EU agency warns against outbreaks of COVID-19 in care facilities

EU agency warns against outbreaks of COVID-19 in care facilities
Credit: Belga

The European Centre for Disease Prevention and Control (ECDC) published yesterday a risk assessment about COVID-19 outbreaks in long-term care facilities in the EU/EEA and highlighted the occurrence of several outbreaks in these homes during the past six months.

While high vaccination coverage among long-term care facilities (LTCF) residents was confirmed in all reported outbreaks, based on the available reported data, vaccination coverage among LTCF health care workers (HCW) and other staff was often sub-optimal, according to ECDC.

In general, long-term care facilities include institutions such as nursing homes, skilled nursing facilities, retirement homes, assisted-living facilities, residential care homes or other facilities.

“Protecting the elderly and the frail must continue to be a priority,” commented Andrea Ammon, ECDC Director (26 July). “COVID-19 vaccine uptake needs to be further promoted among long-term care facilities residents and all persons who come in contact with them such as healthcare workers, auxiliary staff, caretakers and visitors.”

She added that, “In the current epidemiological context, meticulous compliance with non-pharmaceutical interventions like the use of face masks, appropriate hand hygiene and physical distancing should be maintained”.

The first wave of the coronavirus crisis in 2020 hit most countries unprepared and left often retirement and nursing homes in Belgium and other countries to care for their vulnerable residents by themselves.

Once the vaccine rollout started, vaccination programmes in the EU member states prioritised residents and staff in LTCFs, healthcare workers, social care personnel and people with health conditions that made them vulnerable to severe disease as the main target groups for vaccination.

Vaccine uptakes among LTCF residents and staff

According to the report, while the estimated uptake among adults aged 80 years and older is overall high with a median of 78.7% in 27 reporting countries, the situation among LTCF staff is less good and may indicate vaccine hesitancy.

As of week 27 (ending 11 July 2021), the median vaccine uptake among LTCF residents in 12 reporting EU/EEA countries was 80.6% (country range: 37.7-100%) for at least one dose and 75.2% (country range: 33.3-100%) for full vaccination. Only four countries (Denmark, Luxembourg, Spain and Sweden) reported full vaccination coverage of more than 80% in this population.

17 countries reported about the vaccine uptake in healthcare workers, with a median vaccine uptake of 83.9% (country range: 22.2-100%) for at least one dose and 77% (country range: 21.2-100%) for full vaccination. Eight countries (Czechia, Hungary, Iceland, Ireland, Latvia, Malta, Romania and Spain) reported full vaccination coverage of more than 80% in this population.

However, ECDC cautions that data on COVID-19 vaccine uptake among healthcare workers has several limitations.

Firstly, there is significant variability in the definition of ‘healthcare worker’ between countries, which may or may not include all staff working in LTCFs, and there is not a specific category for LTCF staff. It is therefore not possible to infer that the same high vaccine uptake reported for healthcare workers applies to all LTCF staff.

Secondly, staff working in LTCFs usually includes a limited number of healthcare workers and a larger number of auxiliary staff, for whom there are limited data on vaccination coverage. Due to the lack of reliable data on vaccination coverage among LTCF staff, ECDC assumed that over 20% of the staff are unvaccinated.

Measures to protect long-care facilities

Variants of concern (VOCs) such as the Delta variant associated with higher transmissibility have been implicated in most of the outbreaks of breakthrough infections in LTCFs.

Although the effectiveness of COVID-19 vaccines authorised in the EU/EEA is high, no vaccine is 100% effective. Infections amongst fully vaccinated persons are expected, particularly in the elderly, or persons with underlying conditions.  “Vaccines prevent severe disease to a large extent; however, we can still see hospitalisations and even deaths in these populations.”

ECDC lists the following specific measures to reduce the impact of COVID-19 on individuals residing in LTCF:

  • Full vaccination coverage of residents and all people in contact with LTCF residents needs to be rapidly ensured. This includes in addition to residents, healthcare personnel and other staff working in LTCF, as well as visitors.
  • Countermeasures to reduce the risk of virus introduction into these LTCF communities need to be in place.
  • Early identification of COVID-19 cases is essential for the introduction of control measures and the prevention of any further spread of outbreaks. Therefore, testing, contact tracing and investigation of LTCF COVID-19 cases and outbreaks should remain a priority for public health authorities.
  • Meticulous compliance with non-pharmaceutical interventions (NPIs).

In particular, efforts should be undertaken to promote further COVID-19 vaccination to unvaccinated LTCF staff through specific activities targeting vaccine acceptance and barriers to uptake.

Clarifications from ECDC

The article has been updated on Tuesday afternoon to include a definition of LTCFs and clarifications by ECDC of the figures in the risk assessment following a request for comment.

Was the report mainly based on data from seven countries that have reported by week 27?

The Rapid Risk Assessment was based on data on 18 outbreaks associated with breakthrough infections (i.e. infections among fully vaccinated individuals) that took place in LTCFs in six different countries between February and July 2021. The data on these outbreaks were not the result of systematic data collection or surveillance and ECDC is aware that there are many more such outbreaks in other EU/EEA countries.

The data that the risk assessment was based on were submitted to ECDC by EU/EEA countries because they were deemed to be of public health interest. The assessment does not represent a comprehensive overview of all outbreaks that have taken place in LTCFs in EU/EEA countries in the period between February and July 2021.

It appears that the trend in incidence of confirmed COVID-cases in LTCF in fact decreased. Shall the report be seen as a warning of risk of increases in outbreaks in the LTCF?

According to surveillance data and comparing week 27 to weeks 23–26, trends in the incidence of confirmed COVID-19 cases in LTCFs decreased in six out of seven countries that reported data (Austria, Belgium, France, Luxembourg, the Netherlands and Slovenia) and increased in one country (Lithuania).

The Rapid Risk Assessment should be seen as a warning that LTCF residents continue to be vulnerable. Outbreaks in LTCFs will likely continue to occur if community transmission of the virus increases, vaccination coverage of LTCF residents and staff remains suboptimal, and non-pharmaceutical interventions (NPIs) are relaxed too early in these settings. This is the main message we wished to convey.

It appears that there is no correlation between high vaccination rate of residents in LTCF and of health care staff there?

Statistical analyses of the correlation between the vaccination status of staff, that of residents, and the characteristics of the outbreaks have not been carried out. However, the fact that a large proportion of the outbreaks occurred in LTCFs with suboptimal vaccination status among staff highlights the importance of attaining higher full vaccination coverage of all persons interacting with LTCF residents.

What is the main explanation to the latest outbreaks in the long-term care homes?

Vaccines are highly effective, but LTCF residents remain more vulnerable to SARS-CoV-2 due to the aging of the immune system and the coexistence of multiple comorbidities. In week 27, data reported to ECDC on LTCF residents show that their coverage remains suboptimal in many countries (median full vaccination uptake 75.2%; country range: 33.3-100%).

In the risk assessment we summarise studies on vaccine effectiveness carried out in different countries. These studies clearly show that in the population of LTCF residents vaccine effectiveness against SARS-CoV-2 infection after full vaccination is only reaching 64-81% compared to the 90% vaccine effectiveness expected in younger healthier individuals, such as health care workers.

The population residing in LTCFs may have altered vaccine protection due to their age and underlying conditions, albeit data on vaccine effectiveness against the Delta variant of concern (VOC) specifically is missing in this population. In addition, vaccine effectiveness against the Delta VOC in the general population is reduced compared to that against other variants, particularly following the administration of only one vaccine dose (for vaccines requiring a two-dose schedule).

Data on the vaccination rates of LTCF staff specifically (including healthcare workers and auxiliary staff) are lacking at the EU/EEA level. On the other hand, data reported to ECDC for the assessment suggest that LTCF staff remain at suboptimal levels of full vaccination coverage. From the ECDC Vaccine Tracker, we know that the same is also true for visitors (general population) all over the EU/EEA.

If we factor in the continuing circulation of variants with higher transmissibility (e.g. Delta, Gamma) in communities who are showing immune escape signs then we think that outbreaks in LTCFs can be explained.

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