Nursing homes used unproven COVID measures and didn't use vaccines, antivirals enough, review finds

Nurse giving resident pills

Biserka Stojanovic / iStock

Few of the many nonpharmacologic efforts to mitigate the spread of COVID-19 in nursing homes during the pandemic were evidence-based, and vaccinations and antiviral drugs were underused, concludes a scoping review published late last week in JAMA Health Forum.

Boston University–led researchers analyzed the federal COVID-19 Skilled Nursing Facility (SNF) Database to determine trends over time in rates of infection, death, testing, vaccination, and treatment among residents and staff, as well as shortages of staff and personal protective equipment (PPE) from 2020 through 2023. 

They also searched the literature to identify evidence on the use and efficacy of 16 pharmacologic and nonpharmacologic disease-mitigation measures among residents from May 2023 to April 2024 and collected weekly data on COVID-19 cases and deaths from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network database.

"By the end of 2020, despite only representing 1% of the US population, SNF residents constituted 4% of all COVID-19 cases and 31% of its deaths," the study authors noted. "SNF residents are highly susceptible to COVID-19 infection because of their age, comorbidities, and frailty."

Staffing, PPE, test shortages 

About one fifth of SNFs reported staffing shortages in July 2020, which increased through 2022, the most recent year with available data. While the size of the SNF workforce has not rebounded to prepandemic levels, staff-to-resident ratios appear to have recovered.

"Multiple studies evaluated the associations between staffing and COVID-19 outcomes," the researchers wrote. "Most found that higher staffing, measured as hours per day, were associated with fewer resident cases and deaths, consistent with more staff facilitating increased infection control protocol adherence (eg, PPE, etc)."

While PPE was recommended for healthcare settings throughout the pandemic, 20% of SNFs experienced shortages into 2021, and many continued to admit residents.

No US studies have compared the importance of different PPE types (eg, gloves, masks, eyewear, or gowns).

"Several studies reported staff nonadherence to PPE use protocols," the investigators wrote. "A cross-sectional study of 13,156 SNFs found a significant association between N95 mask shortages and prevalence of any COVID-19 case, but no US studies have evaluated adherence and COVID-19 incidence. Furthermore, no US studies have compared the importance of different PPE types (eg, gloves, masks, eyewear, or gowns)."

Routine COVID-19 testing was limited due to supply shortages in 2020, with many SNFs restricting testing to only residents or those with symptoms. "Test result turnaround times, often 3 days or longer in 2020, likely reduced preventive testing's efficacy," the authors noted. "Variation of testing intensity persisted in 2021 to 2022 with the majority of SNFs performing fewer than 1 screening test per week for staff or residents."

One study showed that, before vaccine availability, SNFs with the highest test volumes had 12% and 14% fewer COVID-19 cases and deaths per outbreak, respectively, than those with the lowest volumes. 

Visitors restricted despite lack of evidence

Visitor restrictions were widely implemented, decreasing foot traffic 34%, but evidence for this measure was scarce. Many SNFs tried to substitute virtual visits for in-person visits, but only 22% of residents of assisted-living or SNFs reported weekly contact with family or friends, down from 56% in 2019. And no studies evaluated the effectiveness of restricting social activities such as communal dining in SNFs, despite their widespread implementation early in the pandemic.

Isolating residents or housing them in groups by infection status was not implemented universally. Multiple studies found that adherence to quarantine guidelines on admissions didn't lead to fewer outbreaks after adjusting for community COVID-19 incidence, but a cross-sectional study of SNFs in England found that dedicating specific staff for infected patients was tied to a lower outbreak risk.

Suboptimal hand hygiene was reported in nearly a third of SNFs in 2020, but no research addressed its association with outcomes.

A higher average number of residents per room, higher bed occupancy, and SNFs with shared bedrooms were linked to higher COVID-19 rates in most studies, and crowding predicted the number of infections and deaths among SNFs with existing outbreaks.

Other than a single uncontrolled study, evidence about the association between ventilation technologies and outbreaks was lacking. "Suboptimal hand hygiene was reported in nearly a third of SNFs in 2020, but no research addressed its association with outcomes," the researchers said. "Lack of controlled studies limits our ability to draw conclusions regarding the impact of crowding and the physical environment on infection spread."

Low use of antivirals, monoclonal antibodies

After 81% of SNF residents were vaccinated in the first half of 2021, COVID-19 transmission and deaths declined, but uptake varied considerably. Coverage differences grew as more rounds of vaccines were recommended and the CDC began monitoring up-to-date vaccination status.

"Waning vaccine-induced immunity and increasing natural immunity reduced the effectiveness of the primary vaccination series over time, but booster vaccinations remained highly effective at preventing severe outcomes and deaths," the authors wrote.

Staff vaccination rates were lower than those of residents, especially for boosters, despite the ability to reduce staff infections by up to 83%. Greater staff vaccine uptake was tied to 56% and 19% reductions in risk of COVID-19 infections and deaths, respectively, in residents per 10% of staff vaccinated. But after the Omicron variant emerged in December 2021, a longitudinal cohort study found that 10% increases in staff vaccination were no longer linked to better outcomes. 

When possible, implementation efforts should be commensurate with the demonstrated effectiveness of available preventive measures.

While the use of antiviral drugs and monoclonal antibodies were tied to reduced hospitalizations and deaths, these treatments were underused. "Only an estimated 30% of infected residents received this treatment by 2021, when theoretically close to 100% of COVID-19 cases could have benefitted from treatment," the researchers noted. "By March 2023, only approximately 35% of resident COVID-19 cases were treated with antivirals."

Despite considerable efforts to implement COVID-19 control measures, few were systematically or nationally tracked, and almost none used randomized or staggered rollouts to reveal a causal inference, underscoring missed opportunities to identify best practices, they said. 

"Using the scarce resources and staff of SNFs on measures of questionable effectiveness could distract from known effective ones such as vaccination and antiviral treatment," the researchers wrote. "When possible, implementation efforts should be commensurate with the demonstrated effectiveness of available preventive measures."

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