alcoholic solutes and the occurrence of COVID-19 in LTCFs in France (Appendix 3). 8 LTCFs significantly reduced the prevalence of infection among residents and staff (p<0.001). However, screening did not significantly reduce the rate of hospitalization. 11 Another study by Telford et al. did not show any statistical association between the prevalence of COVID-19 and temperature or symptom screening (p=0.15). 12 Telford et al. showed that LTCFs that placed signage on droplet and contact precaution in required areas reported significantly lower rates of COVID-19 infection (p=0.03). Also, those that conducted trainings and frequent audits to ensure proper mask use among staff members reported significantly fewer rates of infection (p=0.01) ( Table 4 ). 12 The only clinical practice guideline included in this review was developed to guide the reopening of nursing homes to families and visitors in Canada. 13 The guideline provided recommendations on personal protective equipment, policies for visitors, recommendations for supplies, social distancing and surveillance. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint The is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint 7 exp communicable disease control/ or exp "prevention and control"/ 8 contact examination/ 9 exp protective equipment/ or exp surgical attire/ 10 exp hygiene/ or exp hand washing/ 11 patient isolation/ or contact examination/ 12 instrument sterilization/ or exp disinfection/ or decontamination/ 13 bleaching agent/ 14 ("infection control" or "virus control" or "disease control" or prevent* or handwash* or "hand wash*" or quarant* or isolat* or steril* or disinfect* or fumigat* or decontaminat* or resanitiz* or resanitis* or desaniti* or contaminat* or antisept* or biocid* or steriliz* or sanitize* or bleach* or hypochlor* or ozon* or ultraviolet or UV or "contract tracing" or "disease notification").mp. ("protective equipment" or "protective cloth*" or "protective product*" or "protective gear" or PPE or PPEs or mask* or facemask* or half-mask* or facepiece* or n95* or n99* or shield* or faceshield* or "Particulate filter*" or "gas filter*" or glov* or gown or gowns or "space suits" or "respiratory protect*" or visor or "eye protect* " or "eye spectacle* " or "hand protect* " or "hand wash*" or "handwash*" or google or goggles or "head cover* " or "shoe cover*" or respirator* or ventilator*).mp. 16 (restrict* adj3 (resident* or patient* or visit* or family or travel* or staff or provider* or employee*)).mp. 17 ((respiratory or cough or hand) adj2 (hygiene or etiquette)).mp. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint 19 or/7-18 20 6 and 19 21 nursing home/ or home for the aged/ or assisted living facility/ ((elder* or senior or nursing or aged or "old age" or "old people" or "old person*" or "long-term care" or "LTC" or "long term care") adj2 (home or homes or hous* or residenc* or facilit* or hospital*)).mp. ("convalescence hom*" or "convalescence hospital*" or "extended care facility*" or "charitable hom*" or " home based health care facilit*").mp. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ☒Statement of type of strategy used to capture patients'/publics' views and preferences (e.g., participation in the guideline development group, literature review of values and preferences) ☐Methods by which preferences and views were sought (e.g., evidence from literature, surveys, focus groups) ☐Outcomes/information gathered on patient/public information ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 1366 6 . TARGET USERS Report the target (or intended) users of the guideline ☒The intended guideline audience (e.g. specialists, family physicians, patients, clinical or institutional leaders/administrators) 1366 . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint Report the health benefits, side effects, and risks that were considered when formulating the recommendations. ☒Reporting of the balance/trade-off between benefits and harms/side effects/risks ☒Recommendations reflect considerations of both benefits and harms/side effects/risks 12. LINK BETWEEN RECOMMENDATIONS AND EVIDENCE Describe the explicit link between the recommendations and the evidence on which they are based. ☐How the guideline development group linked and used the evidence to inform recommendations ☐Link between each recommendation and key evidence (text description and/or reference list) ☐Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline 13. EXTERNAL REVIEW Report the methodology used to conduct the external review. ☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☒Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations) 14. UPDATING PROCEDURE Describe the procedure for updating the guideline. ☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint ☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations 19. IMPLEMENTATION ADVICE/TOOLS Provide advice and/or tools on how the recommendations can be applied in practice. ☐Additional materials to support the implementation of the guideline in practice. ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint 21. MONITORING/ AUDITING CRITERIA Provide monitoring and/or auditing criteria to measure the application of guideline recommendations. ☐Criteria to assess guideline implementation or adherence to recommendations ☐Criteria for assessing impact of implementing the recommendations ☐Advice on the frequency and interval of measurement ☐Operational definitions of how the criteria should be measured is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 8, 2021. ; https://doi.org/10.1101/2021.11.05.21265759 doi: medRxiv preprint Risk factors associated with mortality among residents with coronavirus disease 2019 (COVID-19) in long-term care facilities in Ontario, Canada Preventing the transmission of COVID-19 and other coronaviruses in older adults aged 60 years and above living in long-term care: a rapid review Rapid reviews to strengthen health policy and systems: a practical guide Technology-Assisted Review in Empirical Medicine: Waterloo Participation in CLEF eHealth 2017 The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses Checklist for analytical cross sectional studies Guidance for the Prevention of the COVID-19 Epidemic in Long-Term Care Facilities: A Short-Term Prospective Study