Analysis of the fight against the COVID-19 pandemic in long-term care facilities in the pre-vaccination period

Carvalho, Jáder Freitas Maciel Garcia de; Santos, Rodrigo Ribeiro dos; Couto, Alcimar Marcelo do; Neves, Juliana Santos; Moraes, Flávia Lanna de; Deslandes, Cristiana Ceotto; Jardim, Viviane Rodrigues; Tavares, Thiara Joanna Peçanha da Cruz; Azevedo, Raquel Souza; Moraes, Edgar Nunes de

doi:10.1016/j.bjid.2024.103748

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Brazilian Journal of Infectious Diseases

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Original Article • Braz J Infect Dis 28 (3) • 2024 • https://doi.org/10.1016/j.bjid.2024.103748 copy

Analysis of the fight against the COVID-19 pandemic in long-term care facilities in the pre-vaccination period

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction

The COVID-19 pandemic has disproportionately affected individuals residing in Long-Term Care Facilities (LTCFs), necessitating tailored strategies to manage outbreaks. This study examines the outcomes of the ILPI BH project, a collaborative effort between the Municipal Health Department and the Hospital das Clínicas of the Federal University of Minas Gerais, designed to mitigate COVID-19 spread within LTCFs.

Methods

Prospective cohort of secondary data: 1,794 old residents in 99 long-term care facilities of Belo Horizonte, Brazil, were followed from May 2020 to January 2021. The study analyzed the prevention strategies, residents’ clinical data, and the characteristics of the long-term care facilities, correlating these variables with the number of infections, hospitalizations, and deaths from COVID-19. It checked absolute numbers and rates of incidence, hospitalization, mortality, and lethality.

Results

There have been 58 COVID-19 outbreaks in long-term care facilities. There were 399 cases among residents, 96 hospitalizations for COVID-19 and 48 deaths from COVID-19 (2.7 % of the cohort), with a case fatality rate of 12 %. After multivariate analysis, the intrinsic variables to residents associated with higher mortality risk were higher degree of frailty (OR=1.08; p = 0.004) and the fact of living in a long-term care facility with a considerable proportion of residents’ coverage by health plans (OR = 1.01; p = 0.028). Early geriatric follow-up showed an association with a reduction in the number of hospitalizations due to COVID-19.

Conclusion

The correct classification of the degree of frailty of institutionalized older people seems to have been relevant for predicting mortality from COVID-19. The extensive assistance by private health plans, contrary to what is supposed, did not result in better health protection. Early geriatric follow-up was beneficial and may be an attractive strategy in the face of health emergencies that affect long-term care facilities to reduce hospital admissions.

Keywords
COVID-19; Long-term care facilities; Prevention; Pandemic; Health strategies

	Philanthropic	Private	Total	p
LTCF, n	27	72	99
Residents by group, n (average per LTCF)	796 (29.4)	998 (13.9)	1794 (18.1)
Median number of residents per LTCF (Q₁‒Q₃)	22 (17‒35)	14 (10‒16)	15 (11‒20)	<0.001^a
Health Vulnerability Index, median (Q₁‒Q₃)	2 (1‒2)	1 (1‒2)	1(1‒2)	0.005^a
Female sex	597	645	1242	<0.001^a
Age, median	81	81	81	0.339^b
VFS of the residents, median	8	8	8	0.663^b
IVCF-20 of the residents, median	21	19	20	<0.001^b
Classification by RCBD 502/2021, median	3	2	2	<0.001^b
Prevalence of diabetes, n (%)	204 (25.6)	204 (20.4)	408	0.009^a
Prevalence of systemic arterial hypertension, n (%)	498 (62.6)	534 (53.5)	1032 (57.5)	<0.001^a
Coverage by health plans, n (average per LTCF in%)	69 (10.5)	427 (42.2)	496 (27.6)	<0.001^a

	Philanthropic	Private	Total
Outbreaks, n (%)	33 (56.9)	25 (43.1)	58 (100)
Early Geriatric Care, n (%)	15 (45.4)	4 (16.0)	19 (32.8)
Early transfer to UAPI, n (%)	6 (18.2)	4 (16.0)	10 (17.2)
Transfer to UAPI, even after 48 h, n (%)	24 (72.7)	12 (48.0)	36 (62.1)
Use of chatbot on the eve of the outbreak, n (%)	14 (42.4)	10 (40.0)	24 (41.4)
Incidence of COVID-19 among residents, n (%)	253 (31.8)	146 (14.6)	399 (22.2)
Hospitalizations due to COVID-19, n (average%)	50 (6.2)	46 (4.6)	96 (5.4)
COVID-19 deaths, n (mean%)	28 (3.5)	20 (2)	48 (2.7)
Incidence of COVID-19 among employees, n	170	41	211

Characteristic of the resident	Univariate Analysis		Multivariate Analysis
Characteristic of the resident	Death from COVID OR (95 % CI)	P	Death from COVID OR (95 % CI)	p
Lives in a philanthropic LTCF	1.04 (0.54; 2.0)	0.91	‒	‒
Female sex	1.4 (0.71; 2.75)	0.33	‒	‒
Health Plan	1.68 (0.79; 3.55)	0.171	‒	‒
Diabetes	1.18 (0.58; 2.42)	0.647	‒	‒
Systemic Arterial Hypertension	1.02 (0.53; 1.96)	0.954	‒	‒
Polypharmacy	1.33 (0.66; 2.7)	0.428	‒	‒
Number of residents in the same LTCF	1.00 (0.99; 1.02)	0.653	‒	‒
% Coverage by health plans^a a Percentage of elderly covered by health plans, among the total number of older people living in the same LTCF as the infected elderly.	1.01 (1.01; 1.02)	0.034	1.012 (1.001; 1.024)	0.028
Age	1.03 (0.99; 1.06)	0.088	‒	‒
Fragility by VFS^b b Visual Frailty Scale.	1.28 (1.01; 1.61)	0.041	‒	‒
Fragility by IVCF-20 score^c c Clinical Functional Vulnerability Index. Note: Sample unit: individuals living in LTCF who were infected by COVID-19 (n = 343).	1.07 (1.02; 1.13)	0.005	1.076 (1.023; 1.132)	0.004
Fragility for the DRC 502/2021	1.06 (0.56; 2.03)	0.851	‒	‒
Chatbot usage ratio by LTCF	0.99 (0.99; 1.00)	0.179	‒	‒

Variables	Outcomes Correlation coefficient (95 % CI)
Variables	N° of Infections (residents)	Number of admissions (residents)	Number of Deaths (residents)	N° of infections (employees)
Philanthropic LTCF	0.16 (−0.12; 0.46)	−0.12 (−0.41; 0.19)	0.12 (−0.18; 0.4)	0.4^a a p-value < 0.05. Note: Univariate analysis; sample unit: COVID-19 outbreaks; for the analysis of the categorical variable referring to the character of the LTCF, the value “zero” was assigned for private LTCF and “one” for philanthropic LTCF. (0.11; 0.65)
N° of residents	0.34^a a p-value < 0.05. Note: Univariate analysis; sample unit: COVID-19 outbreaks; for the analysis of the categorical variable referring to the character of the LTCF, the value “zero” was assigned for private LTCF and “one” for philanthropic LTCF. (0.06; 0.58)	−0.19 (−0.47; 0.1)	0.19 (−0.13; 0.5)	0.41^a a p-value < 0.05. Note: Univariate analysis; sample unit: COVID-19 outbreaks; for the analysis of the categorical variable referring to the character of the LTCF, the value “zero” was assigned for private LTCF and “one” for philanthropic LTCF. (0.11; 0.67)
Use of chatbot before the outbreak	−0.07 (−0.36; 0.22)	−0.13 (−0.44; 0.21)	−0.16 (−0.44; 0.12)	−0.18 (−0.44; 0.13)
Early Transfer	−0.18 (−0.5; 0.2)	−0.43^a a p-value < 0.05. Note: Univariate analysis; sample unit: COVID-19 outbreaks; for the analysis of the categorical variable referring to the character of the LTCF, the value “zero” was assigned for private LTCF and “one” for philanthropic LTCF. (−0.62; −0.21)	−0.11 (−0.34; 0.17)	−0.02 (−0.34; 0.32)
Early geriatric follow-up	0.07 (−0.27; 0.32)	−0.44^a a p-value < 0.05. Note: Univariate analysis; sample unit: COVID-19 outbreaks; for the analysis of the categorical variable referring to the character of the LTCF, the value “zero” was assigned for private LTCF and “one” for philanthropic LTCF. (−0.64; −0.19)	−0.19 (−0.42; 0.09)	0.19 (−0.15; 0.51)

Associated outcome	Variable	Beta (95 % CI)	Standard error	p
Number of infections among employees	N° of residents per LTCF	0.11 (0.06; 0.17)	0.28	<0.001
Number of hospitalizations among residents	Early geriatric follow-up	−1.98 (−3.78; −0.17)	0.89	0.032

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[1] ⁎ Corresponding author. E-mail address:drjaderfreitas@gmail.com (J.F.M.G.d. Carvalho)

COVID-19 outbreaks, n (monthly average)	58 (6.4)
Infections in residents, n (mean monthly)	399 (44.3)
COVID-19 hospitalizations, n (monthly average)	96 (10.6)
Hosted at UAPI, n (monthly average) ^* ⁎ Source: Own authorship, except the data referring to the UAPI. Source: Epidemiological and care bulletins of the Municipal Health Secretariat of Belo Horizonte.	324 (36)
- Confirmed cases, n (monthly average)	158 (17.6)
- Confirmation ratio^a a Percentage of confirmed cases of COVID-19 among the total number of older people received in the period. (%)	48.8
- Cases that have worsened^b b Cases of COVID-19 or other pathologies that were isolated in the UAPI and had to be transferred to the UPA or hospitals due to worsening health condition. , n (monthly average)	60 (6.7)
- Deaths occurring in the UAPI	0
COVID-19 deaths, n (monthly average)	48 (5.3)
Infections in employees, n (average monthly)	211 (23.4)
Case fatality rate (%)	12.0