TECHINCAL GUIDANCE Surveillance of COVID-19 at long-term care facilities in the EU/EEA
3
COVID-19 in long-term care facilities
A high proportion of LTCFs across Europe and globally have reported COVID-19 outbreaks, with high rates of
morbidity and case fatality in residents and high rates of staff absenteeism [4-6]. The transmission dynamics of
COVID-19 combined with low availability of testing have fuelled a rapid spread within and between facilities,
leading to high morbidity and mortality among residents in these settings.
At a skilled
1
nursing facility in King County, Washington State (US), within 23 days of a first SARS-CoV-2 positive
test result, 64% (n=57/89) of LTCF residents had tested positive. The facility performed two comprehensive point
prevalence surveys (PPS) in 76 residents, one week apart. In the first PPS, one third of the LTCF residents (21/76;
28%) tested positive for SARS-CoV-2 and had symptoms, while one third (27/76; 36%) tested positive but had no
symptoms. However, within seven days, 24/27 (89%) ‘asymptomatic’ cases had developed compatible symptoms
(i.e. they had been pre-symptomatic.) As of 3 April 2020, 15/57 (26%) of the SARS-CoV-2-positive residents at this
facility had died [7]. This underlines the importance of taking measures for those without symptoms at facilities
with cases [8]. In Belgium, as of 5 May, systematic testing of all residents and staff in a selection of LTCFs with
confirmed cases identified that 73% (5 695/7 751) of PCR-positive cases were asymptomatic [9].
Under-ascertainment and under-reporting of COVID-19 cases in LTCFs has been a common feature of the COVID-
19 surveillance in Europe. The increasing number of reported outbreaks, which have been associated with high
mortality, indicates the requirement for a targeted approach to the protection of vulnerable groups in such
settings. The majority of European countries did not have surveillance systems for LTCFs in place before the
current pandemic – i.e. systems able to systematically and consistently monitor respiratory diseases and provide
timely reporting at local or national level to inform interventions. In recent weeks, local, regional or national
monitoring systems have been updated or created to include LTCFs. Example systems that can report COVID-19
cases are listed at the end of this document (see Annex). In some EU countries, the proportion of COVID-19 cases
in LTCFs who have died has exceeded 60% of all reported deaths, underlining the severe impact of COVID-19 on
this frail population [4].
In Belgium, as of 17 May 2020, 51% of the 9 052 COVID-19 related fatal cases were reported from LTCFs, with only
23% of cases laboratory-confirmed [9]. Systematic testing for SARS-CoV-2 among all LTCF residents revealed that 4%
(5 640/141 089) were positive and more commonly symptomatic than asymptomatic (25% and 3%, respectively). Tests
were also performed among LTCF staff, with 3 106/136 282 (2%) testing positive. The overall test positivity is higher in
symptomatic than asymptomatic staff (11% and 2%, respectively). However, the overall number of asymptomatic cases
among residents and staff was 75% (6 540/8 746) of all cases that tested positive at these facilities.
France has established a dedicated notification system for COVID-19 cases reported by LTCFs. Between 1 March and
11 May 2020, 7 469 facilities reported cases, of which 4 367 (66%) were in nursing homes for the elderly and 2 245
(34%) were at other LTCFs, such as facilities for disabled persons or children and young adults. Of the 73 435
reported confirmed and probable cases among residents, 13 539 (17%) died, 3 321 in hospitals and 9 501 at the
facilities, which represent 50% of all deaths
[10]. In addition, 39 294 cases were reported among staff members.
As of 17 May 2020, Germany had reported 22 071 infections related to institutions caring for elderly (long-term
care, nursing homes), disabled people, homeless people, migrants, or those in prisons. Of these, 8 536 cases were
in staff (42 died) and 14 740 cases were in residents. Of the residents 2 966 died (20%), representing 37% of all
7 914 deaths related to COVID-19 in Germany [11].
Ireland has a dedicated outbreak reporting surveillance system for all infectious diseases, which is currently being
used for COVID-19. As of 9 May, 418 COVID-19 outbreaks had been notified in residential facilities (including
nursing homes for the elderly, direct provision centres and prisons) in Ireland, with 5 698 laboratory confirmed
cases and 727 deaths in confirmed cases linked to these outbreaks [12].
In Norway, 136 (61%) of all 224 fatal cases reported by 11 May 2020 were in ‘home care’ or ‘other health
institutions’ [13].
In Spain, as of 11 May, 17 730 fatalities have been reported from 5 400 affected care-home residents,
representing 66% of all fatal cases linked to COVID-19 [14].
In Sweden 212 of 400 LTCFs in the Stockholm region have reported 1 711 COVID-19 cases, representing 630 (45%) of
1 406 deaths in Stockholm [15-18]. In Stockholm county, 400 LTCFs participated in a survey during the period 12–15
April 2020, with 212 (53%) reporting that they had had confirmed COVID-19 cases. Of these 212 LTCFs, 123 indicated
the size of their outbreaks, with 37% reporting 4–10 cases, and 22% reporting >10 cases. Across Sweden, 541 care
homes have been affected and 2 866 confirmed COVID-19 cases with 948 deaths have been reported from LTCF
residents aged over 70 years, representing 50% of all COVID-19 related deaths in this age group [19]
In the United Kingdom, the Office for National Statistics lists 6 997 (21%) deaths in care homes as COVID-19-
related out of a total 33 337 registered COVID-19 deaths in England and 404 (25%) deaths in care homes out of a
total of 1 641 COVID-19 deaths in Wales between 28 December 2019 and 1 May/9 May 2020 [20]. The Care
1
US healthcare institution that meets federal criteria for Medicaid and Medicare. For more details see
https://www.skillednursingfacilities.org/resources/what-are-skilled-nursing-facilities-/