A Comparison of COVID-19 Mortality Rates Among Long-Term Care Residents in 12 OECD Countries.

To the Editor:

An early and persistent trend of the coronavirus disease 2019 (COVID-19) pandemic has been the large number of deaths occurring among older adults and those living in long-term care (LTC) homes. Residents of LTC homes are at a disproportionately high risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to their congregant living environments, greater likelihood of being exposed to asymptomatic and pre-symptomatic care providers, and difficulty in effectively implementing infection prevention and control practices. , Most LTC home residents are also older adults, for whom advanced age represents a strong risk factor for COVID-19 morbidity and mortality due to the higher prevalence of immunosenescence and chronic illnesses. Although the proportion of deaths occurring in LTC homes at an international level has been explored, population-specific mortality rates for LTC home residents and their comparison with rates for community-dwelling older, and younger persons have neither been calculated nor analyzed.

Using publicly reported data on COVID-19 deaths for 12 Organization for Economic Co-operation and Development (OECD) member-countries (Belgium, Canada, Denmark, France, Germany, Ireland, Italy, Netherlands, Spain, Sweden, United Kingdom, and the United States), we calculated and compared the population-specific mortality rates and ratios for LTC home residents and community-dwelling older (age ≥65 years) and younger (age <65 years) persons. COVID-19 deaths data were collected directly from publicly available national health and epidemiological reports and were current as of July 24, 2020 (see Appendix 1 for methodology and data sources). COVID-19 deaths included both those reported as confirmed and probable, and those that occurred in LTC home and acute hospital settings.

We report a total of 361,161 COVID-19 deaths for the 12 countries, which accounted for 90% of deaths in all 37 OECD countries and 56% of all global deaths. Within the 12 countries, LTC home residents, community-dwelling older persons, and younger persons accounted for an average of 47.3%, 44.7%, and 8.0% of COVID-19 deaths and an average of 0.9%, 18.2%, and 80.9% of national populations, respectively.

We calculate a 12-country average COVID-19 mortality rate of 2772 per 100,000 LTC home residents (range, 399 for Germany to 5295 for Spain) compared with 122 per 100,000 community-dwelling older persons (range, 22 for Canada to 244 for Spain), representing an average 24.2-fold higher rate of death (range, 14.2 for Germany to 73.7 for Canada). Even greater differences were observed when compared with COVID-19 mortality rates for community-dwelling younger persons, which averaged 4.9 per 100,000, representing a 644-fold higher rate of COVID-19 deaths among LTC home residents (range of 215 for the United States to 1165 for Ireland). (Figure 1 ).

Fig. 1

COVID-19 mortality rates and ratios for LTC home residents and community-dwelling persons. Estimates for 12 OECD countries; deaths per 1000 of specific population.

Here we confirm a very high concentration of mortality of LTC home residents and report substantial variation among 12 OECD countries. Our results suggest that the level of community transmission, as reflected in the mortality rate for community-dwelling persons, and the level of policy response related to infection prevention and control practices in LTC homes and at the broader community level were important factors driving LTC home resident mortality rates. Reporting differences in our multinational data sources may limit some between country comparability, this includes: 1) four countries (Denmark, Germany, Netherlands and Sweden) reporting only confirmed LTC resident deaths, while the remaining eight report confirmed and probable deaths; 2) in the absence of official national estimates, we have used partial official or non-official figures to provide reasonable estimates of all LTC home resident deaths for Italy and Spain.

Countries, such as Denmark and Germany, that maintained relatively low levels of community transmission and acted early and aggressively to prevent the introduction and spread of COVID-19 into their LTC homes had the lowest LTC home resident mortality rates. These policy actions included the early restriction of nonessential visitors, enacting universal masking policies, improving LTC staffing levels, preventing care providers from working across multiple sites, implementing enhanced LTC infection control training and audit procedures, and widespread testing and isolation protocols for infected residents and asymptomatic contacts. , ,

In contrast, countries such as Spain and the United Kingdom, that had relatively high levels of community transmission and less robust LTC home–related policy responses, had the highest LTC home resident mortality rates. Other countries had mixed responses with uneven results. For instance, Canada promoted relatively forceful measures that were effective in limiting community transmission, but its LTC home–related responses were uneven and less robust for a system already characterized as being poorly staffed and funded at its baseline. This may explain why Canada particularly stands out, with the highest mortality ratio comparing LTC home residents with community-dwelling older persons (73.7 vs. the OECD 12-country average of 25.5), and why Canada's LTC home resident deaths accounted for such a high percentage of its overall deaths (78.4% vs. the OECD 12-country average of 47.3%).

As some countries are still grappling with their first waves of COVID-19 infections and others are starting to combat their second waves, understanding the factors that led to substantial mortality rates for LTC home residents in certain jurisdictions could help allow for the implementation of key policies and practices that could prevent introduction, transmission, and death from COVID-19 across all jurisdictions.