ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
1
Mortality associated with COVID-19 in care
homes: international evidence
Adelina Comas-Herrera, Joseba Zalakaín, Elizabeth Lemmon, David
Henderson, Charles Litwin, Amy T. Hsu, Andrea E. Schmidt, Greg Arling
and Jose-Luis Fernández
Last updated 14 October 2020
Authors
Adelina Comas-Herrera (Care Policy and Evaluation Centre, London School of Economics and Political Science),
Joseba Zalakaín (SiiS), Elizabeth Lemmon (Edinburgh Health Economics, University of Edinburgh), David
Henderson (Edinburgh Napier University, Scottish Centre for Administrative Data Research), Charles Litwin (Care
Policy and Evaluation Centre, London School of Economics and Political Science), Amy T. Hsu PhD (University of
Ottawa Brain and Mind Research—Bruyère Research Institute Chair in Primary Health Care Dementia Research),
Andrea E. Schmidt (Austrian National Public Health Institute), Greg Arling (School of Nursing, Purdue University,
US), Jose-Luis Fernández (
Care Policy and Evaluation Centre, London School of Economics and Political Science)
ltccovid.org
This document is available through the website ltccovid.org, which was set up in March 2020 as a rapidly shared
collection of resources for community and institution-based long-term care responses to Covid-19. The website
is hosted by CPEC at the London School of Economics and Political Science and draws on the resources of the
International Long Term Care Policy Network.
Corrections and comments are welcome at info@ltccovid.org
. This document was last updated on 14 October
and may be subject to revision.
Copyright: © 2020 The Author(s). This is an open-access document distributed under the terms of the Creative
Commons Attribution NonCommercial-NoDerivs 3.0 Unported International License (CC BY-NC-ND 3.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source
are credited. See http://creativecommons.org/licenses/by-nc-nd/3.0/.
Suggested citation
Comas-Herrera A, Zalakaín J, Lemmon E, Henderson D, Litwin C, Hsu AT, Schmidt AE, Arling G and Fernández J-L
(2020) Mortality associated with COVID-19 in care homes: international evidence. Article in LTCcovid.org,
International Long-Term Care Policy Network, CPEC-LSE, 14 October.
Acknowledgements
The authors would like to thank Rochelle Amour, Liz Ashcroft, Annette Bauer, David Bell, Paul Cullen, Shuli
Brammli, Robert Gal, Pete Kinross, Kai Leichsenring, Klara Lorenz-Dant, Lee-Fay Low, Norwegian newspaper VG,
Alenka Oven, Andreia Paiva, Eleanora Perobelli, Maria Pierce, Katrin Seeher, Emma Reynolds, Tine Rostgaard,
Marta Szebehely, Heidemarie Staflinger, Courtney van Houtven and Sharona Zadok.
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
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1. Key findings
• Official publicly available data on the numbers of deaths among care home residents linked to
COVID-19 is not available in many countries.
• International comparisons are difficult due to differences in testing capabilities and policies,
different approaches to recording deaths, and differing definitions of what constitutes a “care
home”.
• There are three main approaches to quantifying deaths in relation to COVID-19: deaths of
people who test positive (before or after their death), deaths of people suspected to have
COVID-19 (based on symptoms or epidemiologically linked), and excess deaths (comparing total
number of deaths with those in the same weeks in previous years). Another important
distinction is whether the data covers deaths of care home residents or only deaths in the care
home (as there are variations in the share of care home residents who are admitted to hospital
and may die there).
• Despite the difficulties arising from differences in definitions, in almost all countries where there
have been deaths linked to COVID-19, a substantial proportion of those deaths were among care
home residents. Based on the data gathered for this report, the current average of the share of
all COVID-19 deaths that were care home residents is 46% (based on 21 countries).
• To compare the relative impact of COVID-19 on care home residents in different countries it
may be more useful to focus on the share of all care home residents whose deaths have been
linked to COVID-19. We found that that, for the countries where this data is available, the share
of all care home residents who have died (linked to COVID-19) ranges from 0.01% in South
Korea to over 4% (which would mean that over one in 25 care home residents have died linked
to COVID-19) in Belgium, Ireland, Spain, the UK and the US. This share is highly correlated to
the total number of COVID-19 deaths in the population who live outside care homes.
• It is also worth noting that whilst the focus of this report is on care homes, many older people
receive care in the community. Currently, there is limited evidence from anywhere in the world
on how those individuals have been directly or indirectly affected by COVID-19.
2. Measuring the impact of COVID-19 on care home residents and
staff: imperfect and limited data
International evidence has shown that people living in care homes are particularly vulnerable to severe
COVID-19 infections and they have experienced high rates of mortality as a result. There are also
numerous examples from those countries of care homes becoming unviable, as not enough staff are
available due to sickness and self-isolation measures.
This document uses “care homes” for all non-acute residential and nursing facilities that house people
with some form of long-term care needs. It is important to note that what is considered a care home is
different in most countries and as a result, this means that the data summarised in this report is not
strictly comparable. We have sought to use a consistent definition within each country for both the
number of deaths in care homes, and the total population living in care homes.
Another difficulty in comparing data on deaths is that in some countries the data only record the place
of death, while others also report deaths in hospital of care home residents. We have tried to clarify this
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
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where possible. There may also be differences in the extent to which care home residents are
transferred to hospital or not.
The authors of this report are fully aware of the limitations of existing data and do not consider that the
data presented here are directly comparable, however, the differences on the impact of COVID-19
related mortality in care homes between countries are large, suggesting very different international
experiences.
Data on the COVID-19 impacts among people living in care homes is important, as, if the levels of
infections and deaths of care residents and staff are not measured in a timely (even if imperfect)
manner, there is a danger that opportunities to alert policymakers to the scale of the impact of COVID-
19 in care homes will be missed. This may result in allocations of scarce resources (including testing,
personal protection equipment, medical personnel and medicines) that leave out the settings that are
experiencing some of the biggest challenges in relation to COVID-19.
This document, which will continue to be updated and improved as new information and data become
available, summarises information from three types of sources: epidemiological studies, official
estimates and news reports and relies on national experts for confirmation of sources and definitions.
The countries that are included are those for which the authors had information, mostly with thanks to
the authors of the LTCcovid.org country reports on the COVID-19 long-term care situation, or where
information was accessible through official websites. The authors are grateful for information that
enables the addition of more countries.
3. Methods to estimate deaths linked to COVID-19
There are three main approaches to recording deaths linked to COVID-19. It is important to understand
the differences in the data that is obtained through these different approaches, and to consider the role
of each of these approaches in terms of generating the information that is needed to develop strategies
to reduce the impact of COVID-19.
a. Numbers of deaths of people who have tested positive for COVID-19
If it were possible to test everyone suspected of having COVID-19, either while still alive or post-
mortem, this method would offer the most accurate count of the numbers of people who have died
while being infected with COVID-19. These data are very important to learn more about the
epidemiology of the disease and how it affects people with different characteristics and underlying
health conditions in terms of case fatality, long–term sequelae, etc.
Under this definition, the new International Classification of Diseases, Tenth Revision (ICD-10)
emergency code U07.1 is used in mortality coding. Specifically, this code is used when COVID-19 has
been confirmed by laboratory testing, irrespective of severity of clinical signs or symptoms
1
.
This approach has several limitations in terms of offering an estimate of the impact of the disease in the
population or among a certain population group. The first limitation is that very few countries have the
capacity to test all people with symptoms
2
. The second is that, particularly among care home residents
who have underlying health conditions, the infection may present with atypical symptoms (such as
1
https://icd.who.int/browse10/2019/en#/U07.1
2
https://read.oecd-ilibrary.org/view/?ref=129_129658-l62d7lr66u&title=Testing-for-COVID-19-A-way-to-lift-confinement-
restrictions
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
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delirium) that may be attributed to other potential conditions (for example urinary tract infections) and,
as a result, it is possible that some people may not be tested because their symptoms are not identified
as potential COVID-19. It is also important to note that in many countries, at least initially, care homes
were not prioritised for testing, which means that relying on the numbers of people who died with a
positive test for COVID-19 would leave out most of the deaths that happened in care homes. Another
limitation of this approach is that it does not include deaths that are indirectly linked to COVID-19, for
example, due to people not using health care services for other conditions, or due to difficulties linked
to social isolation measures.
b. Number of deaths of people suspected of having COVID-19
Another approach to measure deaths linked to COVID-19 is to count suspected cases, as is currently
done in Belgium, Canada, France, Ireland, the United Kingdom, some regions of Spain and the United
States. In the short-term, this approach has the advantage of providing timely information that is not
subject to biases introduced by testing priorities. In terms of estimating the number of deaths in care
homes, particularly where initial testing priorities were entirely focused on hospital, a system that
records suspected cases can provide important timely information on the potential scale of deaths
linked to COVID-19 in care homes and private households. Such information can be used to support
decisions, for example, to increase testing in care homes or of staff that provide care in private homes,
as we have observed in Ontario, Canada. However, this approach has the risk of miss-attribution of
deaths and could lead to an overestimation of fatalities attributable to COVID-19. Not surprisingly,
countries that have taken this approach report higher proportions of deaths due to COVID-19 than
countries that report deaths among confirmed cases only (see figure 1 in this report).
Under this definition, ICD-10 emergency code U07.2 is used in mortality coding. Specifically, this code
should be used when COVID-19 is diagnosed clinically or epidemiologically but laboratory testing is
inconclusive or not available
3
.
c. Number of excess deaths during the COVID-19 pandemic compared to
previous years
Comparing the deaths during the COVID-19 pandemic to deaths that have happened in previous years in
the same weeks or months (“excess mortality”) is the most accurate way to estimate the mortality
impact of COVID-19. This approach has the advantage of including deaths that are indirectly linked to
COVID-19. These data on mortality will typically be collected by national statistical offices through the
registration of deaths. It is important to note that in most countries there is a lag between the date in
which a death occurs, and the date in which it is registered, and that disaggregation by place of death
(for example between hospital, care homes and private homes) is not always made available in a timely
manner. Excess deaths should also take into account year-on-year variability in weekly death rates,
which can be affected by, among other things, seasonal flu outbreaks. Ideally, comparisons should show
the range of deaths on each week over a historical time period – such as the previous five years.
3
https://icd.who.int/browse10/2019/en#/U07.1
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4. International data on mortality associated with COVID-19 among
care home residents
This section describes the data available in as many countries as the authors have been able to find, in
many cases with thanks to national experts, including those who have contributed to LTCcovid.org
country reports.
It is very important to note that the data reported here are not directly comparable. Data from official
sources have been used where possible, and, when not available, information from official
announcements collected in reliable news sources have been collected. We have tried to be as explicit
as possible about the approaches to data collection in each of the countries and about potential caveats.
All data sources are acknowledged in the footnotes, with links where possible to facilitate checking and
updating.
Australia
The Department of Health of the Australian Government first published deaths linked to COVID-19 in
care homes on the 15
th
of April, as well as deaths among users of home care services. By 11
th
October
there have been 2,050 confirmed cases of COVID-19 infections among government-subsidized residents
in aged care facilities, 97% of which were in the state of Victoria. There have also been 677 deaths
among residents (95% of those in Victoria). Among people who use government-subsidized home care,
there had been 82 cases of infections and 7 deaths
4
. A weekly report (data from 9
th
October) also
includes data on the number of outbreaks and staff infected in care homes. By the 9
th
October
5
there
were 35 care homes with active outbreaks (involving 21 residents and 15 staff) and in total there had
been 2,217 staff with COVID-19 infections.
In total, by the 9
th
October, there had been 27,286 cases and 898 deaths, suggesting that 75% of all
COVID-19 deaths so far in Australia have been among care home residents. These figures are based on
people who have tested positive for COVID-19 and are for the place of residence, not place of death
(may include residents who died in hospital).
In 2020 there were approximately 208,500 people living in aged care residential accommodation in
Australia
6
, so the numbers of deaths so far would amount to 0.32%.
Austria
Data from the 17
th
September
7
shows that, up to that date, 1,170 residents in care homes (including all
ages) tested positive for COVID-19 and of these, 276 had died with COVID-19. Compared to the 771 total
deaths linked to COVID-19 in Austria on the same date, deaths of care home residents would represent
36% of all deaths (data from the Austrian epidemiological alert system). There have been 756 cases
among staff in care homes, but no deaths among staff.
4
https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-
situation-and-case-numbers#cases-in-aged-care-services
5
https://www.health.gov.au/sites/default/files/documents/2020/10/covid-19-outbreaks-in-australian-residential-aged-care-
facilities-9-october-2020_1.pdf
6
https://www.aihw.gov.au/reports/australias-welfare/aged-care (calculated as number of residents minus those using
temporary respite care)
7
https://goeg.at/PK_COVID-19_in_Alten-_und_Pflegeheimen
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
6
At the end of 2018 there were 69,730 residents in care homes in Austria, using this as the denominator
for the total number of care home residents, 0.4% of care home residents would have died with COVID-
19
8
.
Belgium
Belgium first reported official estimates of the number of deaths in care homes on the 11
th
April. The
data is collected by Sciensano, a public research institution, which publishes very detailed
epidemiological daily reports on COVID-19
9
. They include data on the number of deaths in care homes
(“maisons de repos”). As of the 15
th
April, reports have also included the number of tests done within
care homes. For deaths outside hospital, Belgium reports both “confirmed” cases (through a test or,
since the 1
st
April, a chest scan), and “suspected” cases where the patient had not been tested but a
doctor confirmed that their symptoms were consistent with COVID-19.
On 11
th
October, there had been 10,175 deaths linked to COVID-19 in Belgium, of these, 4,892 people
died in care homes (48%). This number also includes suspected cases.
Data on the number of care home residents who died in hospital is only publicly available up to the 20
th
June. Of the 6,249 deaths linked to COVID-19 up to that date, 22% (1,377) happened in hospital. On that
date, there had been 9,731 deaths in total, so including the deaths of care home residents in hospital
would bring the share of deaths of care residents compared to all deaths to 64%
10
. The weekly bulletin
11
of the 19
th
June reports estimates that in total, there had been 6,213 deaths of care home residents,
including 1,353 deaths in hospital and 15 in other locations, 21.8% of care home residents had died in
hospital. Based on this, 64% of all deaths linked to COVID-19 in Belgium would have been of care home
residents.
Belgium has an estimated 125,000 people aged 65 and over living in care homes
12
, the number of care
home residents whose deaths are linked to COVID-19 so far would represent 4.9% of all care home
residents aged 65 or over, without including the care home residents who died in hospital, the share
would be 3.9%.
Since the 10
th
of April, 611,384 tests have been carried out in care homes, this would have included tests
on staff, but to give an idea of the scale, compared to the number of care home residents, this would be
equivalent to 4.89 tests per resident
13
.
On the 26
th
August, the data on COVID-related deaths in Belgium was corrected using a retrospective
detailed survey of deaths in care homes in Flanders. This resulted in the elimination of duplicated
entries and mis-coded cases for the period between the 18
th
March and the 2
nd
June. As a result the
8
BM Arbeit, Soziales, Gesundheit und Konsumentenschutz (BMASGK) (2019), Österreichischer Pflegevorsorgebericht (Austrian
Report on Long-term Care 2018), Vienna, BMASGK.
8
9
https://covid-
19.sciensano.be/sites/default/files/Covid19/Derni%C3%A8re%20mise%20%C3%A0%20jour%20de%20la%20situation%20%C3%
A9pid%C3%A9miologique.pdf
10
https://covid-19.sciensano.be/sites/default/files/Covid19/COVID-19_Weekly%20report_20200626%20-%20FR_0.pdf
11
https://covid-19.sciensano.be/sites/default/files/Covid19/COVID-19_Weekly%20report_20200619%20-%20FR.pdf
12
https://kce.fgov.be/fr/les-maisons-de-repos-ne-se-pr%C3%A9parent-pas-un-avenir-de-tout-repos
13
https://covid-
19.sciensano.be/sites/default/files/Covid19/Derni%C3%A8re%20mise%20%C3%A0%20jour%20de%20la%20situation%20%C3%
A9pid%C3%A9miologique.pdf
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
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total number of deaths in Belgium up to the 26
th
August was adjusted to 9,878 (instead of 9,999) and
the total number of deaths in care home residents in Flanders was adjusted to 2,623 instead of 2,744
14
Brazil
There are no official data on the number of cases and mortality related to COVID-19 in Brazilian care
homes, nor on the profile of the residents who have died. A report published in September 2020 found
that, based on data collated informally by the researchers, there have been over 4,015 confirmed cases
and 937 deaths in Brazilian care homes, which represents a case fatality rate of 23.33%. Nearly 65% of
care home managers reported to be currently experiencing financial difficulties
15
.
Canada
On March 5, the first outbreak in a Canadian long-term care home was reported in the province of
British Columbia (BC), where a staff member at the Lynn Valley Care Centre in Vancouver had tested
positive for COVID-19
16
. On March 8, a resident at the home became the first Canadian to die from
COVID-19. Since early March, BC’s Provincial Health Officer has provided regular updates to the public
on the number of cases and deaths in care homes through press conferences. Similarly, many other
provincial medical officers of health and premiers have provided frequent updates on the spread of
COVID-19 in Canadian care homes. Some jurisdictions have been publishing updates on care homes
systematically as part of the provinces’ epidemiological reports since late-March, such as the ones
produced by the BC Centre for Disease Control
17
starting on March 23 and Public Health Ontario on
March 31
18
. As of October 1, 8 of 13 Canadian provinces and territories still have had either no or very
few cases in care homes
19
.
According to the 2016 Census, 425,755 Canadians live in long-term care or retirement homes as well as
assisted living facilities. Data collected by Hsu et al
20
and the NIA’s Long-Term Care COVID-19 Tracker
Open Data Working Group, as of the 1
st
of October, found that approximately 20,994 of these residents
(representing 4.9% of all residents in care homes) had been infected with COVID-19, and 7,411 of them
died as a result (1.7% of all care home residents). This amounted to 80% of all COVID-19 deaths in
Canada.
Due to variation in reporting across the provinces, we are unable to determine whether the location of
death was in a care home at this time. It is important to note that, in Canada, many official sources have
been reporting total counts of deaths in care homes, whether or not COVID-19 was determined to be a
contributing or underlying cause of death. This may have inflated the estimates of the proportion of
deaths due to COVID-19. Unfortunately, given the low rates of testing early on in the pandemic, some
14
https://covid-19.sciensano.be/sites/default/files/Covid19/MORTALITE%20COVID-
19%20%E2%80%93%20MISE%20%C3%80%20JOUR%20DES%20DONNEES%20%E2%80%93%2026%20AO%C3%9BT%202020.pdf
15
Wachholz PA, Ferri CP, Mateus E, Da Mata F, Villas-Boas P, Watanabe HAW, Oliveira D. The COVID-19 situation in Brazilian
care homes and actions taken to mitigate infection and reduce mortality. LTCcovid.org, International Long-Term Care Policy
Network, CPEC-LSE, September 2020. https://ltccovid.org/2020/09/14/updated-report-covid-19-situation-in-brazilian-care-
homes-and-actions-taken-to-mitigate-infection-and-reduce-mortality/
16
https://www.theglobeandmail.com/canada/article-how-the-coronavirus-took-north-vancouvers-lynn-valley-care-centre/
17
http://www.bccdc.ca/health-info/diseases-conditions/covid-19/data
18
https://www.ontario.ca/page/how-ontario-is-responding-covid-19#section-0
19
https://ltccovid.org/wp-content/uploads/2020/04/LTC-COVID19-situation-in-Canada-22-April-2020-1.pdf
20
Hsu AT, Lane NE, Sinha SK, Dunning J, Dhuper M, Kahiel Z, Sveistrup H. Report: Understanding the impact of COVID-19 on
residents of Canada’s long-term care homes — ongoing challenges and policy responses. LTCcovid, International Long-Term
Care Policy Network, CPEC-LSE, 10 May 2020 https://ltccovid.org/wp-content/uploads/2020/05/LTCcovid-country-
reports_Canada_Hsu-et-al_May-10-2020-2.pdf
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
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residents who died remain suspected rather than confirmed cases without post-mortem testing.
Comparing the deaths during the COVID-19 pandemic to deaths during the same period in previous
years (e.g., in the same weeks or months to determine the excess mortality) may be the best way to
estimate the true mortality impact of COVID-19.
Denmark
21
By the 6
th
October, there had been confirmed COVID-19 infections in 16% of Danish nursing homes (145
out of 937). 675 residents in nursing homes in Denmark had tested positive for COVID-19 and 232 of
these had died
22
. In the total population, 663 COVID-19 related deaths were confirmed, the share of
confirmed deaths among nursing home residents was 35%.
There were just over 40,000 nursing home residents in Denmark, this suggests that 0.6% of nursing
home residents would have died from confirmed COVID-19. 19,338 residents have been tested so far.
Finland
23
As of the 9
th
October, 11,580 people had tested positive for COVID-19 in Finland and 346 people died. Of
those, 42% (145) died in social care 24-hour units
24
. In 2018 there 50,298 residents in 24-hour units
25
,
the share of COVID-19-related deaths in these units represents 0.29% of residents.
France
France first published official death estimates for people in care homes on the 31
st
of March. Deaths
linked to COVID-19 among care home residents had been stable from the end of July until the week
ending 20
th
September, when they started to increase again.
The most recent numbers published by the Ministry of Health on the 8
th
October reported a total of
32,365 deaths as a result of COVID-19, of which 14,955 (46%) were residents in care homes
26
. Of these,
10,785 (72%) died in the care home and, particularly in the earlier part of the pandemic, were mostly
“probable cases” where a doctor confirmed that the symptoms were associated with COVID-19. The
remaining 4,170 (28%) died in hospital and were confirmed through testing
27
.
Until the 8
th
October there have been 46,520 confirmed infections among care home residents, and
25,171 among care home staff. Deaths among care home staff are not reported in this bulletin. There
are an estimated 605,061 care home beds in France
28
, thus the number of deaths of care home
residents linked to COVID-19 would represent 2.4% of all the available beds.
Germany
29
Germany’s Robert Koch-Institute published the first official number of infections and deaths in different
care settings on 22 April. People in care and nursing homes are covered under §36 of the Protection
Against Infection Law (IfSG). §36 also includes people living in facilities for people with disabilities or
21
With thanks to Tine Rostgaard
22
https://www.ssi.dk/sygdomme-beredskab-og-forskning/sygdomsovervaagning/c/covid19-overvaagning
23
https://ltccovid.org/2020/06/14/new-report-covid-19-and-clients-of-long-term-care-in-finland-impact-and-measures-to-
control-the-virus/, with thanks to Leena Forma, Julta Pulkki and Mari Aaltonen
24
https://thl.fi/en/web/infectious-diseases-and-vaccinations/what-s-new/coronavirus-covid-19-latest-updates/situation-
update-on-coronavirus
25
https://thl.fi/fi/tilastot-ja-data/tilastot-aiheittain/ikaantyneet/sosiaalihuollon-laitos-ja-asumispalvelut
26
établissements sociaux et médico-sociaux (ESMS)
27
https://www.santepubliquefrance.fr/maladies-et-traumatismes/maladies-et-infections-respiratoires/infection-a-
coronavirus/documents/bulletin-national/covid-19-point-epidemiologique-du-24-septembre-2020
28
https://www.insee.fr/fr/statistiques/3676717?sommaire=3696937
29
With thanks to Klara Lorenz-Dant
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
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other care needs, homeless shelters, community facilities for asylum-seekers, repatriates and refugees
as well as mass accommodation and prisons.
Since the 22nd April, the RKI has provided daily updates. In Germany, medical doctors and other health
and care professionals must inform the local health authorities about each suspected case of COVID-19.
The health authorities transmit the information within one working day to the relevant highest health
authority within their federal state. They then provide the Robert Koch-Institute with the relevant data.
There can be a delay in reporting, which is why the data presented here may not entirely represent the
number of cases of COVID-19 and COVID-19 related deaths for the specific dates. Data that is being
transmitted later is being added to the relevant dates as it comes in and feeds into the total case count.
Data recorded here includes only confirmed cases following a laboratory diagnosis independent of
clinical assessment. In addition, the Robert Koch-Institute advises that information on care setting is
missing in 37% of transmitted cases, which means that the number of people affected in specific care
settings, represents the minimum number of cases.
On 11
th
October 2020, 20,798 people living in communal settings and 11,535 people working in these
settings (as defined by §36 IfSG) had been infected with COVID-19. Out of these, 3,752 residents as well
as 41 staff have died. The total deaths in Germany on the 11
th
October were 9,615, so deaths in
communal settings represent 39% of all deaths
30
. So far we have not found data on the suspected
numbers of deaths or excess mortality in care homes.
It is important to emphasize that these data from Germany includes communal settings such as
homeless shelters, accommodation for refugees and prisons, which may house a younger population, so
it is not directly comparable with the data on care homes presented for the other countries in this
report. However, these data suggest that in Germany care residents represent a smaller share of all
deaths compared to other countries with similar number of deaths in total. The total number of people
living in care and nursing homes in Germany in 2017 was 818,000
31
, assuming that there were a similar
number in 2020 and that all the deaths in communal establishment had been care home residents, 0.5%
of all care home residents would have died due to COVID-19 so far. Because the death figures includes
people living in other establishments, the percentage is likely to be lower.
Hong Kong SAR China
32
According to the daily update of the Government as of 29
th
September 2020, there have been 5,080
confirmed cases of COVID-19. Among them, 105 people have passed away
33
. There have been 16 care
homes in outbreaks, resulting in 105 residents and 28 staff members testing positive. 30 residents have
died (29% of all deaths in Hong Kong)
34
. It is estimated that there are 73,231 care home residents in
Hong Kong
35
, the share of deaths among residents would be 0.04%.
30
https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Sept_2020/2020-09-28-
en.pdf?__blob=publicationFile
31
https://de.statista.com/statistik/daten/studie/36438/umfrage/anzahl-der-zu-hause-sowie-in-heimen-versorgten-
pflegebeduerftigen-seit-1999/
32
With thanks to Kayla Wong
33
https://chp-dashboard.geodata.gov.hk/covid-19/en.html
34
Fernando Chiu Hung Cheung Legislative Councilor's Office (28 Sept.2020). 安老院疫情資訊. Retrieved from
https://m.facebook.com/fernandochiuhungcheung/photos/a.10150240176145721/10164103553345721/?type=3&source=48&
__tn__=EH-R
35
Based on data from:
https://www.swd.gov.hk/storage/asset/section/632/en/15.Number_of_Homes_Providing_Residential_Care_Services_for_the_
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
10
Hungary
36
On the 27
th
August 2020 there had been 614 COVID-19 deaths in Hungary and, of these, 142 were in
care homes (23%)
37
. COVID-19 deaths are defined as people who have tested positive and died. The
current number of deaths (28
th
September) is 749, but no data on care home residents data has been
published since the 27
th
August.
As less than 3% of the population aged 65 or more lives in care homes in Hungary, it is expected that the
share of deaths in care homes in Hungary will be lower than in other countries. In 2018, the total
number of residents of care homes was 55,170 of which 50,589 were aged 65 or more. No newer figures
are available, assuming that the number of residents hasn’t changed, the share of care home residents
who died until the 27
th
August would be 0.3%.
Ireland
38
Ireland has a centralised system to collect epidemiological information in relation to cases of COVID-19
infections
39
. All deaths, in all care settings and dwellings, related to COVID-19 that are notified to the
Health Prevention Surveillance Centre (HPSC) are included in the official count of deaths. However, the
number of notified deaths in care homes is only made publicly sporadically, the last data we found was
from mid-July 2020, in an expert panel report on nursing homes and COVID-19
40
. Until the 14
th
July 2020
there had been 985 COVID-19 related deaths in nursing homes, representing 56% of total deaths (at the
time 1,748) in Ireland. The latest report from HPSC is that there have been a total of 1826 Covid-19
related deaths in Ireland on the 11
th
October
41
.
Ireland carried out a census of mortality in long-term care residential facilities
42
for the period from the
1
st
January to 19
th
April. The data published on the 1
st
May showed that in that period there had been
3,368 deaths in these facilities, of these, 616 were linked to COVID-19. Of the 616 COVID-19 related
deaths, 395 had been confirmed with a laboratory test and 221 were probable COVID-19 deaths.
There are an estimated 30,000 people living in nursing homes. Out of these, 3.3% of all nursing home
care residents would have died as a result of COVID-19 up to mid-July.
Israel
43
The first COVID-19 patient in Israel was diagnosed on February 27th and, by the 8
th
of October, the
number of confirmed cases has risen to 282,000, with 1,824 deaths
44
. Of the deaths, 704
45
were
Elderly_(By_district)(30.6.20).pdf.,
https://www.swd.gov.hk/storage/asset/section/632/en/3.Provision_of_RCHEs_(Subsidised_versus_Non-
subsidised_Places)(30.6.20).pdf and https://www.statistics.gov.hk/pub/B72002FA2020XXXXB0100.pdf
36
With thanks to Robert Gal
37
https://koronavirus.gov.hu/cikkek/idosotthonok-142-koronavirussal-fertozott-gondozott-hunyt-el-kozuluk-55-en-pesti-uton
38
With thanks to Maria Pierce
39
https://ltccovid.org/wp-content/uploads/2020/04/Ireland-COVID-LTC-report-updated-28-April-2020.pdf
40
COVID-19 Nursing Homes Expert Panel (2020) Examination of Measures
to 2021, Report to the Minister for Health (
https://www.gov.ie/en/publication/3af5a-covid-19-nursing-homes-expert-panel-
final-report/)
41
https://www.gov.ie/en/press-release/18291-statement-from-the-national-public-health-emergency-team-sunday-11-
october/
42
https://www.gov.ie/en/publication/868ad8-mortality-census-of-long-term-residential-care-facilities-1-january-/
43
With thanks to Shuli Brammli and Sharona Zadok
44
Daily report Corona spread – situation in Israel, MoH
https://www.gov.il/he/departments/publications/reports/daily-report-20201008
45
MoH internal report 12.10.2020
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
11
residents in long-term care facilities (39%).There were 45,000
46
people in long-term care facilities in
Israel, comparing this to the numbers of residents who died would suggest a rate of 1.56%.
The first outbreak in Israeli long-term care facilities began in mid-March, sixteen days after the first
patient was diagnosed in Israel. Only a month after the initial outbreak, and following massive public
criticism and a call for help from the managers of long-term care facilities, the Israeli government
appointed a national-level team to manage the COVID-19 outbreaks long-term care facilities
47
.
Italy
The only data available on the COVID-19 outbreak in nursing homes is from the results of the National
Health Institute (Istituto Superiore di Sanità, ISS)’s survey, which was sent to 3,276 nursing homes out of
the 4,629 operating on the national territory.
On June 17
th
ISS published the final results of the survey. Data are referred to the period between February
1
st
and May 5
h
. As of May 5
th
, 1,356 nursing homes responded. The total mortality rate during that
timeframe is 9.1% (considering all deaths). The Covid-19 related mortality rate (tests + suspected) is
3.1%
48
. No new data was available as of 11
th
October 2020.
Jamaica
49
As of 11
th
October 2020, 7,343 people have tested positive and there have been 132 deaths. About 67%
of all deaths have occurred among persons 60 years and older
50
. There is no information on whether
any of these cases, deaths or recoveries have taken place among residents or staff of care homes.
51
Jordan
52
On 29
th
of September
53
there have been 9,226 cases of Covid-19 in the country and 51 deaths, but no
infections or deaths in care homes have been reported so far.
Malaysia
54
Up to the 30
th
of September, 11,224 people have tested positive and 136 of these have died
55
. There is
no official data on the number of deaths of care home residents, but some are known to have occurred.
As of 31
st
July, a total of 16,425 residents and staff had been screened, finding 47 positive cases, of
these, 36 were asymptomatic (76%)
56
.
46
Shnoor, Y., & Cohen, Y. (2020). Elderly in Israel Statistical Yearbook. Retrieved from
https://brookdale.jdc.org.il/publication/statistical-abstract-elderly-israel-2020/
47
https://ltccovid.org/2020/04/30/the-impact-of-covid-19-on-people-using-and-providing-long-term-care-in-israel/
48
https://ltccovid.org/2020/06/26/updated-estimates-of-mortality-of-nursing-home-residents-and-staff-linked-to-the-covid-
19-pandemic-in-italy/
49
With thanks to Rochelle Amour
50
https://jamcovid19.moh.gov.jm/
51
http://jamaica-gleaner.com/article/lead-stories/20200527/nursing-home-scare-infirmary-worker-infected-coronavirus-
triggering
52
With thanks to John Black
53
https://petra.gov.jo/
54
With thanks to Maw Pin Tan
55
http://covid-19.moh.gov.my/
56
https://ltccovid.org/2020/10/09/updated-country-report-the-long-term-care-covid-19-situation-in-malaysia/
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
12
Malta
57
On the 28
th
September 3,006 people have tested positive in Malta and there have been 33 deaths
58
.
While during the first wave care homes in Malta remained free of COVID-19 infections, infections in care
homes have been reported since the 4
th
of September 2020, so far up to 8 deaths have been linked to
care home residents
59
.
New Zealand
In Aotearoa New Zealand the Aged Residential Care (ARC) sector comprises 38,000 beds accommodated
in over 650 facilities throughout the country. On the 29
th
of September 2020, there have been 1,479
confirmed and 356 probable cases of COVID-19 identified, for a total of 1,835 cases, and 25 deaths
60
. Of
these, 16 were in ARC Facilities, accounting for 64% of all COVID-19 related fatalities in the country. The
number of deaths in aged care facilities represents 0.04% of all beds.
Norway
61
On the 15th of April, the Norwegian Institute of Public Health published data on the number of deaths
linked to COVID-19 that have occurred in institutions/care homes for the first time. On the 12 October
there were 15,524 people with a positive COVID-19 test in Norway and 276 deaths
62
. Of those deaths,
145 (53%) happened in care homes. The Norwegian newspaper VG publishes detailed data on the
location of all deaths, including care homes
63
. At the end of 2019, there were 39,466 beds in care homes
in Norway
64
, so deaths in care homes would amount to 0.4% of all beds.
Portugal
Although no official reports have been published, the Government of Portugal released to the media the
number of deaths in nursing homes. According to data published on May 9, 450 people have died in
these nursing homes, 40% of all deaths in the country
65
. We have not found more recent data.
Singapore
66
The Ministry of Health centrally collects and publishes epidemiological information about COVID-19 on a
daily basis
67
. As of the 11
th
October there had been 57,876 cases of COVID-19 infection (the majority,
54,484, in dormitories of migrant workers) and 27 deaths. There have been 3 COVID-19 related deaths
in nursing homes (representing 11% of all deaths). Compared to 16,059 nursing home beds in Singapore,
the number of deaths would represent 0.02% of all beds
68
.
57
With thanks to Maria Aurora Fenech
58
https://deputyprimeminister.gov.mt/en/health-promotion/covid-19/Pages/covid-19-infographics.aspx
59
https://timesofmalta.com/articles/view/coronavirus-patient-82-dies-at-elderly-home.820858
60
https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-
19-current-cases#summary
61
With thanks to Norwegian newspaper VG
62
https://www.fhi.no/en/id/infectious-diseases/coronavirus/daily-reports/daily-reports-COVID19/
63
https://www.vg.no/spesial/2020/corona/#norge-dode
64
https://www.ssb.no/en/pleie/
65
«Coronavírus: já morreram 450 idosos em lares». may 09, 2020, Accedido: may 10, 2020. [En línea]. Disponible en:
https://www.sabado.pt/portugal/amp/coronavirus-ja-morreram-450-idosos-em-lares.
66
With thanks to Wan Chen K Graham and Chek Hooi Wong
67
https://www.moh.gov.sg/covid-19/situation-report
68
https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
13
Slovenia
69
As of the 29
th
of September, 5,487 people had had positive tests in Slovenia, of these, 713 were in care
homes, corresponding to 481 residents and 232 members of staff. In total, there had been 149 deaths
70
.
Data on the numbers of deaths of care home residents can be obtained from an announcement that, as
of the 20
th
of May (when there had been 105 deaths in Slovenia), 52% of these deaths happened in care
homes and another 29% were deaths in hospital of care home residents. This would bring the total
share of deaths of care home residents to 81%
71
. The COVID-19 Sledilnik (tracker) team has advised that,
as of late September 2020, they considered that these percentages had not changed substantially.
Therefore, we estimate that, as of 29
th
September there would have been 121 deaths of care home
residents, 43 of whom would have died in hospital. In 2017 there were 22,904 people living in long-term
care institution in Slovenia
72
, the share of residents who would have died linked to COVID-19 would be
0.5%.
South Korea
73
Based on data provided by the Ministry of Health and Welfare and the Korea Centers for Disease Control
and Prevention, of 336 deaths linked to COVID-19 in South Korea on the 7th of September, 27 (8.0%)
were people presumed to have been infected in nursing homes, and another 76 deaths (22.6% of the
total) in Long-Term Care Hospitals. Deaths among residents in both types of settings would amount to
31% of total deaths. However, there were no deaths in care homes as all residents with potential COVID
infections were transferred to hospitals.
In 2018 there were 177,318 beds in nursing homes
74
, comparing the number of beds to the number of
COVID-19 related deaths of nursing home residents suggests that the share of nursing home residents
who have died from COVID-19 so far is around 0.01%. Of the 483,433 patients hospitalized in the 1,560
long-term care hospitals in 2018
75
, the share of deaths linked to COVID-19 would also amount to 0.01%.
Spain
The mortality impact of COVID-19 in nursing homes in Spain can be analyzed using two different data
sources, which have significant methodological differences. The first relies on the information provided
by the regional governments with regards to the number of deaths in nursing homes. The second option
is based on analyzing excess mortality among people registered with the National Long Term Care Service
system (SAAD). This analysis has been carried out by the Spanish public agency in charge of the long term
care system (IMSERSO), and includes both people living in their own homes who use care and people living
in nursing homes.
In order to obtain a national estimate of the mortality linked to COVID-19 among people living in care
homes, on the 3
rd
of April, the Spanish Health Ministry required that every regional Government provides
data on COVID-19 related deaths in care homes in a homogenous way. The data that each community is
required to send to the Ministry every Tuesday and Friday are as follows:
69
With thanks to Alenka Oven and the COVID-19 Sledilnik team
70
https://covid-19.sledilnik.org/en/stats
71
https://www.gov.si/novice/2020-05-29-celotna-izjava-dr-beovic-glede-zdravstvene-oskrbe-stanovalcev-domov-za-starejse/
72
https://www.stat.si/StatWeb/en/News/Index/8579
73
With thanks to Hongsoo Kim
74
https://stats.oecd.org/Index.aspx
75
Kim, H (2020) The impact of COVID-19 on long-term care in South Korea and measures to address it. LTCcovid, International
Long-Term Care Policy Network, CPEC-LSE, 7 May 2020.
https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-
Care-COVID19-situation-in-South-Korea-7-May-2020.pdf
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
14
- Total sum of deaths in care homes from the 8th of March, 2020 to the present date.
- Total sum of confirmed COVID-19 deaths in the nursing home from the 8th of March, 2020 to the
present date.
- Total sum of deaths with symptoms that are compatible with COVID-19 (not confirmed) in the
nursing home from the 8th of March, 2020 to the present date.
Despite this requirement, the Health Ministry has not yet made public the data regarding the total number
of deaths in nursing homes. All of the available information comes from the media
76
and from regional
governments. Although the information offered by regional governments has been progressively clarified,
the data are not yet completely comparable: some regions differentiate between deaths of people who
have been diagnosed with COVID-19 and deaths of those with symptoms of the illness but who have not
been diagnosed, while other regions do not make that distinction. In the latter case, there is no way of
knowing whether a region’s data refers only to confirmed cases or if non-confirmed cases are also
included. In addition, some regions, but not all, have included deaths in care homes for adults with
disabilities or mental illness in their data.
Taking these limitations into account, and using the last data provided by the regional Governments, the
total number of deaths attributed COVID-19 on 7
th
October are estimated to be 20,649). This number
includes both the deaths of people who have been diagnosed with COVID-19 and the deaths of those with
symptoms of the illness but who have not been diagnosed. These deaths would represent 63% of all
COVID-19 confirmed deaths in Spain (32,929) which only include deaths of people with a positive test.
There are no national estimates of suspected COVID-19 deaths for the whole population. The most recent
estimate of care home residents is 333.920
77
, based on these estimates, the deaths linked to COVID-19
would amount to 6.18% of the care home population in Spain.
The data from IMSERSO on excess mortality shows that, between March and end of July 2020, there was
an estimated excess mortality of 35,120 among people registered the public long-term care system
78
. This
was a 43% increase on the expected mortality rate, and represents 76% of the total excess mortality
estimated in Spain. Of these excess deaths, 18,911 (53%) would have been of people living in care homes,
equivalent to 7.6% of the population who lives in care homes. The rest were people receiving long-term
care in the community. The excess mortality rate in nursing homes represents nearly 50% of the total
mortality rate excess recorded amongst long-term care users in Spain.
There is emerging evidence to understand the factors that may have contributed to the high mortality
rates in care homes in Spain. One of these studies
79
reached interesting conclusions on the factors related
to the mortality rate in nursing homes in Navarra. According to this study, the factors most closely related
to high mortality rates are the general contagion rate of the area in which the home is located, the size of
the home (number of users), the amount of people who visited the home during the week previous to
lockdown and staff ratios. There are also some other factors related to higher mortality rates such as the
76
«Radiografía del coronavirus en residencias de ancianos: más de 20.600 muertos con Covid-19 o síntomas compatibles». oct
7, 2020, Accedido: oct 8, 2020.
https://www.rtve.es/noticias/20201007/radiografia-del-coronavirus-residencias-ancianos-
espana/2011609.shtml
77
http://envejecimientoenred.es/una-nueva-estimacion-de-poblacion-en-residencias-de-mayores/
78
“MoMo en el sistema para la autonomía y atención a la dependencia (SAAD)”. Disponible en:
https://www.imserso.es/InterPresent1/groups/imserso/documents/binario/inf_momo_dep_20200831.pdf
79
“Auditoría de los centros residenciales en Navarra ante la crisis de la Covid-19”. Disponible en:
https://www.navarra.es/appsext/DescargarFichero/default.aspx?CodigoCompleto=Observatoriors@@@Estudios/Auditoria-
Covid-Navarra-Residencias.pdf
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
15
availability of PPE, the amount of staff on leave, the availability of tests or the completion of general
disinfecting. Whether the home is privately or publicly owned was not found to be statistically related to
mortality rates.
Sweden
80
On the 5th October there had been 5,863 deaths in Sweden where COVID-19 was mentioned in the
death certificate, of which 2,714 (46%) were among care home residents, and 2,646 COVID-19 related
deaths happened in care homes (45%)
81
.
On the 31st October 2019 there were 82,217 care home residents in Sweden, using that as the
denominator for total number of residents, 3.3% of care home residents would have died.
Turkey
82
On the 30
th
of September 2020, the Minister of Heath announced that the official figures of COVID-19 of
Turkey refers to the number of COVID-19 ‘patients’ (who have received treatment), whereas COVID-19
‘cases’ (who tested positive but do not show any symptoms) have not been included in the published
data since 29 July 2020
83
.
As of the 2
nd
October 2020, the total number of patients (hasta sayısı) is 321,512 and 8,325 COVID-19
related deaths were recorded
84
.
No recent official data on deaths of care home residents has been released by the Ministry, based on
public statements of government officials provided in different platforms, as of 7
th
May, there were
1,030 diagnosed COVID-19 cases in care institutions who had been admitted to hospitals and 150 deaths
of care home patients had been reported. The deaths in nursing homes accounted for 4% of all COVID-
19 deaths in Turkey
85
. No data has been provided so far concerning the infection or mortality rates of
care home staff.
United Kingdom
The UK Government publishes daily statistics on COVID-19 related deaths
86
. These data include
information on deaths of people who have had a positive test result confirmed by a Public Health or NHS
laboratory. As of the 2
nd
of October, there had been 467,146 lab-confirmed COVID-19 cases in the UK
and 42,268 deaths. In addition, NHS England provides the same figures disaggregated by NHS Trust,
region, age of the patient, and recently by ethnicity
87
. These death figures do not include people who
had not been tested.
The Office for National Statistics (ONS) also provide weekly updates of deaths registered in each of the
four UK home nations
88
. The nature of these figures differ from the NHS figures in that they include all
deaths where “COVID-19” was mentioned (by a doctor) on death certificates (i.e. where ICD10 codes
80
With thanks to Marta Szebehely
81
https://www.socialstyrelsen.se/statistik-och-data/statistik/statistik-om-covid-19/statistik-over-antal-avlidna-i-covid-19/
82
With thanks to Başak Akkan and Cemre Canbazer
83
https://www.euronews.com/2020/10/01/turkey-not-counting-positive-covid-19-cases-unless-there-are-symptoms-health-
minister-admi)
84
https://covid19.saglik.gov.tr/?_Dil=2
85
https://ltccovid.org/wp-content/uploads/2020/06/The-COVID-19-Long-Term-Care-situation-in-Turkey.pdf
86
https://coronavirus.data.gov.uk/
87
https://www.england.nhs.uk/statistics/statistical-work-areas/covid-19-daily-deaths/
88
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfigure
sondeathsregisteredinenglandandwales
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
16
U07.1 and U07.2 were used) i.e. irrespective if the individual had a confirmed positive test. Up to 12
th
September, there had been 57,113 deaths registered where COVID-19 was mentioned on the death
certificate.
Figures including care homes are not reported in the same way in England, Wales, Northern Ireland and
Scotland, therefore we present them in separate sub-sections. For a detailed analysis of COVID-19
related deaths in care homes across the UK please see Bell et al (2020)
89
.
England
The ONS provide weekly updates of deaths registered in England, these deaths include any death where
COVID-19 was mentioned (by a doctor) on death certificates. Up to the 18
th
of September, there were
49,982 deaths registered in England involving COVID-19
90
. ONS weekly figures are usually published
approximately 11 days in arrears as the registration process takes time. As of 18
th
of September, 31,624
COVID-19 related deaths occurred in hospital (63%), 14,850 occurred in care homes (30%), 2,368
occurred in private homes (5%) and 1,140 in hospices, other communal establishments and elsewhere
(2%)
91
.
The ONS also publishes estimates of excess mortality during the period of the pandemic. Between week
11 (starting 9
th
March) and the 18
th
of September 2020 there were 56,481 additional deaths in England
compared to the same time of the year in the previous five years
92
. Therefore, deaths linked to COVID-
19 represented 88% of all excess deaths during that period.
In England, since 11
th
April, ONS have published CQC data on all care home resident deaths, not only
those occurring in the care home. Data up until the 18
th
September show that 18,833 care home
residents in England died from COVID-19 or related causes
93
. For this period, of those where the place of
death was stated (18,825), 14,117 (75%) died in the care homes. Prior to the ONS release of the CQC
data, ONS also published data on location on death for care home residents occurring between 28
th
December and 19
th
June and registered up to 20
th
June. These data show that between 6
th
March and
10
th
April, a total of 3,454 care home residents’ deaths were registered in England where COVID-19 was
mentioned on the death certificate. Thus, in total since the first death of a care home resident due to
COVID-19, 22,287 deaths of care home residents have been registered in England
94
.
89
Bell D, Comas-Herrera A, Henderson D, Jones S, Lemmon E, Moro M, Murphy S, O’Reilly D and Patrignani P (2020) COVID-19
mortality and long-term care: a UK comparison. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE,
August 2020. Available: https://ltccovid.org/wp-content/uploads/2020/08/COVID-19-mortality-in-long-term-care-final-Sat-29-
1.pdf
90
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfigure
sondeathsregisteredinenglandandwales
91
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfigure
sondeathsregisteredinenglandandwales
92
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfigure
sondeathsregisteredinenglandandwalesWeekly figures 2020.
93
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/numberofdeathsincareh
omesnotifiedtothecarequalitycommissionengland Table 5.
94
This figure only includes COVID-19 deaths of care home residents in Wales up until 1
st
June.
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
17
Furthermore, Public Health England publish data on the number of care homes with COVID-19
outbreaks in England. During the period up to the 19
th
of July 6,811 care homes have experienced
outbreaks, this represents 44% of all care homes
95
.
Wales
In Wales the ONS show that up to the 18
th
of September, there were 2,575 deaths registered in Wales
involving COVID-19
96
. Of those, 1,696 occurred in hospital (66%), 707 occurred in care homes (27%), 134
occurred in private homes (5%) and 38 in hospices, other communal establishments and elsewhere
(1%)
97
.
Care inspectorate Wales (CIW) also publish weekly data on notifications of deaths of care home
residents by date of notification and cause
98
. Since the first notification of a care home resident COVID-
19 related death on the 16
th
March, up until the 18
th
September, a total of 745 care home resident
COVID-19 deaths had been notified to CIW.
England and Wales
Between week 11 (starting 9
th
March) and the 18
th
of September 2020 there were 25,374 excess deaths
in care homes in England and Wales
99
.
Thus, up until the 18
th
September, 23,032 (745 + 22,287) care home residents died due to COVID-19 in
England and Wales. Accordingly, deaths of care home residents linked to COVID-19 represent 39%
(23,032/58,371) of all excess deaths in England and Wales.
Northern Ireland
Since 19 April, the Department of Health of Northern Ireland has been releasing daily statistics on
COVID-19
100
. As of 2
nd
of October, 13,612 cases of COVID-19 have been confirmed in Northern Ireland,
with 583 deaths. Of those deaths, 188 (32%) occurred in care homes. There were 39 active confirmed or
suspected COVID-19 cases in care homes and 209 closed outbreaks
101
.
The Northern Ireland Statistics and Research Agency also publish data on deaths, including those where
COVID-19 (suspected or confirmed) is mentioned on the death certificate
102
. According to these data,
95
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/903085/COVID19_Care_H
omes_22_July.pdf
96
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfigure
sondeathsregisteredinenglandandwales
97
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfigure
sondeathsregisteredinenglandandwales
98
https://gov.wales/notifications-deaths-residents-related-covid-19-adult-care-homes-1-march-25-september-2020
99
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredweekly
inenglandandwalesprovisional/weekending18september2020. Data for Figure 5.
100
https://app.powerbi.com/view?r=eyJrIjoiZGYxNjYzNmUtOTlmZS00ODAxLWE1YTEtMjA0NjZhMzlmN2JmIiwidCI6IjljOWEzMGRlL
WQ4ZDctNGFhNC05NjAwLTRiZTc2MjVmZjZjNSIsImMiOjh9
101
https://app.powerbi.com/view?r=eyJrIjoiZGYxNjYzNmUtOTlmZS00ODAxLWE1YTEtMjA0NjZhMzlmN2JmIiwidCI6IjljOWEzMGRlL
WQ4ZDctNGFhNC05NjAwLTRiZTc2MjVmZjZjNSIsImMiOjh9
102
https://www.nisra.gov.uk/publications/weekly-deaths Excel Spreadsheet Weekly Deaths 2020
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
18
between the 21
st
March and the 25
th
September, there had been 900 registered COVID-19 deaths in
Northern Ireland. Of those, 356 (40%) occurred in care homes. Excess deaths during this period were
1,157, meaning that COVID-19 related deaths accounted for 77% of excess deaths in Northern Ireland.
For the same period, the total number of care home residents
103
who died from suspected or confirmed
COVID-19 was 437, meaning that around 81% of all COVID-19 care home resident deaths occurred
within the care home. Furthermore, this would mean that care home resident deaths make up 49% of all
COVID-19 deaths in Northern Ireland.
Scotland
The Scottish Government publish daily data confirmed COVID-19 deaths
104
. As of 2
nd
October, 2,526
confirmed COVID-19 deaths had been registered in Scotland. National Records of Scotland (NRS) also
publish a weekly analysis of death registrations that mention COVID-19 in the death certificate, again
using the new emergency ICD10 codes
105
. Data for the period 16
th
March up to the 13th September
show that there were 4,236 deaths where COVID-19 was mentioned on the death certificate. Of those,
1,966 deaths occurred in care homes, representing 46% of all COVID-19 related deaths. During the same
period there were 5,032 excess deaths (compared to the 5-year average) in total and 2,263 excess
deaths in care homes (45%). COVID-related deaths in Scotland represented 84% of all excess mortality.
Similarly to Wales, since 25
th
May, the Care Inspectorate Scotland (CIS) has reported weekly data on
notifications of deaths of care home residents
106
. This data report that up until 13
th
September, 220 care
home residents had died where COVID-19 had been confirmed or suspected. Prior to this, NRS published
data up until 17
th
May, which showed there had been 1,777 COVID-19 related registered deaths of care
home residents
107
. Thus, in total, there were at least 1,997 care home resident deaths due to COVID-19.
This represents 47% of all COVID-19 related deaths registered up until 13
th
September. Overall, care
home resident COVID-19 related deaths accounted for 40% of all excess deaths in Scotland.
The Scottish Government daily data also report data on infections in care homes in Scotland
108
. There
are 38,614 registered beds in care homes in Scotland and figures from 2017 suggest 93% occupancy
rates
109
. Based on this, the number of residents in Scotland in 2020 would be around 35,911.
As of the 30th of September, 92 (9%) adult care homes in Scotland had a current case of suspected
COVID-19, down from a peak of 45% on 30
th
May. A total of 3,948 cumulative cases of confirmed
103
In these statistics, care home residents have been identified where either (a) the death occurred in a care home, or (b) the
death occurred elsewhere but the place of usual residence of the deceased was recorded as a care home.
104
https://www.gov.scot/publications/coronavirus-covid-19-trends-in-daily-data/ (Excel spreadsheet at the bottom of the page,
Table 8.)
105
https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/general-publications/weekly-
and-monthly-data-on-births-and-deaths/deaths-involving-coronavirus-covid-19-in-scotland
106
https://www.webarchive.org.uk/wayback/archive/20200716093128/https:/www.gov.scot/publications/coronavirus-covid-
19-additional-data-about-adult-care-homes-in-scotland/
107
https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/general-publications/weekly-
and-monthly-data-on-births-and-deaths/deaths-involving-coronavirus-covid-19-in-scotland/related-statistics Deaths of care
home residents involving COVID-19 (3 June 2020)
108
Bell D, Henderson D and Lemmon E (2020) Deaths in Scottish care homes and COVID-19. LTCcovid, International Long-Term
Care Policy Network, CPEC-LSE, 17 May 2020 https://ltccovid.org/2020/05/18/deaths-in-scottish-care-homes-and-covid-19/
109
Bell D, Comas-Herrera A, Henderson D, Jones S, Lemmon E, Moro M, Murphy S, O’Reilly D and Patrignani P (2020) COVID-19
mortality and long-term care: a UK comparison. Article in LTCcovid.org, International LongTerm Care Policy Network, CPEC-LSE,
August 2020. Available: https://ltccovid.org/wp-content/uploads/2020/08/COVID-19-mortality-in-long-term-care-final-Sat-29-
1.pdf
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
19
COVID-19 have been reported in care homes between 9
th
March and 4
th
October
110
. Up until 20
th
July, it
was reported that 65% of care homes in Scotland had reported at least one case of COVID-19.
111
More
recent figures are not available due to concerns in the reporting of suspected cases to the Care
Inspectorate.
In addition, the Scottish Government publish data returned to the Care Inspectorate on the number of
care home staff being reported as absent in adult care homes due to COVID-19
112
. Since 21
st
April,
where 10% all adult care home staff in those care homes who submitted a return were reported as
absent, the proportion of staff being reported as absent has fallen steadily , to just 1.2% as of 5
th
October.
United States
This report covers cumulative deaths in US care homes (nursing facilities, assisted living facilities and
other long-term care facilities) from January 1 through September 20, 2020. Information about deaths in
care homes comes from three sources. First, the Center for Medicare and Medicaid Services (CMS), the
official government data system for COVID-19 in nursing facilities. The other sources are two
independent organizations that track COVID-19 in nursing facilities, assisted living facilities, and other
types of care homes: the Kaiser Family Foundation (KFF) and The Atlantic’s COVID Tracking Project (CTP).
Information about the number of COVID-19 deaths in the general population comes from the Johns
Hopkins University Coronavirus Resource Center.
The CMS data
113
are collected and reported weekly at the facility level for the over 15,000 certified
nursing facilities in the US. The CMS can impose a financial penalty on facilities that do not report; as a
result, compliance is nearly 100%. Data collection began on 17th May 2020 with instructions to nursing
facilities that they report cumulative figures from January through 17
th
May. Data consist of weekly and
cumulative totals for number of COVID-19 cases and deaths, both confirmed and suspected, for nursing
facility residents and staff, each of which is supported separately. The facilities also must report number
of beds, occupied beds, resident admissions with COVID-19, and total deaths from all causes during the
week and cumulatively. The CMS performs edit checks for completeness and for outlier or implausible
data entries. The main weaknesses of this data source are its coverage of nursing facility data only, and
the possibility that historical data on COVID-19 related cases and deaths from January through May
were under-reported because of the long lag between early outbreaks and the beginning of reporting.
The main strengths of these data are their full coverage of all nursing facilities and the detailed data
about COVID-19 cases and deaths. In this report we included CMS nursing facility deaths that were
confirmed and suspected among both residents and staff until the 20
th
September. We aggregated
facility level deaths up to the state level.
110
https://www.gov.scot/publications/coronavirus-covid-19-trends-in-daily-data/ (Excel spreadsheet at the bottom of the page,
Table 7a.)
111
Bell D, Comas-Herrera A, Henderson D, Jones S, Lemmon E, Moro M, Murphy S, O’Reilly D and Patrignani P (2020) COVID-19
mortality and long-term care: a UK comparison. Article in LTCcovid.org, International LongTerm Care Policy Network, CPEC-LSE,
August 2020. Available: https://ltccovid.org/wp-content/uploads/2020/08/COVID-19-mortality-in-long-term-care-final-Sat-29-
1.pdf
112
https://www.gov.scot/publications/coronavirus-covid-19-trends-in-daily-data/ (Excel spreadsheet at the bottom of the page,
Table 7b.)
113
Centers for Medicare and Medicaid Services. (2020). COVID-19 Nursing Home Data. Retrieved from
https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
20
The KFF collects data on both resident and staff deaths in nursing facilities and other care homes
114
.
Data collection began the week of 29
th
March. Cumulative figures are updated weekly. Its staff and
volunteers collect these data from state health departments, local health departments, press releases,
newspaper accounts, and other sources. Figures are reported at the state level. According to the KFF
web site, the number of cases is reported for residents and staff, where available. Presumed and
confirmed cases/deaths are also reported, where available. Definition of "long-term care facility" differs
by state, but data reflect a combination of nursing facilities, assisted living facilities, adult care centers,
intermediate care facilities, and/or other long-term care facilities. The main weakness of the KFF system is
its heavy reliance on state and local data sources which are of inconsistent quality and completeness. The
main strength of this system is its history of data collection going back to the 29
th
of March and the
reporting of deaths occurring in both nursing facilities and other care homes, when available. In this report
we included all state-level COVID-19 linked care home deaths reported by KFF through the 16-17
th
September.
The CTP system for COVID-19 in LTC facilities
115
is similar in data collection strategy and content to the KFF
system. Although the CTP had been collecting data related to COVID-19 for several months, it did not begin
its COVID in LTC initiative until August. Cumulative figures were recorded up to the mid-August start date
and then updated weekly. The CTP has staff and volunteers that collect these data from a variety of
state and local, official and unofficial sources. Figures are reported at the state level. Depending on the
state, its count of deaths could be among residents of nursing facilities, assisted living facilities, long-
term care facilities (undifferentiated between nursing facility and other types) or other long-term care
facilities. Also, deaths could have been among residents or residents and staff. Similar to the KFF data
system, the main weakness of CTP system is its heavy reliance on state and local data sources which are of
inconsistent quality and completeness. The main strength of the CTP system is its reporting of deaths
occurring in both nursing facilities and other care homes, when available. We have included all state-level
COVID-19 linked care home deaths reported by CTP through the 24
th
of September.
Other figures in this report include total population COVID-19 deaths taken from the Johns Hopkins
University Coronavirus Resource Center (199,509)
116
; the number of beds in care homes, which we
approximated by adding beds in nursing facilities from the CMS data and number of beds in assisted
living facilities taken from a report by the National Center for Assisted Living (2,582,775); number of
residents in care homes which was approximated using data from the same two sources; and total
population figures from the US Census
117
(1,937,345).
To obtain the best estimate of total number of COVID-19 related deaths in care homes, reflecting
nursing facilities and other settings, we derived the best estimates of deaths from each state by
selecting the highest number of deaths recorded for that state from among the three sources. In most
states, the choice was between the KFF and CTP figure, whichever was highest. In a few cases, the CMS
number of deaths exceeded the KFF and CTP figure. We wanted to achieve high sensitivity in our
estimate– capturing as many “true” COVID-19 linked deaths as possible. We assumed that each death
recorded by each source was accurate. That is, each source was identifying “true” COVID-19 linked
deaths. We further assumed that differences in recorded deaths between sources resulted from
differences in the completeness of their data. For example, the CMS system would have lower deaths
114
Kaiser Family Foundation. (2020). COVID-19 LTC Facilities. Retrieved from https://www.kff.org/coronavirus-covid-19/issue-
brief/state-data-and-policy-actions-to-address-coronavirus/
115
The Atlantic Monthly Group. (2020). The COVID Tracking Project: Long Term Care COVID Tracker. Retrieved from
https://covidtracking.com/data/longtermcare
116
Johns Hopkins Coronavirus Resource Center. (2020). COVID-19 US Cases. Retrieved from https://coronavirus.jhu.edu/us-map
117
U.S. Census Bureau: Population Division. (2020). Annual Estimates of the US Resident Population - 2019.
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
21
recorded for a state than KFF or CTP because the CMS system collected data only on nursing facility
deaths. The KFF and CTP systems could vary in their figures for a state because they were drawing from
different state and local sources.
Even though figures varied at the state-level, the aggregate counts of deaths at the national level were
80,006 from KFF and 80,193 from CTP. The final best estimate was 82,105 COVID-19 linked deaths in
care homes. When comparing this figure to the 57,894 deaths in nursing facilities (obtained from the
CMS data), we estimate that of the total care home deaths linked to COVID-19, about 70% of deaths
were in nursing facilities and 30% were in assisted living facilities and other care homes.
Based on these data, the share of all deaths linked care homes up to the 24
th
September would be 41%,
and, assuming that all those who died were residents, the share of all care home residents who died
would be 4.24%.
5. Summary tables and graphs
This section summarises the most recent data from official sources gathered in this document so far, but
needs to be interpreted with the limitations and caveats described above. In Table 1, we have tried to
distinguish the numbers of deaths among care home residents from the number of deaths in care
homes and between confirmed and probable deaths. There are more details on the differences in
sources and definitions of the data provided in this table in the descriptions of the data available for
each country above. As emphasized throughout this document, differences in data collection methods
mean that these data are not suitable for direct comparisons or for ranking countries.
Where data for both care home residents who died and deaths in care homes are available for the same
country, we have prioritized data on the numbers of care home residents, as this provides a proxy for
the infections in care homes. Data on the number of people living in care homes who tested positive for
COVID-19 has not been included, as, in many countries, in the earlier part of the pandemic there was
very little testing in care homes.
On average, for the 20 countries in the report for which there were deaths in care homes, the average
share of all COVID-19 related deaths that were care home residents was 46%. While this average needs
to be treated with caution (due to differences in data collection method and definitions, as illustrated in
figure 1 below), these figures show that the care home population has been disproportionally affected
by COVID-19. The average share of the population living in care homes is 0.73%.
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
22
Table 1. Number of COVID-related or confirmed deaths in the population and in care homes (or among care
home residents).
Country Date
Approach to
measuring
COVID-19
linked
deaths in
care homes
C: confirmed
P: probable
Total
number
deaths
linked to
COVID-
19*
Number of
deaths of
care home
residents
linked to
COVID-19
Number
of deaths
in care
homes
linked to
COVID-19
Number
of care
home
resident
deaths as
% of all
COVID-19
deaths
Number
of deaths
in care
homes as
% of all
COVID-19
deaths
Australia
11/10/2020
C
898
677
75%
Austria
17/09/2020
C
771
276
36%
Belgium
11/10/2020
C + P
10,175
6249
4,892
61%
48%
Canada
01/10/2020
C + P
9,319
7,411
80%
Denmark
06/10/2020
C
663
232
35%
Finland
09/10/2020
C
346
145
42%
France
08/10/2020
C + P
32,365
14,955
10,785
46%
33%
Germany
11/10/2020
C
9,615
3,752
39%
Hong Kong
28/09/2020
C
105
30
0
29%
0%
Hungary
27/08/2020
C
612
142
23%
Ireland
14/07/2020
C + P
1,748
985
Israel
08/10/2020
C
1,824
704
39%
Jordan
28/09/2020
C
9
0
0
0%
0%
New Zealand
10/10/2020
C + P
25
16
64%
Norway
12/10/2020
C
276
145
53%
Singapore
11/10/2020
C
27
3
0
11%
Slovenia
29/09/2020
C
149
121
78
81%
South Korea
07/09/2020
C
336
27
0
8%
0%
Spain
07/10/2020
C + P
32,929*
20,649
63%
Sweden
05/10/2020
C + P
5,863
2,714
2,646
46%
45%
England (UK)
18/09/2020
C + P
49,982
22,287
14,850
45%
30%
Wales (UK)
18/09/2020
C + P
2,575
745
707
29%
27%
N. Ireland (UK)
25/09/2020
C + P
900
437
356
49%
40%
Scotland (UK)
13/09/2020
C + P
4,236
1,997
1,966
47%
46%
United Kingdom
As above
C + P
57,693
25,466
17,879
44%
31%
United States
27/09/2020
C + P
199,509
82,105
41%
Sources: as per the data described in this document
*For some countries the national total number of COVID-19 related deaths only refers to confirmed deaths, so the national
figures may be an underestimate as, particularly in the early part of the pandemic, people who died outside hospitals were
not tested.
For some countries, we have been able to obtain number of care home residents (or beds) that would
correspond to the definition used in the number of deaths statistics in this report. Table 2 shows the
share of care home residents who died (linked to COVID-19) compared to all care home residents, the
share of the population who live in care homes, and the rate of deaths attributed to COVID-19 per
100,000 of the population who do not live in care homes. We found no correlation between the share of
care home residents who have died and the proportion of the total population who have died.
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
23
Table 2. Share of care home residents who may have died as a direct or indirect result of the COVID-pandemic
Country Date
Deaths
attributed to
COVID as % of all
care home
residents/beds
% of pop living in
care homes
Deaths per 100,000
community-living
population
Australia
11/10/2020
0.32%
0.82%
3.55
Austria
17/09/2020
0.40%
0.77%
8.63
Belgium
11/10/2020
5.00%
1.08%
88.75
Canada
01/10/2020
1.74%
1.13%
19.63
Denmark
06/10/2020
0.58%
0.69%
11.53
Finland
09/10/2020
0.29%
0.91%
6.30
France
08/10/2020
2.47%
0.93%
50.05
Germany
11/10/2020
0.46%
0.98%
11.48
Hong Kong
28/09/2020
0.04%
0.98%
1.41
Hungary
27/08/2020
0.26%
0.57%
6.37
Israel
08/10/2020
1.56%
0.52%
21.18
New Zealand
10/10/2020
0.04%
0.79%
0.52
Norway
12/10/2020
0.37%
0.73%
5.09
Singapore
11/10/2020
0.02%
0.27%
0.46
Slovenia
29/09/2020
0.53%
1.10%
7.25
South Korea
07/09/2020
0.01%
0.42%
0.66
Spain
07/10/2020
6.18%
0.69%
70.92
Sweden
05/10/2020
3.30%
0.81%
58.53
England (UK)
18/09/2020
5.24%
0.76%
89.47
Wales (UK)
18/09/2020
3.13%
0.75%
82.29
Northern Ireland (UK)
25/09/2020
2.93%
0.79%
47.90
Scotland (UK)
13/09/2020
5.55%
0.66%
78.05
United Kingdom
As above
5.09%
0.75%
87.0
United States
27/09/2020
4.24%
0.59%
60.63
Sources: based on data collected for this report (see each country section for sources), data on population (used to calculate
size of community-living population) is from United Nations
118
Since the last update of this report, there have been major changes in the number of COVID-19 related
deaths among people living in care homes in Australia, following a major COVID-19 outbreak in Victoria,
more information is available in the LTCcovid country report for Australia
119
. The number of deaths have
also increased substantially in Israel and the USA. While much of Europe, until September, had
comparatively low rates of COVID-19 infections and deaths in care homes, rates are starting to increase
in many countries in the last few weeks (see Figures 4 and 5 with detailed data from Denmark).
118
https://population.un.org/wpp
119
Charlesworth, S & Low, L-F (2020) The Long-Term Care COVID-19 situation in Australia. Report in LTCcovid.org, International
Long-Term Care Policy Network, CPEC-LSE, 12 October 2020.
https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-
COVID19-situation-12-October-2020-1-2.pdf
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
24
Table 3. Changes in the number of deaths of care home residents since the previous report (26
th
June)
Number of deaths of care
home residents linked to
COVID-19, up to 12
October
Number of deaths of care
home residents linked to
COVID-19, 26 June report
% increase in the number
of deaths in care homes
compared to data in the
26 of June report
Australia
677
29
2,234%
Austria
276
222
24%
Canada
7,411
6,236
19%
Denmark
232
211
10%
France
14,955
14,341
4%
Germany
3,752
3,491
7%
Hong Kong
30
0
Hungary
142
127
12%
Israel
704
137
414%
New Zealand
16
16
0%
Norway
145
144
1%
Singapore
3
2
50%
Slovenia
121
85
42%
Spain
20,649
19,553
6%
Sweden
2,714
2,280
19%
United Kingdom
25,466
21,889
16%
United States
82,105
50,185
64%
The figures below seek to illustrate some of the data summarized in Tables 1 and 2.
a. Comparing deaths in care homes and deaths of care home residents
In Figure 1, we plot the data for those countries who record both the number of COVID-19 deaths
occurring within the care home and the number of COVID-19 deaths of care home residents (including
those who may have died in hospital). In this figure, COVID-19 deaths are based on confirmed and
suspected cases, with the exception of Hong Kong and South Korea who use confirmed cases only. As
one might expect, the share of deaths accounted for by care home residents is considerably higher than
the share of deaths occurring within care homes. The differences between the countries ranges from 1
percentage point in Scotland and Sweden, to 29 percentage points in Hong Kong. These differences may
reflect both differences in policies (for example in Hong Kong and South Korea all care home residents
with confirmed COVID-19 infections were moved to quarantine centres or hospitals, so there have been
no deaths in care homes)
120
, and differences in hospital capacity, particularly in the earlier part of the
pandemic. Where countries only provide data of deaths in care homes, these figures are likely to be an
120
Kim, H (2020) The impact of COVID-19 on long-term care in South Korea and measures to address it. LTCcovid.org,
International Long-Term Care Policy Network, CPEC-LSE, 7 May 2020.
https://ltccovid.org/wp-content/uploads/2020/05/The-
Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf and Wong K, Lum T and Wong G (2020) The COVID-19
Long-Term Care situation in Hong Kong: impact and measures. LTCcovid.org, International Long-Term Care Policy Network,
CPEC-LSE, 8 July 2020.
https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-
situation_updates-on-8-July-1.pdf
ltccovid.org | Mortality associated with COVID-19 outbreaks in care homes
25
underestimate of the deaths of care home residents. In many countries, there are no information
systems that allow the identification of care home residents in death certificates, particularly where
people have only lived in a care home for a short period.
Figure 1: Confirmed and probable or suspected COVID-19 deaths accounted for by deaths within care homes and
by care home residents overall
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Source: table 1 in this report, data sources are summarized in each country section
b. Share of care home residents whose deaths were linked to COVID-19, compared to the
care home population
In Figure 2 we plot the data presented in Table 2, specifically, the share of the care home population
(based on number of residents, or beds where resident numbers are not available) whose deaths were
attributed to COVID-19. Once again, there is substantial variation between countries. In Spain, over 6%
of the care home resident population died due to COVID-19 compared to in South Korea where this
figure was only 0.01%.
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Scotland’s data based on figures up until 17
th
May.
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Figure 2. Share of care home residents whose deaths were linked to COVID-19, compared to the care home
population
Source: table 2 in this report, data sources are summarized in each country section
c. Relationship between deaths linked to COVID-19 of care home residents and deaths
linked to COVID-19 among the population living in the community
In Figure 3, COVID-19 deaths per 100 in the care home population are compared to COVID-19 deaths per
100,000 in the non-care home population. This chart demonstrates the relationship between
community transmission and deaths in care homes. Specifically, in countries where deaths in the
community were low, deaths in care homes were also low. This highlights that once there is a high
transmission of the virus within the community, it is likely that it will also spread to care homes.
Interestingly, Canada has a relatively low number of deaths both within and out with the care home
population, yet of all COVID-19 deaths, 80% were accounted for by care home residents.
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Figure 3. Total number of deaths linked to COVID-19 in the population living in the community, compared to the
number of deaths among care home residents
Source: based on figures collected for this report
d. A good example of public data reporting: the case of Denmark
Data on the impact of COVID-19 among care home residents is not available for many countries, in
some the data is only mentioned sporadically in press releases or official reports, and in others it is
only provided in daily or weekly snapshots. In most countries it is also very difficult to find out about
the numbers of COVID-19 tests carried out in care homes over time, which makes it difficult to
ascertain the extent to which data on number of confirmed cases provides a reliable estimate of
infection rates. Being able to compare the numbers of tests carried out per resident, or the positivity
rates, would enable a much better comparison of the infection rates in care homes than the data we
have been able to find so far.
In the case of Denmark
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it is possible to obtain weekly data on number of cases, numbers of tests
carried out and numbers of deaths linked to COVID-19 since the beginning of the first cases in March
in a single table, which provides a much clearer picture than we have been able to find for all other
countries, of what the evolution of the pandemic in the care homes sector. Figures 4 and 5
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https://www.ssi.dk/sygdomme-beredskab-og-forskning/sygdomsovervaagning/c/covid19-overvaagning
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reproduce data showing how, as in many other European countries, after almost no new infections
in care homes during July and August, infections started to increase in early September (week 37)
and deaths in mid September (week 38).
Figure 4: Confirmed COVID-19 infections in care homes and deaths in Denmark, by week, 2020
Source: https://www.ssi.dk/sygdomme-beredskab-og-forskning/sygdomsovervaagning/c/covid19-
overvaagning
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Figure 5: Testing of care home residents and positivity rates in Denmark, by week, 2020
Source: https://www.ssi.dk/sygdomme-beredskab-og-forskning/sygdomsovervaagning/c/covid19-
overvaagning
6. Discussion
Since the first version of this report of the 12
th
of April, an increasing number of countries are publishing
data on deaths of care home residents (or deaths in care homes) linked to COVID-19. The authors are
very grateful to all who have provided information about data availability in their countries. However, in
some countries (for example Ireland), these data are increasingly difficult to find.
There continue to be substantial differences in how the data is collected and what it covers. The key
differences in the data reported are due to whether the data covers deaths of care home residents
(irrespective of whether they die in the care home or hospital) or just deaths that happen in the care
homes, and the definition used for care homes. Another important difference is whether the deaths
reported (both among care home residents and the whole population) cover cases confirmed through
testing, cases where COVID-19 was considered to be the probable cause of death, or excess mortality
during the period of the pandemic. Contextual data on the number of tests carried out in care homes
are very difficult to find, except for in Denmark where these data are published regularly.
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As outlined earlier in this report, the most reliable way to measure the impact of COVID-19 on mortality
is via excess deaths. Unfortunately, historical data on deaths in care homes or among care home
residents are rare internationally. Excess mortality in care homes is only available in the UK and in Spain
(for those registered with the social care system in Spain who receive institutional care benefits).
Without historical mortality data, it is difficult to quantify the full impact of the COVID-19 pandemic, in
the terms of mortality, among the care home population.
This report aims to present the data in a way that illustrates the differences in definitions and coverage.
The authors are continuing to work to obtain more complete data for all countries included in the
report, and hopefully additional countries, therefore continuing to improve the quality and
comparability of the data presented here.
A striking finding of the first version of this report published on the 12
th
of April and when data were
only available for 5 countries, was that in all those countries the share of deaths of care home residents
was around 50% of all deaths linked to COVID-19. As data for more countries have been added, and
more detailed data has become available for some of the countries, it has become clear that the impact
of COVID-19 on care home residents has been very different internationally. Notably, one country
(Jordan) reported no deaths (or infections) in care homes and two countries (Canada and Slovenia)
reported that over 80% of COVID-19 deaths were of care home residents. With the caveat that the
definitions used vary, on average the share of all COVID-19 deaths that were care home residents is 46%
(based on 21 countries).
To compare the relative impact of COVID-19 on care home residents in different countries, it is more
useful to focus on the share of care home residents whose deaths have been linked to COVID-19. There
are issues with comparability of care home definitions- in this report we have sought to use the same
definition within the same country for both the numerator (reported COVID-19 deaths among care
residents) and the denominator (number of care home residents or, where not available, beds)- even if
this results in slightly different definitions across countries. Using this approach, we have found that the
share of care home residents who have died ranges from 0.01% in South Korea to over 4% (which would
mean that over one in 25 care home residents have died linked to COVID-19) in Belgium, Ireland, Spain,
the UK and the US (see Table 2 for all countries for which we have found data so far). This share is highly
correlated to the total number of COVID-19 deaths in the population who live outside care homes, but it
is not correlated to the share of the population who live in care homes.
In addition to its direct impact on the lives of care residents and their families, mortality associated with
COVID-19 is likely to have important consequences on the care sectors’ economy for years to come. It is
for instance likely to lead to changes in public perceptions of the risk associated with care homes, and
therefore to reductions in levels of demand for institutional care. Even ignoring such demand effects, it
is likely that the observed reductions in care home residents generated by COVID-19 excess mortality
will take several years to be “absorbed” by new cohorts of care home admissions. Finally, many
governments are likely to introduce regulatory changes aimed at preventing the risk of the spread of
infectious diseases in care homes, through for instance changes in training, use of PPE, testing regimes
and staffing levels. Such changes are likely to increase the costs of providing institutional care, and as a
result push prices up and reduce further demand or impose additional financial burdens on public
coffers at a particularly difficult fiscal time.
Finally, this report only covers the mortality impacts of COVID-19 among people living in care homes. It
does not cover other impacts of the infection for example potential sequaele or “long COVID”, or the
wellbeing, conditioning and mental health impact of isolation measures. Where data on the mortality
among community-based users of care was available we have included it in the report, but very few
countries seem to report this.
