Impact of a COVID-19 outbreak in a long-term care facility in Barcelona, Spain: The role of a COVID-19 prevention and control program

The COVID-19 pandemic (coronavirus disease 2019) is a devastating disease that has affected more than a hundred countries causing a serious impact on the health, economy and society [1]. COVID-19 mortality is higher in people aged 60 years or over and with underlying medical conditions, such as cardiovascular disease, chronic respiratory disease, diabetes and cancer [2-5]. During the ongoing COVID-19 pandemic, long-term care facilities and other congregate living settings have been identifi ed as high-risk settings for severe outbreaks and poor outcomes [6-11]. These facilities are particularly susceptible as many of their residents are older, frail, with disabilities and multiple and severe chronic comorbidities or Abstract


044
Citation: Vallecillo  immunocompromised status [12]. Moreover, clinical and social characteristics of long-term care facilities provide an ideal environment for acquisition and spread of COVID- 19, resulting in large outbreaks [6][7][8][9][10][11]. Gathering of a large number of residents who share multiple resident rooms, group activities and clinical care, together with a high number of health care professionals and visitors, are factors that promote the coronavirus spreading in the facility [13,14]. Moreover, control measures are diffi cult to enforce for residents with dementia and behavior disturbances [13,14]. In addition, most facilities are poorly prepared to implement infection control policies owing to shortage of protective equipment and relatively low level of staff training [13][14][15].
Anyway, the rapid evolution and mortality of COVID-19 outbreaks in long-term care facilities highlight the critical need of implementing a strong COVID-19 prevention and control (CPC) program to protect both residents and Healthcare Professionals (HCP) [16][17][18]. However, characteristics and functioning of CPC programs vary depending on the resources of each facility [6][7][8][9][10][11], so studies are necessaries to evaluate the effectiveness of CPC programs to reduce the morbidity and mortality of outbreaks in long-term care facilities.
Therefore, the objective of this study was to describe the effectiveness of a COVID-19 prevention and control action program, including social isolation, active symptoms screening for all residents and staff, SARS-CoV-2 testing for symptomatic individuals, droplet and contact isolation measures for asymptomatic residents, confi nement of the unit and clinical care in a separate unit for patients in a long-term care facility during the fi rst wave of COVID-19 epidemic in Spain [19].

Setting
The study was conducted at the Emili Mira Healthcare

Interventions
From the beginning of the national state of alarm (declared on the 14 th March, 2020), a structured CPC program was implemented in the facility to prevent and control COVID-19 among residents. The CPC program was designed by the clinical staff and was approved by the medical direction of the facility.
The CPC program was coordinated by a physician specialized in infectious diseases and included preventive measures for residents, HCP and facility according to the international guidelines [16][17][18].

Residents
All residents were screened for symptoms every day

Defi nitions
The COVID-19 primary case was defi ned as the fi rst case The attack rate was calculated as the number of confi rmed cases divided by the total number of exposed individuals, and case fatality rate as the deceased confi rmed cases divided by the total number of confi rmed.

Statistics
Descriptive statistics was expressed as mean and standard deviation, whereas quantitative variables with nonparametric distribution were expressed as median and interquartile range.
Absolute frequencies and percentages were expressed for the qualitative variables. One-way ANOVA and Kruskal-Wallis test were used to compare quantitative variables. Analyses were made using SPSS software, version 17.0.0 (Chicago, Illinois).

Ethics
The study followed the ORION statement guidelines for transparent reporting of outbreak reports and intervention studies of nosocomial infection [20] and complied with the ethical statements in the Declaration of Helsinky (64th General Assembly, Fortaleza, Brazil, October 2013).

Results
The outbreak affected the two geriatric (unit-1 and 2) and

Discussion
The results of this study describing the effectiveness of a CPC program focused on symptom-based screening, showed similar results than programs based on facility-wide SARS-CoV-2 testing in terms of incidence [10]. Facility-wide testing is essential to detect asymptomatic patients who can keep active the outbreak in the facility [21,22]. However, the virus spread has already occurred at the time the fi rst case is identifi ed in the facilities and some patients can test negative because the disease is under the incubation period [9] and thus, implementing isolation measures by contact and drops for all residents at this time is a suitable preventive measure to control the outbreak. The results of this study supports this option for CPC programs of facilities which have limited access to laboratory for asymptomatic patients.
Moreover, this study showed nearly twice of infections among residents of geriatric units compared to the psychiatric unit. This fact is important, as residents from the geriatric units had high needs of nursing care secondary to their functional disability, according to the Barthel index, that predisposed them to an intense contact with HCP during the daily routine care [23], which is a risk factor for infection [24,25]. Thus, HCP should be aware of the risk of nursing care and adhere strictly to CPC practices to prevent the spread of infection.  This study has some limitations and advantages. Lack of a facility-wide SARS-CoV-2 testing initiated before identifi cation of a COVID-19 case is essential to prevent outbreaks and to detect asymptomatic patients who can spread the virus during outbreak [10]. However, the CPC program, including droplet and contact isolation to prevent that hypothetical asymptomatic patients spread the virus, proved to be effectiveness for controlling the outbreak in a more diffi cult and complex center, with two facilities, high number of residents and HCP and common spaces for HCP [11].

Conclusions
In conclusion, COVID-19 outbreaks in long-term care facilities cause serious adverse outcomes among residents and affect a high number of HCP. The extent to which COVID-19 outbreaks in these facilities can be prevented and reduced their clinical impact depend on the application of Community-facility contact restrictions, increased testing of residents and staff, and heightened infection control including more access to personal protective equipment for staff. In facilities where wide testing SARS-CoV-2 is restricted for asymptomatic residents, droplet and contact isolation measures for all residents is a useful alternative.
As the COVID-19 crisis continues, long-term care facilities are in critical need of these resources to protect their vulnerable populations.
1. HighlightsA COVID-19 prevention and control program is necessary to reduce the negative clinical impact of COVID-19 outbreak, especially in older adults with comorbidities and disabilities.
2. Including a droplet and contact isolation for all residents in the program is a useful alternative to wide-facility SARS-CoV-2 testing.