The global toll of Covid-19 has hit one vulnerable population harder than any other: nursing-home residents.
A Wall Street Journal review of data from more than two dozen nations with significant elder-care facilities shows that such institutions are tied to more than a third of Covid-19 deaths, though they typically house less than 2% of the population. These countries linked at least 233,000 of 641,000 overall Covid-19 deaths to nursing homes and other long-term elder-care sites. In the U.S. alone, the death toll tied to these facilities tops 125,000.
Nursing homes were a soft target for a highly contagious and deadly virus because they house the frailest people in close proximity. The novel coronavirus has generally proved most dangerous for the elderly, who have had the highest mortality rates overall.
But even among older people susceptible to Covid-19, nursing homes proved uniquely perilous. An analysis published in November in JAMDA, the Journal of Post-Acute and Long-Term Care Medicine, looked at a dozen Organization for Economic Cooperation and Development member countries and found the Covid-19 mortality rate among long-term care residents was more than 20 times higher than that among older people living outside such facilities.
The devastating toll wasn’t inevitable. Countries such as South Korea managed to limit the deaths among nursing-home residents by avoiding widespread community outbreaks and moving quickly to prevent infections from spreading inside the facilities. Even as it faces a recent surge of Covid-19 cases, the entire east Asian nation has still reported only about 70 long-term care deaths in total. Eight U.S. states have reported more than 7,000 deaths.
“We left the barn door open,” said Dr. Samir Sinha, director of health policy research and co-chair at the National Institute on Ageing, a think tank at Toronto’s Ryerson University which attributes more than 70% of Canada’s approximately 14,000 known Covid-19 deaths to long-term care homes. “It was a tragedy,” he added.
Around the world, the Journal found:
•Many countries had done little to fortify nursing homes before the coronavirus arrived at their borders, and didn’t have the ability to track the contagion’s spread there, despite the known risks.
•Nations often reacted slowly, even after outbreaks erupted. The U.S. waited weeks before putting nursing-home residents in the highest-priority tier for access to Covid-19 testing and months to mandate regular testing of staff.
•Failure to contain community spread of the virus reignited nursing-home outbreaks despite improved testing and equipment, with deaths ramping back up as younger, healthier people gathered.
“Long-term care is forgotten, neglected, at the bottom of the list for almost every country, when you look at the data,” said Joseph Ibrahim, a professor focused on health law and aging at Monash University in Australia.
Covid-19 has been particularly devastating for residents of long-term care facilities, who represent small fractions of overall populations but huge shares of coronavirus deaths.
Long-term care deaths as a percentage of total Covid-19 deaths
722 total Covid 19 deaths
Long-term care deaths as a percentage of total Covid-19 deaths
722 total Covid 19 deaths
Long-term care deaths as a percentage of total Covid-19 deaths
722 total Covid 19 deaths
Long-term care deaths as a percentage of
total Covid-19 deaths
722 total Covid 19 deaths
Inquiries into individual nursing homes and the broader government response to outbreaks in the sector are under way in nations including Canada, Sweden, Spain, Italy and France. A nursing-home commission launched by the Trump administration in the U.S. called in September for a more muscular federal response, including greater help for nursing homes with staffing, testing and protective gear.
Covid-19 deaths in elder-care facilities slowed during parts of the summer and early fall, but they have recently risen again in wide swaths of the U.S, along with European countries like France and Belgium.
In the U.K., where almost 22,000 known Covid-19 deaths have been tied to elder-care homes, or roughly 27% of the total, bereaved families are calling for a public investigation.
Britain’s Care Quality Commission, the regulator for the long-term care sector, said in a preliminary report this month that it has learned of dozens of care-home residents made subject to do-not-resuscitate orders early in the pandemic without their consent or their family’s knowledge. The commission said it is investigating how widespread the practice was to determine whether any breaches of British human-rights law took place.
On April 6, Helen Keenan found out that her mother, Kathleen Keenan, an elder care-home resident near Birmingham in England’s west Midlands, had tested positive for the coronavirus while she was in the hospital. Rather than getting care there, she was sent back to the facility where she lived, Bracken House, two days later.
The younger Mrs. Keenan said she was told by hospital staff that her mother’s age, dementia and chronic respiratory illness meant she wouldn’t be eligible for intensive care even if her Covid-19 worsened because she’d be less likely to survive than someone younger and healthier. She was declared medically fit, despite the positive Covid-19 test, and returned to her care home.
On April 26, two weeks after she turned 84, Kathleen Keenan died. People like her mother “were just written off,” said Mrs. Keenan.
Kathleen Keenan celebrated her 82nd birthday in 2018 with her daughter Helen at a care home in England.
Ann-Marie Riley, director of nursing at Walsall Healthcare NHS Trust, which manages the hospital where the elder Mrs. Keenan was treated, said at the time of her discharge Mrs. Keenan didn’t require high levels of care. As Mrs. Keenan was living with dementia, hospital staff made the clinical decision for her to return to familiar surroundings where she felt most comfortable, she added, noting that staff told her care home of her positive test result and it was happy to receive her and help her isolate.
She added the hospital acknowledged that communication with Helen Keenan could have been handled better.
A spokeswoman for Accord Group, which manages Bracken House, declined to comment.
There are significant differences in how nations track data, including Covid-19 deaths, making direct comparisons challenging. There are also wide variations in how long-term care facilities are regulated and categorized. Still, many countries show a similar pattern of highly concentrated Covid-19 deaths linked to these facilities, according to researchers.
While many countries that have curbed Covid-19 deaths overall have also kept long-term care death rates to a minimum…
COVID DEATHS AS
A PCT. OF long-
term care BEDS
… others, particularly in the West, have experienced much higher levels.
The sector has long struggled with understaffing and safety lapses. An OECD working paper, released in September but largely written before the pandemic, pointed to a workforce not large or well-trained enough to cope with an expanding and increasingly frail population. “Preventable safety failures are endemic,” the report said, including falls, pressure injuries and infections.
The risk of an airborne virus to many traditional nursing homes had long been known. Often, they are crowded with unhealthy elders who may share bedrooms or bathrooms without the protective ventilation or equipment found in hospitals.
The setups were ready-made for a respiratory virus to run rampant. Researchers examining outbreaks in Ontario, Canada’s most populous province, found crowded nursing homes that predated 1999 design standards tended to have worse outbreaks once the coronavirus got inside.
“Once the virus gets in, the crowded homes had many more deaths and the highest rates of infection,” said Dr. Nathan Stall, one of the study authors, and a geriatrician at Toronto’s Mount Sinai Hospital.
A spokeswoman for Ontario’s Ministry of Long-Term Care, established in 2019, said the government is investing in improvements after decades of neglect and acted swiftly to address outbreaks.
Some governments with memories of prior respiratory outbreaks were closely focused on the danger even before Covid-19 struck, and their efforts often made a difference.
Crosses were erected in May at Canada’s Camilla Care Community nursing home, where 50 residents had died due to a Covid-19 outbreak.
In the 2003 outbreak of severe acute respiratory syndrome, or SARS, a coronavirus like the one that causes Covid-19, Hong Kong’s senior-care residents were five times more likely to be infected than the general public, and 57 died. Afterward, the Hong Kong government imposed new infection-control requirements, and facilities there routinely stocked months’ supply of personal protective gear, said Terry Lum, a professor at the University of Hong Kong.
As Covid-19 loomed in late January 2020, Hong Kong shut its care homes to most visitors. Nearly everyone in Hong Kong was wearing a mask by mid-February to limit community spread of the virus. The government decided any infected care-home residents would immediately be sent to hospitals, and other exposed residents or staff removed from the facility to quarantine. As of Nov. 29, Hong Kong, with more than 76,000 nursing-home beds, had seen 30 resident Covid-19 deaths, according to Dr. Lum.
Karin Huster, a nurse and project coordinator for Doctors Without Borders, an international medical-aid organization, flew to Hong Kong in January to offer support to nursing homes. “We all know nursing homes are sort of petri dishes, Covid or not,” she says. It was “pretty darn obvious” they would be among places hit hardest by a virus particularly deadly for the elderly. She found the facilities there well-fortified and left Hong Kong in mid-March.
Later, she would spend about a month helping facilities plunged into crisis in a place she said was far less prepared—Michigan, where her organization worked with more than 30 nursing homes on infection control.
South Korea moved quickly to shut its nursing homes to visitors, taking action Feb. 17. Despite tough infection-control measures, South Korea saw cases in at least five nursing homes as part of a major outbreak in Daegu, its fourth-largest city, in late February.
Public-health authorities limited community spread of the virus through rigorous testing, contact tracing and quarantining of infected people. That month, health authorities screened 1,470 nursing homes nationwide to remove caretakers who had recently traveled to China or exhibited symptoms of Covid-19. Soon after, they began testing nursing-home residents and staffers nationwide even though many regions hadn’t reported any coronavirus infections. South Korean officials would also test nursing homes anytime a cluster of cases popped up in a nightclub, church or other venue in a region.
People are tested for Covid-19 at a temporary center in Seoul, South Korea, on Christmas Eve.
When the virus infiltrates a facility, the government sends in contact tracers to check medical records and track where staffers had been in the past few weeks, using GPS records. Recently, nursing-home caretakers were banned from attending private gatherings outside of work, to ensure they don’t bring the virus into nursing homes—a step that goes well beyond efforts in the U.S. and other countries.
“The best strategy is to prevent the patients from being exposed to the virus in the first place,” Jung Eun-kyeong, head of Korea Disease Control and Prevention Agency, said during a briefing Dec. 21.
The U.S. and many European countries took few early steps to bolster their nursing homes with equipment, testing or manpower. By the end of February, the consequences began emerging.
On Feb. 28, a hospitalized resident from Life Care Center of Kirkland, a nursing home near Seattle, became the first there to test positive for Covid-19, revealing an outbreak that would kill dozens. The 73-year-old died on March 2.
A mother and daughter communicate in March at the Life Care Center of Kirkland, a long-term care facility linked to several early coronavirus cases.
One day later, a worker at a Sydney care home was diagnosed with Covid-19, the start of Australia’s first long-term care outbreak; three-quarters of Australia’s approximately 900 Covid-19 fatalities have been linked to such facilities.
In France, President Emmanuel Macron visited the Péan nursing home March 6 to highlight the dangers Covid-19 posed to the elderly. Nine days later, the home reported its first infection and by the end of April seven of its 94 residents had died.
At the Vitalia Leganés nursing home in Madrid, about 50 residents died in the second half of March alone, and Spanish authorities found bodies of residents in several facilities abandoned in their beds. An hour’s drive from Milan, in the Italian town of Coccaglio, the local nursing home lost 24 people in March, more than a third of its residents. Doctors and local officials blamed the virus, though none of the residents had been tested because, at the time, only those admitted to hospitals were screened.
Funeral-home workers carry a body from a nursing home in Leganes, Spain, in April.
Many countries, including the U.S., Spain and Italy, initially couldn’t accurately track the devastation among their nursing-home residents, as they had no national data on Covid-19 deaths in the facilities.
The lack of testing has made the Covid-19 toll even harder to quantify. In April, after a public outcry, France ordered nursing homes to report any deaths staff suspected were linked to Covid-19. More than 3,000 were reported for the month of March alone. The tally recently topped 19,000, representing nearly a third of known Covid-19 deaths.
Public reports released on March 18 and April 3 by the U.S. Centers for Disease Control and Prevention, about the Kirkland outbreak and others in Washington state, highlighted how the virus spread rapidly and invisibly inside facilities, often carried by residents and workers who lacked clear symptoms, making mass testing a vital bulwark. Staffers had “inadequate familiarity and adherence” to infection-control practices.
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Staffers who worked at both the Kirkland nursing home and others in the region also appeared to seed outbreaks in several facilities, the March 18 CDC report said. Such practices have long been common, as low-paid workers take multiple jobs to make ends meet.
The Kirkland investigators saw the finding of asymptomatic spread as central, said Dr. Jeffrey Duchin, health officer for the public-health entity of Seattle and King County, where Kirkland is located. “We were all aware of what this meant at the time that we discovered it. There was no uncertainty about the fact that this was an important observation.”
The U.S. CDC issued testing guidelines on March 24 that didn’t put nursing homes in the top priority category for testing. According to emails reviewed by the Journal, the White House coronavirus task force was closely involved in those guidelines, with testing czar Bret Giroir sending the final draft to top CDC officials on March 23.
Long-term care facility residents with symptoms didn’t get into the top testing tier until April 27, according to a Journal reconstruction of the evolving guidelines. Even then, asymptomatic nursing-home residents weren’t mentioned in the priority groups. Ultimately, federal regulators didn’t mandate testing of nursing-home staff until August. They never blocked workers—among whom the government has counted more than 400,000 infections and at least 1,268 deaths—from moving between facilities.
A CDC spokesman declined to comment. Seema Verma, administrator of the Centers for Medicare and Medicaid Services, which regulates nursing homes, said her agency had acted quickly and aggressively to protect nursing homes. She said the testing mandate came in tandem with a federal effort to provide equipment, and banning staffers from working in multiple facilities could have worsened shortages. CMS began releasing data on Covid-19 in nursing homes in early June.
“Because of the work that we’ve done, we’ve actually saved many, many lives,” she said. She faulted responses in some states, and said, “at the end of the day, the ultimate responsibility is the nursing homes’.”
A spokeswoman for Adm. Giroir’s office said that “early in the pandemic, Covid-19 tests were strategically prioritized to allocate resources and help prevent the spread of the virus.” Hospitalized patients and symptomatic health-care workers were highest on the list “so they would not infect others in their hospitals and not overwhelm health-care systems.”
Many European countries focused closely on the needs of hospitals. In France and Belgium, some nursing-home employees have said they weren’t allowed to send ill residents to hospitals, leaving them without effective treatment and raising the risk of infection spreading inside the facilities.
A nurse puts on protective equipment at the Wren Hall care home in Nottingham, England in April.
In the U.K., the rush was to protect the country’s National Health Service from being overwhelmed by Covid cases. The NHS told hospitals to discharge patients to clear up capacity, according to a report by the National Audit Office, which monitors government spending. Between March 17 and April 15, around 25,000 were sent to care homes without mandatory testing for the novel virus, the report said.
The Department of Health and Social Care, the government department responsible for the NHS, said in June when the report was published that it made the right decisions at the right time and 60% of care homes avoided an outbreak.
In Italy, nursing-home staffing shortages in some regions became even worse when public hospitals, short-handed themselves, began hiring nurses who had worked at elder-care facilities. The hospital jobs were more secure and desirable, said Andrea Rotolo, a professor at SDA Bocconi School of Management in Milan. “That left nursing homes even more understaffed,” he said. “They could not replace overnight the people who were resigning.” Hospitals were also initially prioritized for protective equipment and testing, he said.
By late summer, in the U.S. and many other countries, shortages of testing and protective equipment in nursing homes had finally eased somewhat. But this fall, fatalities started rising again in the facilities, though in some places not as quickly as in the spring, because cases outside the nursing homes’ walls were surging and their defenses remained permeable.
A deadly outbreak in Maine this summer highlighted the risk. The problem appeared to start with an Aug. 7 indoor wedding attended by 55 people in Millinocket, a small town in the state’s rural interior. Until then Millinocket had no reported Covid-19 cases, according to the Maine Center for Disease Control and Prevention. By Aug. 12, the state agency received lab results showing two attendees were positive for the disease, the first warning of an outbreak that would reach at least 178 people.
One attendee carrying the virus had contact with a parent who was a nursing assistant at the Maplecrest Rehab & Living Center in Madison, Maine, about 100 miles away, according to state reports. This employee worked an overnight shift Aug. 11, despite reporting symptoms that included sore throat, chills, cough and a headache, according to a state inspection report.
North Country Associates, Maplecrest’s parent company, said the 58-bed home worked with state authorities to stop the spread of Covid-19 and correct all deficiencies found in that inspection. Improvements include adding a dedicated infection control preventionist, according to the state.
The infection from the wedding would touch off 40 infections in the nursing home, including 25 residents and 15 staff members, the state said. Seven residents didn’t survive.
Anna Maria Alborghetti sits in a wheelchair at a nursing home in Italy in May.
—Xavier Fontdegloria in Barcelona, Giovanni Legorano in Rome, Daniel Michaels in Brussels, Paul Vieira in Ottawa and Betsy McKay in New York contributed to this article.
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