key: cord-0767344-kk4h6n9s authors: Resciniti, Nicholas V.; Fuller, Morgan; Sellner, Joshua; Lohman, Matthew C. title: COVID-19 Incidence and Mortality among Long-Term Care Facility Residents and Staff in South Carolina date: 2021-08-16 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2021.08.006 sha: 0cfe7922976417243eb1e385bb8cc4a717053f27 doc_id: 767344 cord_uid: kk4h6n9s Objectives This study explored differences in COVID-19 incidence, mortality, and timing among long-term care facility (LTCF) residents and staff with those living in the community in South Carolina (SC). Design Longitudinal secondary data analysis. Setting and Participants Adults age ≥18 in SC with confirmed COVID-19 diagnosis from 3/15/2020 and 1/2/2021 (n=307,891). Methods COVID-19 data came from the SC Department of Health and Environmental Control (SCDHEC). We included all COVID-19 cases, hospitalizations, and deaths among adult residents. Residence and employment in LTCF were confirmed by SCDHEC. Descriptive statistics and trends for cases, hospitalizations, and deaths were calculated. We used Cox proportional hazards to compare COVID-19 mortality in LTCF residents and staff to community dwelling older adults and adults not employed in LTCF, respectively, controlling for age, gender, race, and pre-existing chronic health conditions. Results LTC residents experienced greater incidence of cases throughout the study period until the week ending on 1/2/21. LTCF residents with COVID-19 were more likely to be hospitalized compared to older adults in the community and 74% more likely to die (HR: 1.74, 95% CI: 1.59-1.90), after adjusting. LTC staff experienced greater incidence of cases compared to adults not employed in LTCF until the week ending on 12/26/2020, while experiencing similar incidence of death compared to the similar community members. After adjusting, LTC staff had 0.58 (HR=0.58; CI: 0.39-0.88) times lower hazard of death compared to community members that did not work in a LTCF. Conclusions and Implications Narrowing of the gap between LTCF and community-wide infection and mortality rates over the study period suggests that early detection of COVID-19 in LTCFs could serve as a first indicator of disease spread in the greater community. Results also indicate that policies and regulations addressing staff testing and protection may help to slow or prevent spread within facilities. (HR=0.58; CI: 0.39-0.88) times lower hazard of death compared to community members that did 24 not work in a LTCF. 25 Conclusions and Implications: Narrowing of the gap between LTCF and community-wide 26 infection and mortality rates over the study period suggests that early detection of COVID-19 in 27 LTCFs could serve as a first indicator of disease spread in the greater community. Results also 28 indicate that policies and regulations addressing staff testing and protection may help to slow or 29 prevent spread within facilities. 30 The novel SARS-CoV-2 (COVID- 19) virus was first detected in South Carolina (SC) on 33 March 4th, 2020, and case numbers have grown in the state since. COVID-19 has 34 disproportionately impacted vulnerable populations, 1 namely those with pre-existing 35 conditions, 2,3 overweight/obese, 4,5 dependency, 6 dementia, 7 frailty, 8 and those age ≥ 60. 9,10 36 Long-term care facilities (LTCF) tend to have more vulnerable populations, including older 37 adults with pre-existing conditions. 11 Consequently, LTCF residents are at greater risk of 38 COVID-19 and adverse consequences such as hospitalization and death. 12 Concerns regarding 39 spread in LTCF populations are compounded by findings of asymptomatic and/or atypical 40 manifestation among residents, as well as a negative impact on well-being and mental health of 41 residents without COVID-19. 13 42 State-and facility-level pandemic response may significantly impact the spread of 43 COVID-19 in LTCF, especially through staff mitigation measures. 14-16 Important facility-level 44 factors include the availability of necessary protective equipment, staff cases, testing, and 45 visitation policies. 17 Facility factors are in-turn influenced by state and federal guidelines and 46 J o u r n a l P r e -p r o o f policies such as stay-at-home orders and visitation recommendations. 18 Mitigation efforts may 47 also have negative impacts on resident well-being. For instance, restrictions implemented to slow 48 COVID-19 have been found to decrease residents' social encounters, leading to increased 49 loneliness, anxiety, and depression. 19, 20 The balance of resident well-being and safety is an 50 important consideration when implementing control strategies in LTCF. 21 51 The disproportionate impact of COVID-19 on LTCFs highlights the need to understand 52 and describe the spread of COVID-19 to help inform policies, preparedness, monitoring, and 53 coordination of future pandemic response. Given wide variability of state and LTCF responses to 54 the COVID-19 outbreak, describing how rates of disease have changed concurrently with 55 mitigation measures over time may provide valuable information to future outbreak strategies. 56 Likewise, given the likely bidirectional links between LTCF resident and staff infections, it is 57 important to describe and compare the parallel spread of COVID-19 among LTCF employees 58 and support staff. This study explored descriptive differences and associations in COVID-19 59 incidence and mortality among older adults living in the community and those living LTCFs in 60 SC. We describe the timeline of spread among LTCF residents and staff, along with relevant 61 state-specific and national changes in policy and guidance. information. All data for this study were obtained through a data use agreement with DHEC and 71 the analysis was approved by the DHEC Institutional Review Board. 72 We included all COVID-19 cases among SC residents age 18 or older reported between 73 3/15/2020 and 1/2/2021. For the comparison of LTC residents to community-dwelling older 74 adults, only individuals 65 and older were included; however, for analyses of LTCF staff, we 75 included all adults while excluding those in LTCFs. In SC, LTCFs included nursing homes and 76 community residential care facilities. Cases were confirmed by detection of severe acute 77 respiratory syndrome coronavirus 2 ribonucleic acid (SARS-CoV-2 RNA) in a clinical specimen 78 using a molecular amplification detection test. Probable cases met one of the following criteria: 79 clinical criteria AND epidemiologic linkage with no confirmatory laboratory testing performed 80 for SARS-CoV-2; presumptive laboratory evidence (detection of SARS-CoV-2 by antigen test in 81 a respiratory specimen); or vital records criteria with no confirmatory laboratory evidence for 82 SARS-CoV-2. Detailed information on case determination is available from the CDC. 22 State 83 LTC resident population size was determined from reporting by all certified LTC facilities to 84 DHEC. Mandatory LTC resident population reporting began on 5/17/2020; analyses using LTC 85 resident population size before mandated reporting assumed the same resident population size as 86 reported on 5/17/2020. 87 Individuals were classified as a resident or employee of an LTCF based on response to 88 DHEC case reports, which was then verified with DHEC for each LTCF. Individuals who did 89 not report residence in an LTCF were considered community-dwelling. Demographic and health-90 Between 3/15/2020 and 1/2/2021, 54,514 cases of COVID-19 were identified among 105 older adults in SC (Table 1) . Of these, 86.5% (n=47,148) were in the community, while 13.5% 106 (n=7,366) resided in a LTCF. Compared to older adults in the community, LTCF residents were 107 older, more likely to be female, white, and report more of pre-existing conditions. LTCF 108 residents with COVID-19 were significantly more likely to be hospitalized (26.5% vs. 14.9%) 109 compared to older adults living in the community. Table 2 Although our results are consistent with this previous study, it is unclear whether any differences 161 J o u r n a l P r e -p r o o f are due to international variability in testing availability, policies, and recording of cases and 162 deaths. 26 This study extends these previous findings by tracking longitudinal changes in cases 163 and mortality rates of LTC residents compared to those in the community. Differences between 164 LTCF and community cases and deaths diminished over the study period, potentially reflecting 165 implementation of more testing in LTCF or mitigation measures within LTCF settings, such as 166 availability of personal protective equipment and quarantining. However, many state-and 167 national-level policies and recommendations related to LTCF occurred months after the 168 pandemic began, 27 so the influence of broad policies on LTCF is unclear. 169 Results of the present study highlight the parallel, but commonly overlooked, spread of 170 COVID-19 among LTCF staff. Like residents, COVID-19 incidence rates and case-fatality rates 171 were higher than in the general community from early in the pandemic until December 2020. In 172 contrast to LTCF residents, staff had significantly lower risk of death compared to those in the 173 general population. This finding may be explained by better general health or access to 174 healthcare among healthcare workers compared to the general population. 28 Taken together, high 175 infection suggest that the prevalence of COVID-19 in LTCF staff may play a role in driving 176 resident infection rates. 29 As staff may serve as a link for infection between LTCF residents and 177 the community, these findings highlight the importance of clearly defining staff testing, 178 quarantine, and protection policies. Furthermore, one explanation of the lower mortality risk 179 among staff compared to comparable community-dwellers is the recommended increased Focusing on Vulnerable Populations During COVID-19 Association of 218 cardiovascular disease and 10 other pre-existing comorbidities with COVID-19 mortality: 219 A systematic review and meta-analysis Obesity as a risk factor for COVID-19 mortality in women and men in the UK biobank: Comparisons with influenza/pneumonia 222 and coronary heart disease Sociodemographic, clinical and laboratory factors on admission associated with COVID-228 19 mortality in hospitalized patients: A retrospective observational study Dementia as a mortality predictor among 231 older adults with COVID-19: A systematic review and meta-analysis of observational 232 study. Geriatr Nurs (Minneap) Association of frailty with mortality in older 235 inpatients with Covid-19: a cohort study Comorbidity and its Impact on Patients with 238 COVID-19. SN Compr Clin Med The effect of age on mortality 241 in patients with COVID-19: a meta-analysis with 611,583 subjects Patterns of chronic co-morbid 244 medical conditions in older residents of U.S. nursing homes: differences between the 245 sexes and across the agespan A Comparison of COVID-19 Mortality Rates Among 248 Long-Term Care Residents in 12 OECD Countries Asymptomatic transmission of covid-19 COVID-19: towards controlling of a pandemic The Impact of COVID-19 Pandemic on Long-256 Term Care Facilities Worldwide: An Overview on International Issues The Importance of Long-term Care Populations in 259 Models of COVID-19 COVID-19 in Nursing Homes: Calming the Perfect Storm Infection Control for Nursing Homes Social connectedness, dysfunctional interpersonal behaviors, 265 and psychological distress: Testing a mediator model A systematic review of 268 interventions for loneliness among older adults living in long-term care facilities Functional Connectivity Density Mapping of 271 Depressive Symptoms and Loneliness in Non-Demented Elderly Male COVID-19) 2020 Interim Case Definition COVID-19: towards controlling of a pandemic Mitigating the wider 281 health effects of covid-19 pandemic response Mortality associated with COVID-19 in 287 care homes: international evidence. Artic LTCcovid org, Int Long-Term Care Policy 288 Long-Term Care, Residential Facilities, and COVID-290 19: An Overview of Federal and State Policy Responses Healthcare and Lifestyle Practices of Healthcare Workers: Do 293 Healthcare Workers Practice What They Preach? Risk Factors, Presentation, and 296 Course of Coronavirus Disease 2019 in a Large, Academic Long-Term Care Facility American Geriatrics Society Policy Brief: COVID-19 and Nursing Homes A Rapid Review of COVID-19 Vaccine Prioritization in 301 the U.S.: Alignment between Federal Guidance and State Practice Note: Unknown responses were removed from calculations.