How to cite this document:
Canadian Institute for Health Information. Pandemic Experience in the Long-Term Care
Sector: How Does Canada Compare With Other Countries?. Ottawa, ON: CIHI; 2020.
CIHI
Snapshot
June 2020
Pandemic Experience in the
Long-Term Care Sector
How Does Canada Compare With Other Countries?
Issue
Canada’s long-term care (LTC) sector has been especially hard hit by the COVID-19 pandemic.
More than 840 outbreaks have been reported in LTC facilities and retirement homes, accounting
for more than 80% of all COVID-19 deaths in the country (as of 9 p.m. ET on May 25, 2020).
This short analysis examines the similarities and dierences between Canada’s pandemic
experience in LTC and that of other countries in the Organisation for Economic Co-operation
and Development (OECD). Specically, it focuses on 3 areas of comparison:
•
COVID-19 outcomes in LTC (cases and deaths);
•
Baseline sector characteristics; and
•
Policy responses to address the pandemic.
Comparisons must be interpreted with extreme caution due to rapidly evolving
infection case numbers, dierent denitions of LTC and variations across
countries in COVID-19 testing and reporting practices.
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CIHI Snapshot
Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?
Key findings
The analysis includes Canada and 16 other OECD countries that had sucient data for reporting:
Australia, Austria, Belgium, France, Germany, Hungary, Ireland, Israel, Italy, the Netherlands, Norway,
Portugal, Slovenia, Spain, the United Kingdom and the United States.
COVID-19 outcomes in LTC
•
As of May 25, 2020, the number of reported COVID-19 deaths among LTC residents varied
substantially, from 28 in Australia to 30,000 in the United States, with more than 10,000 in France,
Italy, Spain and the U.K. The number of LTC residents who had died of COVID-19 in Canada
(5,324) was similar to the average of OECD countries.
•
While Canada’s overall COVID-19 mortality rate was relatively low compared with the rates in other
OECD countries, it had the highest proportion of deaths occurring in long-term care. LTC residents
accounted for 81% of all reported COVID-19 deaths in Canada, compared with an average of 38%
in other OECD countries (ranging from less than 10% in Slovenia and Hungary to 66% in Spain).
•
Variation among Canada’s provinces and territories was greater than variation among OECD
countries. As of May 25, Newfoundland and Labrador, Prince Edward Island, New Brunswick
and the territories had no reported deaths in retirement homes and LTC facilities, whereas LTC
deaths represented over 70% of all COVID-19 deaths in Quebec, Ontario and Alberta and 97%
of all deaths in Nova Scotia. Generally, jurisdictions with lower COVID-19 infection rates in the
community reported fewer LTC cases and deaths.
•
As a proportion of total COVID-19 cases in Canada, about 1 in 5 (18%) were among LTC residents.
Internationally, this proportion ranged from under 1% of total cases in Australia to 51% in France
and 73% in the U.K.
•
The proportion of infected LTC residents who died from the disease also varied considerably across
countries, from 4% in Slovenia to 83% in Norway. In Canada, the mortality rate for those infected
with COVID-19 in LTC was about 35% as of May 25.
•
Many countries have reported high rates of infection among health care workers, leading to
absenteeism and stang shortages. In Canada, more than 9,650 LTC sta members were infected
by COVID-19, representing more than 10% of the country’s total cases. As of May 25, 9 of these
health care workers had died of COVID-19.
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CIHI Snapshot
Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?
Figure 1 COVID-19 deaths as of May 25, 2020, at 9 p.m.
A Number per million population, total and LTC
0
100
200
300
400
500
600
700
800
900
Australia
Israel
Norway
Slovenia
Hungary
Austria
Germany
Portugal
Canada
OECD average
U.S.
Ireland
Netherlands
France
Italy
U.K.
Spain
Belgium
Number of COVID-19
deaths per million population
Number of LTC COVID-19
deaths per million population
B Percentage of all COVID-19 deaths, LTC
Australia Israel Norway Slovenia Hungary Austria Germany Portugal Canada
OECD
average U.S. Ireland Netherlands France Italy U.K. Spain Belgium
28 58 58 9 7 19 34 25 81 38 31 56 15 48 32 27 66 50
Notes
OECD: Organisation for Economic Co-operation and Development.
LTC: Long-term care.
The situation is evolving rapidly and this data represents a snapshot of the pandemic in countries reported by May 25, 2020, at 9 p.m. ET.
Reporting of COVID-19 cases and deaths in the LTC sector is not directly comparable due to dierent testing and reporting standards across countries,
as well as to dierent denitions of LTC. In many countries, COVID-19 cases in this sector are under-reported.
Data for Italy is available from only 52% of the nursing homes operating in the country.
Sources
World Health Organization. Coronavirus disease (COVID-2019) situation reports. Accessed May 25, 2020.
World Health Organization Europe. Coronavirus disease (COVID-19) outbreak reports: Country information. Accessed May 25, 2020.
United Nations Department of Economic and Social Aairs, Population Division. World Population Prospects 2019. 2019.
European Centre for Disease Prevention and Control. Accessed May 25, 2020.
National Institute on Ageing. NIA Long-Term Care COVID-19 Tracker. Accessed May 25, 2020.
Daily epidemiological summaries produced by each country, where available, March 1 to May 25, 2020 (e.g., Public Health Agency of Canada,
Robert Koch Institute of Germany).
International Long-term care Policy Network. Accessed May 25, 2020.
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CIHI Snapshot
Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?
Baseline sector characteristics
•
The proportion of seniors (age 65 and older) living in LTC and retirement homes is higher in Canada
than it is in the average of OECD countries. However, results may vary due to dierent denitions of
LTC across countries.
•
Variation in LTC use among seniors also exists within Canada, where a more consistent denition
of LTC is used (see Figure 2).
•
Compared with other OECD countries, Canada’s LTC population tends to be older, with 91% of LTC
and retirement home residents over age 65 and 74% over age 80.
•
Compared with the OECD average, Canada had fewer health care workers (nurses and personal support
workers) per 100 senior residents of LTC homes in 2018, with a rate that was half as high as the rates in
the Netherlands and Norway.
•
OECD countries varied widely in reported patient safety issues prior to the pandemic. Countries with
higher rates of infection and pressure ulcers in LTC in 2019 (Spain, Portugal, Italy) tended to have more
COVID-19 cases and deaths in this sector.
•
OECD countries have dierent models of funding and regulation for LTC. While no clear dierences
in pandemic outcomes were observed across funding models (public, private or mixed), countries with
centralized regulation and organization of LTC (e.g., Australia, Austria, Hungary, Slovenia) generally
had lower numbers of COVID-19 cases and deaths.
Figure 2 Percentage of seniors (65+) in LTC by province and
territory, 2018–2019
Canada
Prince Edward Island
Nova Scotia
New Brunswick
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
Nunavut
Newfoundland
and Labrador
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
Notes
LTC: Long-term care.
Data includes nursing homes, retirement homes and homes for residents with disabilities or mental health needs.
Source
Statistics Canada. Data tables, 2016 Census: Type of collective dwelling (16), age (20) and sex (3) for the population
in collective dwellings of Canada, provinces and territories, 2016 Census — 100% data. Accessed May 25, 2020.
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CIHI Snapshot
Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?
Policy responses to address the pandemic
•
Countries that implemented specic, mandatory prevention measures targeted to the LTC sector at the same
time as their stay-at-home orders and closure of public places (Australia, Austria, the Netherlands, Hungary,
Slovenia) had fewer COVID-19 infections and deaths in LTC. These prevention measures included immediate
infection control measures, such as broad LTC testing and training, isolation wards to manage clusters,
and additional supports for LTC workers such as surge stang, specialized teams and personal protective
equipment (PPE) (see Figure 3).
Figure 3 Impact of COVID-19 on LTC residents by level of policy
response at the time of 1,000 COVID-19 cases
0%
10%
20%
30%
40%
50%
60%
Policy response 1
• Stay-at-home order
• Economic stimulus
• Acute care funding
Policy response 2
All in response 1 and
• LTC visitor restrictions
• LTC guidance
Policy response 3
All in response 2 and
• Hazard pay
• LTC surge staffing
• LTC recruitment
• PPE funding
Policy response 4
All in response 3 and
• LTC isolation wards
• Broad LTC testing
• LTC infection control
training and audit
• LTC rapid response control
and prevention teams
Canada, France, Norway,
Spain, U.S., U.K.
Israel, Belgium,
Italy
Hungary, Portugal,
Ireland, Netherlands
Austria, Australia,
Slovenia
COVID-19 deaths in LTC as a
percentage of all COVID-19 deaths
COVID-19 deaths in LTC as a
percentage of COVID-19 cases
Notes
LTC: Long-term care.
PPE: Personal protective equipment.
Countries are grouped according to which policy interventions were announced as mandatory at the time of a country’s rst reported
1,000 COVID-19 cases.
Policy implementation can vary substantially within countries as some of these measures may be applied at the local level only. Each COVID-19
policy response includes the interventions from the previous level.
Specic policies and their implementation dier widely across regions or provinces of a country. For instance, the level of enforcement measures
may vary across regions of a country and may have changed with the evolution of the outbreak in certain regions where more local measures may
have been implemented. Some regions or provinces may have acted earlier than the national announcement in order to better manage their own
outbreaks; however, the category of policy response did not change as a whole for the country.
Sources
World Health Organization. COVID-19 Health System Response Monitor. Accessed May 25, 2020.
International Long-term care Policy Network.
Organisation for Economic Co-operation and Development. AI Policy Observatory.
North American Observatory on Health Systems and Policies.
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CIHI Snapshot
Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?
Notes and limitations
Data for this analysis was sourced from ocial international publications (from the OECD, World Health
Organization, etc.), country websites, and the media and published literature. Interpretation of this
information needs to consider the following:
•
The situation is evolving rapidly and this data represents a snapshot as of May 25, 2020, at 9 p.m. ET.
•
Data on COVID-19 cases and deaths was collected from ocial surveillance websites. OECD peer
countries that do not report publicly on their LTC sector were not included.
•
Reporting of COVID-19 cases and deaths in the LTC sector is not directly comparable due to dierent
testing and reporting standards across countries, as well as to dierent denitions of LTC. In many
countries, COVID-19 cases in this sector are under-reported due to a lack of testing in care homes
or lag times in reporting test results.
•
The denition of LTC for COVID-19 reporting varies by country. For Canada, Hungary, France and
Belgium, LTC includes both residential facilities with 24-hour nursing care and facilities with fewer
services, such as retirement homes and assisted-living facilities. Data for Germany and the Netherlands
includes all communal institutions such as prisons, shelters and homes for residents with disabilities
in addition to assisted-living and residential care facilities. Data for Italy and Israel includes only those
seniors’ homes with intensive nursing support. Data for Austria includes residences for residents
with disabilities. Data for Australia, Ireland, Norway, Portugal, Spain, Slovenia, the U.K. and the U.S.
includes residential and nursing homes and skilled nursing facilities.
•
Information is not available at the country level for many factors that may inuence COVID-19 outcomes
in LTC. These factors include sta working at multiple sites, the density of the resident population in
care homes, hospital transfer policies and access to PPE.
More information can be found in our companion data tables.
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CIHI Snapshot
Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?
Appendix: Text alternative for figures
Figure 1: COVID-19 deaths as of May 25, 2020, at 9 p.m. — Number per million population,
total and LTC
Country
Number of COVID-19
deaths per million
population
Number of LTC deaths
per million population
Australia
3 1
Israel
33 19
Norway
44 25
Slovenia
51 5
Hungary
52 3
Austria
72 13
Germany
99 34
Portugal
130 32
Canada
176 142
OECD average
266 112
U.S.
295 91
Ireland
329 184
Netherlands
341 50
France
436 208
Italy
543 176
U.K.
547 150
Spain
574 379
Belgium
807 400
Notes
OECD: Organisation for Economic Co-operation and Development.
LTC: Long-term care.
The situation is evolving rapidly and this data represents a snapshot of the pandemic in countries reported by May 25, 2020, at 9 p.m. ET.
Reporting of COVID-19 cases and deaths in the LTC sector is not directly comparable due to dierent testing and reporting standards
across countries, as well as to dierent denitions of LTC. In many countries, COVID-19 cases in this sector are under-reported.
Data for Italy is available from only 52% of the nursing homes operating in the country.
Sources
World Health Organization. Coronavirus disease (COVID-2019) situation reports. Accessed May 25, 2020.
World Health Organization Europe. Coronavirus disease (COVID-19) outbreak reports: Country information. Accessed May 25, 2020.
United Nations Department of Economic and Social Aairs, Population Division. World Population Prospects 2019. 2019.
European Centre for Disease Prevention and Control. Accessed May 25, 2020.
National Institute on Ageing. NIA Long-Term Care COVID-19 Tracker. Accessed May 25, 2020.
Daily epidemiological summaries produced by each country, where available, March 1 to May 25, 2020 (e.g., Public Health Agency of
Canada, Robert Koch Institute of Germany).
International Long-term care Policy Network. Accessed May 25, 2020.
8
CIHI Snapshot
Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?
Figure 2: Percentage of seniors (65+) in LTC by
province and territory, 2018–2019
Jurisdiction Percentage 65+ in LTC
Canada
7.0
Newfoundland and Labrador
5.0
Prince Edward Island
6.5
Nova Scotia
5.3
New Brunswick
6.5
Quebec
9.5
Ontario
5.8
Manitoba
7.8
Saskatchewan
7.7
Alberta
8.1
British Columbia
5.6
Yukon
3.8
Northwest Territories
3.4
Nunavut
1.8
Notes
LTC: Long-term care.
Data includes nursing homes, retirement homes and homes for residents with disabilities
or mental health needs.
Source
Statistics Canada. Data tables, 2016 Census: Type of collective dwelling (16), age (20)
and sex (3) for the population in collective dwellings of Canada, provinces and territories,
2016 Census — 100% data. Accessed May 25, 2020.
9
CIHI Snapshot
Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?
Figure 3: Impact of COVID-19 on LTC residents by level of policy response at the time of
1,000 COVID-19 cases
Policy response Countries
COVID-19 deaths in LTC
as a percentage of all
COVID-19 deaths
COVID-19 deaths in
LTC as a percentage of
COVID-19 cases
Policy response 1
• Stay-at-home order
• Economic stimulus
• Acute care funding
Canada, France,
Norway, Spain,
U.S., U.K.
52 37
Policy response 2
All in response 1 and
• LTC visitor restrictions
• LTC guidance
Israel, Belgium, Italy 47 33
Policy response 3
All in response 2 and
• Hazard pay
• LTC surge staffing
• LTC recruitment
• PPE funding
Hungary, Portugal
Ireland, Netherlands
28 26
Policy response 4
All in response 3 and
• LTC isolation wards
• Broad LTC testing
• LTC infection control training and audit
• LTC rapid response control and prevention teams
Austria, Australia,
Slovenia
15 17
Notes
LTC: Long-term care.
PPE: Personal protective equipment.
Countries are grouped according to which policy interventions were announced as mandatory at the time of a country’s rst reported 1,000 COVID-19 cases.
Policy implementation can vary substantially within countries as some of these measures may be applied at the local level only. Each COVID-19 policy
response includes the interventions from the previous level.
Specic policies and their implementation dier widely across regions or provinces of a country. For instance, the level of enforcement measures may
vary across regions of a country and may have changed with the evolution of the outbreak in certain regions where more local measures may have been
implemented. Some regions or provinces may have acted earlier than the national announcement in order to better manage their own outbreaks; however,
the category of policy response did not change as a whole for the country.
Sources
World Health Organization. COVID-19 Health System Response Monitor. Accessed May 25, 2020.
International Long-term care Policy Network.
Organisation for Economic Co-operation and Development. AI Policy Observatory.
North American Observatory on Health Systems and Policies.
cihi.ca
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