Table 4 Included studies

Vijh et al., 2021 [41]

Canada

Quasi-experimental study

To evaluate the effectiveness of a multisectoral intervention (a bundle of outbreak control measures) 14 days after implementation in terms of reducing subsequent transmission among

residents and staff

February 28, 2020, and May 30, 2020

7

7 LTCF

Pré- intervention: early outbreak period (RR, 1.07; 95% CI, 1.03–1.11; p < 0.001)

Post- intervention: during the post-intervention period (RR, 0.73; 95% CI, 0.67–0.80; p < 0.001)

In total, 275 COVID-19 cases (165 staff and 110 residents) were reported to public health

Pré:

After adjusting for case type, there was a significant upward trend in the COVID-19 incidence rate during the early outbreak period (RR, 1.07; 95% CI, 1.03–1.11; p < 0.001)

Post:

A significant reversal in trend was identified (RR, 0.68; 95% CI, 0.62–0.75; p < 0.001). In particular, the postintervention trend demonstrated a 27% decrease in the COVID-19 incidence rate every 2 days (RR,0.73; 95% CI, 0.67–0.80; p < 0.001)

NR

NR

In British Columbia, 59% of COVID-19–

related deaths were in LTCFs, compared to 75% in Canada overall

and 30%–60% across Europe

Our study provides evidence for the effectiveness of this intervention to reduce the transmission of COVID-19 in LTCFs. This intervention can be adapted and utilized by other jurisdictions to protect the vulnerable individuals in LTCFs

Aghili et al. 2022 [34]

Iran

Case–control study

To identify the predictors of contracting COVID-19 among older people in nursing homes in Iran

From 25 March to 12 July 2021

6

409 residents

Cases: 136 residents Covid + 

Control: 273 residents Covid-

Cases: 136

Control:273 covid-

NR

NR

There are no formal statistics about the

mortality rate due to COVID-19 in nursing homes in Iran. Nursing homes are predominantly

non-government-owned organizations that are authorized, supervised and funded by the State Welfare Organization of Iran

The results indicate that an increase in older people becoming infected by SARS-CoV-2 in nursing homes is probably because of not wearing a mask in common places, use of a cloth mask, longer staff shift durations and not having a glass shield when interacting with visitors from outside of nursing homes

Telford et al., 2021 [35]

USA

Case–control study

Determine the efficacy of recommendations for infection prevention and control of COVID-19 in LTCF for reducing transmission among high-risk populations

June and July 2020

24

24 LTCF

Cases: 11 LTCF, 1310 residents Higher-prevalence group (HPG) (infection prevalence among residents greater than the overall infection proportion (39%))

Control: 13 LTCF, 1270 residents—Lower-prevalence group (LPG)

(infection prevalence lower than the overall proportion)

Cases: HPG – 817

Control: LPG – 187

Cases:HPG124

Control: LPG – 38

Cases: HPG – 196

Control: LPG – 51

Fulton County, Georgia, which covers the

city of Atlanta, had received reports of 1,183 COVID-19

infections among residents from 45 LTCFs within its jurisdiction; 51% of COVID-19 deaths in Fulton County were

attributed to LTCF residents

LTCFs with lower COVID-19 prevalence among residents had a significantly greater implementation of IPC recommendations compared to those with higher COVID-19 prevalence

Wang et al., 2021 [36]

USA

Case–control study

This study compares key nursing home

characteristics, infection prevention and control deficiencies, and five-star ratings among Florida nursing homes with and without resident COVID-19 cases and deaths. The study further examines the association between facility and resident characteristics, quality indicators, and COVID-19 cases and deaths

July to October 2020

686

686 Nursing Homes (2 reports: A—July 26, 2020;

B- October 25, 2020)

Cases1: 499 Nursing Homes with at least one confirmed resident COVID-19 case

Control1: 187 Nursing Homes with no COVID-19 cases

Cases2: 271Nursing Homes with at least one resident COVID-19 death

Control2: 415 Nursing Homes with no COVID-19 deaths

Cases:

A-499*

B-629*

Control:

A-187

B-57

*COVID-19 cases was coded as “yes” if the nursing home had at least one confirmed resident COVID-19 case

Cases:

A-271**

B-456**

Control:

A-415

B-271

**COVID-19

deaths was coded as “yes” if at least one resident COVID-19 death was

reported in the nursing home

NR

Approximately one-fifth to two-fifths of all COVID-19 deaths in

the U.S. occur in nursing homes or other long-term care facilities

The

likelihood of having COVID-19 cases is related to facility size, average occupancy rate, infection prevention

and control deficiencies and low

nurse staffing hours per resident day

Ohta et al. 2021 [37]

Japan

Case–control study

To clarify the effect of coronavirus disease (hereafter, COVID-19) control on patients’ health conditions and staff’s working conditions in rural nursing homes

1 April 2019 to 31 March 202

1

96 participants: all the staff and patients in a rural nursing home

Cases:  48 pre-COVID-19 group (2019–2020)

Control:  48 post-COVID-19 group (2020–2021)

NR

NR

Visits to the outpatient department

Cases (Post-COVID

(2020–2021): 210 visits

Control (Pre-COVID

(2019–2020): 261 visits

Visits to the emergency department

Cases (Post-COVID

(2020–2021):62 visits

Control (Pre-COVID

(2019–2020)

:66 visits

During the

study period, 287 persons were infected with COVID-19 in Shimane prefecture

This study showed that the implementation of strict infection control measures against COVID-19 in a rural nursing home can reduce the contact between the nursing home patients and healthcare staff, without an increase in the number of patients experiencing emergency situations. Due to the

low statistical power of this study, we did not observe any statistically significant results

Orlando 2022 [38]

Italy

Case–control

To understand which organizational –structural characteristics of nursing homes and the preventative measures adopted in response to the pandemic are associated with the risk of a COVID-19 outbreak

March–December 2020

100

Cases: 20 LTCF reported an outbreak COVID-19

Control: 80 LTCF without COVID-19

Cases: 20 LTCF reported an outbreak COVID-19

Control: 80 LTCF without COVID-19

NR

NR

The article does not provide any local or national statistics

There was evidence of a higher risk of

COVID-19

in larger facilities and when new patients

were admitted during the pandemic. All other structural–organisational characteristics and preventative measures were not associated with an outbreak

Stemler et al., 2022 [42]

Germany

Quasi-experimental study

To investigated whether repeated non-mandatory RT-PCR SARS-CoV-2 surveillance of Nursing Homes (NH) staff and visitors reduces COVID-19 incidence rates in NH residents and allows to reduce visiting restriction

From early October 2020 to mid-December 2020 at maximum

4 (2 Interventional Nursing Homes (INH); 2 control Nursing Homes (CNH))

Cases:

2 INH

260 residents

335 Health Care Workers (HCW) (865 tests)

3150 visitors (722 tests)

Control:

2 CNH

261 residents

425 HCW

3649 visitors

Cases:

2 INH

Staff – 23

Visitors – 3

Control:

2CNH NR

Cases:

Residents –23 (8.8%)

Control:

Residents – 4 (1.5%)

NR

At the beginning of the study period, the local incidence

of SARS-CoV-2 in the City of Cologne was 99.4 infections/100,000 inhabitants/week, then rose to a maximum

of 227.9 infections/100,000 inhabitants/week on October

30th, subsequently decreased to a lowest level of 129.3

infections/100,000 inhabitants/week on November 27th,

and then rose again to 161.8 infections/100.000 inhabitants/week by December 18th, 2020

In a real-world setting without available rapid testing, voluntary RT-PCR SARS-CoV-2 testing of HCW and visitors does not prevent COVID-19 outbreaks in NH. Complete, non-selective testing for these groups should be instituted before visiting restrictions can be reduced

Shallcross et al., 2021 [46]

England

Cohort study

To identify factors associated with SARS-CoV-2 infection and outbreaks

among staff and residents in LTCFs

Between May 26 and June 19, 2020

5126

Residents-160033

Staff-248594

Residents-19571

Staff-10630

LTCF at least with one COVID-19 case-2724

Large outbreack-469

NR

NR

LTCFs, which provide care to the elderly and those with

disabilities have experienced among the highest rates of SARS-CoV-2 infection, and

account for 30–50% of all COVID-19 related deaths in countries including the USA,

England,

Scotland,

France, Spain, and Sweden

In the UK, there are an estimated 400,000 residents living in approximately 11,000

LTCFs for the elderly

Reduced

transmission from staff is associated with adequate sick pay, minimal use of agency staff, an increased staff-to-bed

ratio, and staff cohorting with either infected or uninfected residents. Increased transmission from residents is

associated with an increased number of new admissions to the facility and poor compliance with isolation procedures

Lombardo et al., 2021 [74]

Italy

Cohort study

To collect information on the spreading and impact of severe acute respiratory

syndrome coronavirus 2 (SARS‐CoV‐2) infection in nursing homes, and on how

suspected and/or confirmed cases were managed

From March 25 to May 5, 2020

1356

100,806 residents

LTCF:

161 had residents with SARS‐CoV‐2 positive;

381 had had at least one resident with flu‐like symptoms;

278 had SARS‐CoV‐2 positive staff members

Residents: 680 COVID + 

3092 flu‐like symptoms

Residents:

965 SARS‐CoV‐2 +; 

2021 flu‐like symptoms

Italy reported 245,864 cases of COVID-19 and 35,102 related deaths

Larger facility size was significantly (p < 0.05) related to increased

probability of having COVID‐19 cases

Some critical issues characterized NHs with COVID‐19 outbreak

compared to ones without an outbreak, such as lack of personnel,

difficulty in transferring to the hospital or other facility patients or isolating them in a single and NHs with a higher number of

beds

Green et al., 2021 [39]

England

Cohort study

To describe the epidemiology and transmission of COVID-19 in outbreak free care homes

April and May 2020

34

714 residents

22 residents

NR

NR

The article does not provide any local or national statistics

The use of agency staff was associated with an eightfold

increased risk and this needs to be considered in future

support to care homes. Closing shared spaces was not associated

with an increased risk of infection

Cazzoletti et al., 2021 [44]

Italy

Cohort study

To examine the association between certain measurable factors (structural, organizational and practice-related) and the cumulative incidence of COVID-19 among nursing home residents in the Autonomous Province of Trento, Italy, during the peak of the COVID-19 outbreak, the so-called “first wave” (March–May 2020)

From 1 March 2020 to 1 June 2020

45

4158 residents

Cases: 37 LTCF with an outbreak

Control:

20 LTCF without an outbreak

NR

NR

The number of long-term care beds per 100,000 people aged ≥ 65 is two times greater than the national average (38.5 in the Autonomous Province of Trento versus 14.6 in Italy)

This study performed the evaluation in a timeframe covering the entire “first wave” of the COVID-19 epidemic, when containment measures were not fully in place. The cumulative incidence of COVID-19 was higher in the nursing home facilities located in the western area of the province, which borders the Lombardy region, the most affected area during the first phase of the pandemic

Structural/organizational factors and standard IPC measures may not predict the epidemiology of COVID-19 outbreaks and be sufficient alone to protect nursing homes against them

Zimmerman et al., 2021 [40]

USA

Cohort study

This cohort study compared rates of COVID-19 infections, COVID-19 admissions/readmissions, and COVID-19 mortality, among Green House/small nursing homes with rates in other nursing homes

Between January 20, 2020 and July 31, 2020

435

A-Green House/small Nursing Homes—43

B-Traditional Nursing Homes with < 50 beds—177

C-Traditional Nursing Homes with ≥ 50 beds—215

COVID-19 cases per 1000 resident days

(90th Percentile):

A = 0,30

B = 1,61 C = 2,10

A vs B – p = 0,014

A vs C p < 0,001

COVID-19 mortality per 100 positive cases (median):

A = 0 B = 10 C = 12.5

A vs B – p < 0,001

A vs C p < 0,001

COVID-19 admissions/ readmissions per 1000 resident days (90th Percentile):

A < 0.01

B = 0,74 C = 0,49

A vs B – p = 0,007

A vs C p = 0,007

As of January 8, 2021, 6% of COVID-19 cases, and 38% of COVID-19 deaths, have been attributed to long-term care

COVID-19 incidence and mortality rates are less in Green House/small nursing homes than rates in traditional nursing homes with < 50 and ≥ 50 beds, especially among the higher and extreme values. Green House/small nursing homes are a promising model of care as nursing homes are reinvented post-COVID

Brown et al., 2021 [45]

Canada

Cohort study

To develop a reproducible index of nursing home crowding and determine whether crowding was associated with COVID-19 cases and mortality in the first months of the COVID-19 epidemic

From March 29 to May 20, 2020

618

Low Crowding Index – 310 nursing homes

Hight Crowding Index – 308 nursing homes

78 607 residents

Low Crowding Index – 46,028 residents

Hight Crowding Index – 32 579 residents

5218 (6.64%) residents Covid + 

Low Crowding Index – 2071 (4.50%) residents

Vs

Hight Crowding Index – 3147 (9.66%) residents

(p < 0,001)

1452 (1.85%) residents died

Low Crowding Index – 578 (1.26%) residents

Vs

Hight Crowding Index –874 (2.68%) residents

(p < 0,001)

NR

Recent estimates suggest that nursing home residents

comprise approximately 35% of COVID-19 deaths in the US and

between 66 and 81% of deaths in Canada. Compared with

community-dwelling older adults, nursing home residents are

5 times more likely to die of COVID-19

Shared bedrooms and bathrooms in nursing homes are associated with larger and deadlier COVID-19 outbreaks