Covid-19: The Forgotten Frontline

As a number of countries enter their second lockdown, protective measures must be put in place to limit the casualties on the frontline of the pandemic.

Although debate continues to simmer (and occasionally boil over) regarding the Covid-19 pandemic, there is one thing upon which all but the most obdurate can now agree, and that is who among us are most vulnerable to becoming seriously ill or dying from this virus. It is, by a very wide margin, the elderly. Put bluntly, if you are over 75 you are over 100 times more likely to die from this virus.

As Infectious disease researcher, Marm Kalpatrick of University of California Santa Cruz, puts it “…age is by far the strongest predictor of an infected person’s risk of dying.” But there is one particular segment of the elderly who are even more vulnerable still — residents of long-term care facilities (often called ‘care homes’).

In fact, residency in a care home is the single most crucial indicator of age-related mortality when it comes to Covid-19.

In a study of 21 countries by the International Long-term Care Policy Network, care home residents have accounted for 46% of all COVID-19 deaths. Let that sink in for a moment. Almost half. According to data from the European Centre for Disease Prevention and Control care home resident deaths ran to 66% in Spain, 60% in Ireland, 59% in Norway, 51% in Belgium, 50% in France and 40% in the UK. Care homes have become incubators for the virus and their residents have every right to be afraid, particularly when it is unclear what is being done to protect them.

In the US the numbers are just as devastating. According to the Covid Tracking Project, as of October 29, 2020, they account for 40% of US COVID-19 deaths, a total of 89,000 people.

In Canada the percentage of deaths from Covid-19 for people in LTC settings has been an incredible 81%. Even though Canada’s infection mortality rate has remained relatively low it has the highest death rate of LTC residents in the world — two times higher than almost anywhere else. While Sweden received sharp criticism for not doing more to protect its elderly, at the height of the pandemic, you would have been almost twice as likely to die of Covid-19 in a care home in Ottowa than in Stockholm.

How is it that these shocking statistics have not received more attention? For one thing many countries did not begin to publicly report care home deaths until the pandemic was well underway. To complicate matters, not all countries carry separate data for care homes, and some have none at all. There are also differences in how care home residents who die in hospital are counted into the statistics.

France was one of the first to begin such reporting, but even so, it was not until April 2nd — a full six weeks after the first reported Covid-19 fatality. The UK government’s Health Ministry also did not initially report care home deaths, and when it did their figures contradicted the data coming from the Office for National Statistics (ONS). It wasn’t until May that it was discovered that Covid-related deaths in care homes were over 50% higher than previously thought accounting for 47% of all fatalities.

Researchers from Tel Aviv University crunched data from 32 countries. They found a startling correlation between care home beds and Covid-19 fatalities. The highest death rates among LTC residents were in countries with a higher proportion of care home beds to population, such as the UK, Italy, Spain and Belgium. Their findings refute those who claim that such people would have died anyway. Without the institutionalization, they say, many of these people would still be alive. In countries such as Albania and Greece fared better, even though the health care systems were less robust because they still have a tradition of caring for their elders at home. The researchers conclude that “living in long-term care facilities is a significant risk factor for death from COVID-19”.

The word ‘death’ however, doesn’t do the reality justice. A seniors’ home in Montreal, Canada launched a criminal investigation after 31 residents died in under a month after terrified staff abandoned the home and residents were found by health officials in conditions that one source described as like a “concentration camp.”

There were (two) patients who were dead in their beds,” the source added in a story by the Montreal Gazette. “Their deaths had not been recognized. There were patients who had fallen on the floor. There were patients who hadn’t had any basic care for a number of days, diapers that hadn’t been changed for three or four days, excrement that was covering their skin and patients who hadn’t been fed. At a care home in the Southern Ile-de-France region at least 24 of 140 residents were reported to have died in only five days. Authors of a study that intervened at this care home did not observe any evidence among these fatalities of the acute respiratory distress syndrome associated with Covid-19. Instead, it appears that the residents had died of starvation from neglect. ‘Most of the victims had been left alone in their rooms for days without help because of the lack of protective masks and the work overload for caregivers affected by a 40% staff absenteeism rate.’

So how did it get so bad? Researchers are now getting a clearer picture. The lack of clear directives and the chaos prevailing in hospitals at the height of the pandemic in April led to Covid-19 positive patients being discharged from hospitals directly into care homes — a practice that Raffaele Antonelli Incalzi, head of the Italian geriatric society SIGG, in a statement in early April, caused care homes to become “biological time bombs.”

Add this in with blanket Do-Not-Resuscitate (DNR) orders, and unprepared and undervalued staff with without training or protocols, no access to testing or PPE, and you achieve a perfect storm. The UK government advised that the elderly in nursing homes were “very unlikely” to be infected, and this misplaced optimism dominated health policy in this sector for the next two and a half weeks. It was withdrawn on March 13, but by that time the damage had been done.

According to a recent report by Amnesty UK who are calling for a public inquiry, the UK government “effectively abandoned” care home residents to their fate. Kate Allen, Director of Amnesty International UK, has called it ‘a scandal of monumental proportions.’ Public inquiries into care home deaths have also been called for in Italy and the US.

Acknowledging the problem and the failure of an adequate response is essential to addressing it. Sweden had high numbers of care home deaths, and yet their health ministry has at least admitted its mistake. By contrast, the UK government continues to defend its response, saying that it had created a “protective ring” around care homes where it had implemented an early lockdown, a claim which has yet to be substantiated.

Other factors have also contributed to care home casualties. Staff in long-term care facilities are the most poorly payed in the health care sector and are mostly part-time. This means that they often take on second jobs at other LTC facilities to make ends meet, making them vectors for the virus. Carl Heneghan, professor of evidence-based medicine at the University of Oxford, describes this staff movement as having “huge” significance in allowing the infection to spread.

The Canadian Institute for Health Information conducted an international analysis after the shocking discovery that the percentage of their care home deaths from Covid-19 was the highest in the world. They found that countries that did better (Australia, Austria, the Netherlands, Hungary, Slovenia) had a number of things in common, including:

· Higher ratio of health care workers to residents.
· Better centralized regulation and organization of facilities.
· More effective prevention measures, including broad COVID-19 testing and tracing in homes, isolation wards to manage clusters, and PPE kits.
· Better treatment of staff.

The close living quarters of the residents, with open plan layouts of shared dining areas and commons rooms make care homes a challenging environment protecting from a highly contagious virus like Covid-19. But before we simply assume that it is not possible to protect LTC residents from the pandemic, it’s worth taking a look at Hong Kong where there have been zero care home deaths from the virus among this population. That’s right, zero. Even though Hong Kong has one of the highest proportions of LTC residents in the world. They had learned their lessons from SARS in 2003, where 72 percent infection rate. LTC facilities were required to have a designated, government-trained infection-control officer and to maintain at least a month’s supply of face masks and other PPE. Residents suspected of having contracted Covid were isolated in hospital coronavirus wards outside of the care home until they had tested negative for the virus at least twice.

State and local authorities need to prioritize testing in LTC including staff and visitors and immediately reorient their health policies towards LTC residents. Any still existing policy of discharging hospitalized Covid positive patients back into care homes should be rescinded without delay.

As for the question of visiting rights. It is becoming increasingly clear that simply banning the visits is not the way forward, since family members often play a direct and vital role in the residents psychological and physical health. A 50-page WHO policy brief published July 24, 2020: Preventing and managing COVID-19 across long-term care services, criticizes blanket measures to reduce infection in such facilities such as banning outdoor exercise or visits by family members, which increases the psychological suffering of the residents, calling instead for measures that are ‘appropriate and tailored’.

Family visits obviously pose challenges in a pandemic setting but they can surely be managed in ways to protect those involved. One idea would be for family members to provide regular negative test results along with the usual precautionary measures such as social distancing and proper PPE. Many airlines already require a negative Covid test before the flight, so surely it makes sense to require them for visits to places where the risks of contagion are even higher.

Emmanuel Macron made the right decision to allow family members to visit their loved ones in care homes for the second lockdown in France, but it is still unclear exactly what is being done to ensure that this population get protection they deserve and desperately need. Figures from November 6 are ominous, and reveal that almost one-third of the ‘clusters’ in France are in care homes. The very term ‘care home’ becomes jarringly ironic in light of the evidence.

The picture is a damning indictment of the way that elderly in care homes do not win the value of other populations. They are voiceless, marginalized and in many ways forgotten. Colin Furness, an infection-control epidemiologist at the University of Toronto, says, “The reality is that we as a society are so neglectful of people who are institutionalized in long-term care homes. We just don’t face it.”

Back in April, Pope Francis held a Mass for the elderly, with a focus on those in care homes and addressed the tendency to under appreciate both their suffering and their contribution to society. “They are our roots, our story, our history,” he said.

Even as governments across Europe put their populations into another strict lockdown to fight the pandemic, it is hard to see how these measures will do much to mitigate the death toll without a clear plan to protect those on the frontlines, who are many times more at risk. How governments respond to the care home crisis, says the WHO, will be ‘one of the fundamental and essential steps in mitigating the COVID-19 pandemic’. But can we afford to wait for healthcare authorities to take action as care home deaths continue to mount? If you have a loved one in a care home, the answer can only be a resounding “no”.