SOLUTION: Senior Centres Discussion – Studypool

BioMed Research International
Volume 2020, Article ID 8870249, 7 pages
Review Article
The Impact of COVID-19 Pandemic on Long-Term Care Facilities
Worldwide: An Overview on International Issues
Dana-Claudia Thompson ,1 Madalina-Gabriela Barbu ,1 Cristina Beiu ,2
Liliana Gabriela Popa ,2 Mara Madalina Mihai ,2 Mihai Berteanu ,3
and Marius Nicolae Popescu 3
Fetal Medicine Excellence Research Center, Alessandrescu-Rusescu National Institute for Mother and Child Health, 365 Calea
Grivitei street, 010717 Bucharest, Romania
Department of Dermatology, Elias University Emergency Hospital, 17 Marasti Blvd., 011461 Bucharest, Romania
Department of Rehabilitation Medicine, Elias University Emergency Hospital, 17 Marasti Blvd., 011461 Bucharest, Romania
Correspondence should be addressed to Cristina Beiu;
Received 1 September 2020; Accepted 30 October 2020; Published 11 November 2020
Academic Editor: Stavros Baloyannis
Copyright © 2020 Dana-Claudia Thompson et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
The COVID-19 pandemic had a great negative impact on nursing homes, with massive outbreaks being reported in care facilities all
over the world, affecting not only the residents but also the care workers and visitors. Due to their advanced age and numerous
underlying diseases, the inhabitants of long-term care facilities represent a vulnerable population that should benefit from
additional protective measures against contamination. Recently, multiple countries such as France, Spain, Belgium, Canada, and
the United States of America reported that an important fraction from the total number of deaths due to the SARS-CoV-2
infection emerged from nursing homes. The scope of this paper was to present the latest data regarding the COVID-19 spread
in care homes worldwide, identifying causes and possible solutions that would limit the outbreaks in this overlooked category of
population. It is the authors’ hope that raising awareness on this matter would encourage more studies to be conducted,
considering the fact that there is little information available on the impact of the SARS-CoV-2 pandemic on nursing homes.
Establishing national databases that would register all nursing home residents and their health status would be of great help in
the future not only for managing the ongoing pandemic but also for assessing the level of care that is needed in this particularly
fragile setting.
1. Introduction
In December 2019, several cases of pneumonia of unknown
origin were reported in Wuhan, China [1], leading to the
identification of a new RNA coronavirus which was named
SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). The nomenclature derived from its genetic similarities
to other viruses from the Coronaviridae family, namely, over
80% similarity with SARS-CoV (severe acute respiratory syndrome coronavirus) and 50% with MERS-CoV (Middle East
respiratory syndrome coronavirus), both responsible for two
high-mortality epidemics in the last two decades [2–6]. The
novel coronavirus has quickly spread from its point of origin
to various continents, determining the World Health Organization (WHO) to declare the COVID-19 (coronavirus disease 2019) to be pandemic on March 11th, expressing their
concerns regarding both the spread of the virus and the inaction of the authorities [7].
As of August 10th, 2020, a number of 19,718,030 cases
have been reported worldwide, with a total of 728,013 deaths
[8]. According to the WHO, some of the most affected countries were the United States of America, with 14,960 confirmed cases per 1 million population and 486 deaths per
million, Peru with 14,285 confirmed cases and 632 deaths
per 1 million population, and Brazil with 14,172 confirmed
cases and 472 deaths per million [9]. The COVID-19
pandemic forced authorities in several countries to impose
strict restrictions on the general population to limit the
spread of the virus, leading to an economic backlash and a
healthcare crisis.
Previous studies showed that the elderly and those with
preexisting conditions, attributes that also describe most residents of long-term care facilities, had a significantly higher
risk of severe disease and death. Nursing homes were possibly the most vulnerable institutions even before the
COVID-19 pandemic, the CDC (Centers for Disease Control
and Prevention), indicating in a study in 2014 that 80% of
nonfood borne outbreaks of norovirus in the USA took place
in long-term care facilities [10].
Since the beginning of the ongoing pandemic, numerous
outbreaks of SARS-CoV-2 have been reported in nursing
homes worldwide, affecting both the residents and the care
workers. In the USA, it was estimated that 35,000 reported
deaths due to COVID-19 emerged in nursing homes, representing 42% of the total number of COVID-19 deaths [11],
with fatality rates amongst the residents reaching up to
33.7% in a care facility in King County, Washington [12].
Similar data regarding the percent of nursing home
COVID-19 deaths in relation to the total COVID-19 deaths
were also reported in numerous countries in Europe, such
as Belgium (42%), France (44.6%), and Ireland (54%) [13].
It is crucial to identify and correct the possible shortcomings
related to nursing home procedures to better manage the
COVID-19 pandemic and any other future epidemics.
2. The High-Risk Characteristics of Nursing
Home Residents
Since the beginning of the pandemic, researchers indicated
that the aged population should be shielded from the virus,
as they pose a higher risk of developing a more severe form
of the disease, which could further lead to increased mortality
[14]. Studies showed that age over 60-65 years was associated
with a significantly higher risk of severe and critical manifestations, disease progression, and exitus, with men being more
at risk for worse outcomes (see Table 1) [14–16]. One prospective, 12 months study conducted in 8 countries on 4156
residents of nursing homes found that the mean age of the
residents was 83:4 ± 9:4 years, and that 81.3% of them suffered from ADL (activities of daily living) disability, while
68.0% presented cognitive impairment [17], thus representing one of the most at-risk population in light of the recent
SARS-CoV-2 outbreak.
Comorbidities such as diabetes, cardiovascular disease,
chronic respiratory disease, cerebrovascular disease, malignancy, and dementia were proved to independently increase
the risk of COVID-19 progression, severe outcomes, and
death (see Table 1) [15, 16, 18–23]. One previous study, conducted on 43,510 nursing home residents in the USA,
showed that 65.5% were diagnosed with dementia, 46.8%
had hypertension, 20.9% suffered a stroke, 20.6% had diabetes mellitus, and 14.3% chronic obstructive pulmonary disease, all of these preexisting conditions being associated
with 1-year mortality more than 30%, even higher for the latter one which generated 1-year mortality of up to 43.8% [24].
BioMed Research International
Similar to the study presented above, this paper also found
the mean age of the residents to be 84:4 ± 7:8 [24]. Considering the fact that most of the participants had more than one
comorbidity, it is predictable that the impact of a SARS-CoV2 infection would be severe. Thus, a strategy for protecting
this category of population from contracting SARS-CoV-2
is imperative.
Another possible shortcoming that may contribute to the
high infection rate amongst nursing homes is the fact that
residents of long-term care facilities frequently suffer from
various degrees of disability, and this may often lead to
inability to properly perform preventive health measures,
such as diligent hand washing. One study that focused on
determining the level of disability amongst diabetesdiagnosed nursing home residents found that the mean number of underlying comorbidities was 4, the most frequent
being dementia, stroke, hypertension, and ischemic heart disease. More than half of the residents (62%) were not able to
feed themselves, 51% had speech impairment, and 89%
required at least a frame or the help of one carer in order to
walk [25]. Consequently, is therefore likely that the physical
interaction between the facility personnel and these residents
is prolonged, thus increasing the risk of contamination on
both parts. Studies on previous epidemics also showed that
the high number of outbreaks in nursing homes may also
be explained by the large numbers of residents that share
the same sources of water, food, air, the same facilities, and
the fact that a limited number of care workers are responsible
for numerous inhabitants [26, 27].
Implementing protocols that would address these matters, together with establishing training programs for all care
workers might diminish the number and the severity of outbreaks that take place in nursing homes.
3. Impact on Nursing Homes
As was the case with many other natural disasters, such as
hurricane Katrina, nursing homes have been one of the most
affected sectors by the COVID-19 pandemic [28]. Studies
that analysed previous influenza epidemics and the way they
impacted long-term care homes made a number of recommendations on how to better manage the spread of a pathogen in these facilities [29–32]. In spite of considerable efforts
being made to protect residents, the response to this healthcare crisis still needs to be improved to avoid further lives
to be lost.
In addition, data regarding the residents, which should be
easily accessible, is still lacking altogether with standardization of this data and cross-sector cooperation on how to
gather, share, and make use of it, leading to a scarcity of basic
information, such as the number of residents and deaths
among them [33]. Due to these limitations encountered
across most nations, there is not enough knowledge about
the true impact of COVID-19 in this environment. However,
a few countries managed to report relevant data, and several
studies were conducted, which could partially shed light on
the grim picture inside care homes around the world.
One of the countries with the most comprehensive data
set is the United States of America. The Nursing Home

Cerebrovascular disease
Respiratory disease
Cardiovascular disease
OR = 2:0, 95% CI
Li et al. [15]
OR = 2:2, 95% CI
OR = 2:436, 95% CI
Zhang et al. [16]
OR = 4:791, 95% CI
OR = 0:520, 95% CI
OR = 2:47, 95% CI
OR = 2:29, 95% CI
OR = 2:93, 95% CI
OR = 5:97, 95% CI
OR = 3:89, 95% CI
Wang et al. [21]
OR = 1:84, 95% CI
Bianchetti et al. [23]
HR = 1:13 (1.02-1.24)
HR = 1:40 (1.28-1.52)
HR = 1:17 (1.06-1.29)
HR = 1:17 (1.09-1.27)
HR = 1:16 (1.08-1.24)
Docherty et al.∗∗ [20]
Only patients over 60 years old were taken into consideration. ∗∗ The HR values are calculated for the hazard representing death. All the values presented in the table had statistical significance (p value
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