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COVID in care homes

Watch Dr Maria Krutikov talk about the VIVALDI study, which explores how the COVID-19 pandemic has affected care homes.
Hello. My name is Dr. Maria Krutikov, and I am an infectious disease epidemiologist working at the Institute of Health Informatics at University College London. I will be telling you about a large, national study that I’m working on, which aims to understand the effect of SARS-CoV-2 virus on care home staff and residents in England, which is called the Vivaldi study. I will start by setting the scene for you by outlining some of the key questions that are currently unanswered in relation to this population. Subsequently, I will describe an example of a study that I’m working on that aims to address these questions and the ways in which it will do this.
Links to references and extra reading can be found in the ‘see also’ section below.
In 2020, the COVID-19 pandemic swept the globe with a high number of deaths, as well as the resultant introduction of strict preventive public health measures, such as closure of borders and lockdown in a number of countries. COVID-19 is caused by the severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2 virus. The virus is transmitted predominantly through the respiratory route as it is inhaled as tiny airborne particles or as larger droplets. although there is also some evidence of transmission through contact with contaminated surfaces or fomites. The most common severe complications in adults are respiratory failure and thromboembolic disease. There is evidence that older people are at higher risk of these complications and subsequent death.
This is particularly true for care home residents with over a quarter of all deaths from COVID-19 in England since the start of the pandemic occurring in the 450,000 care home residents. This disproportionate impact is highlighted by evidence showing that care home residents had a significantly higher risk of COVID-19 associated death than age matched controls in 2020, with a sharp spike seen in the number of deaths in England in this population.
The reasons behind the pandemic’s disproportionate impact in care homes are not clearly understood. However, they are likely to be multifactorial. As a significant proportion of SARS-CoV-2 infections are asymptomatic, these are not picked up if testing is triggered by clinical illness alone. Regular surveillance in all staff and residents is necessary to detect these infections. But it was only introduced in England four months into the pandemic. Therefore, swab based estimates of prevalence before this time are not reliable. Detecting antibodies in blood samples can give an idea of how many people have previously been infected.
As care home residents are rarely enrolled in research studies for logistical reasons and due to issues with consent, little is understood about how their immune response differs to that of the general population and how effective preventive measures such as vaccination are. It is likely that immunosenescence results in less effective immune responses in this frail population. Another contributing factor is the environment, as residents in care homes have frequent contact with other residents and staff, therefore increasing their risk of exposure to infections. New admissions to the home may have been recently exposed to the virus in the community and screening on admission is not always possible. Isolation of infected individuals can be challenging, due to a number of factors.
I have outlined some of the factors that may contribute to the impact of the pandemic in care homes. This raises a number of questions, which include does the immune response differ between older and younger people? How long does the protective immune response last? Can people who have been infected get reinfected? Is the vaccine as effective in older people as in younger people? What individual level factors are associated with becoming infected? What care home level factors are associated with outbreaks? What measures can prevent spread of infection in care homes? Are care homes that have had COVID-19 outbreaks protected against future outbreaks? Understanding the impact of the pandemic in care homes could inform disease control strategies, such as targeted testing and vaccination.
The Vivaldi study is a UCL led, government funded, urgent public health study in care homes in England, that is collaborating with researchers at University of Birmingham. It is a prospective cohort study that started in June 2020 and will run until April 2022. The study will recruit care home staff and residents from 350 geographically distributed care homes in England, a mixture of large chains and small independent homes, to enable generalisability. There were no exclusion criteria. However, consultees will be sought for subjects who are assessed as lacking capacity to consent. Participants will undergo regular blood sampling, which will be tested for cellular and humoral components of the SARS-CoV-2 immune response. I will outline the study in more detail.
The aim of the study is to investigate the SARS-CoV-2 seroprevalence immunity and its duration in care home staff and residents. There are a number of objectives, which include estimating SARS-CoV-2 seroprevalence and how this varies by care homes, identifying risk factors for infection on an individual and care home level, characterising the immune response, and evaluating vaccine efficacy in this population. The study is divided into three main components. The first involves five rounds of blood sampling at regular intervals, which allows evaluation of time dependent changes to the immune response following first infection or vaccination.
The second component uses results of PCR testing from screening, nose, or throat swabs, in staff and residents, which is performed as part of the PHE outbreak response, known as pillar one, or the routine surveillance screening that the Department of Health and Social care have coordinated since June 2020, known as pillar two, currently performed weekly in staff and monthly in residents. The third component involves collection of individual and care home level epidemiological data, such as demographics, building characteristics, and vaccine history. These three components are linked with outcome data on hospital admissions and mortality to form a rich data set that will enable the study team to address many of the important study questions.
In conclusion, I have outlined that care homes have been majorly impacted by the COVID-19 pandemic, with a high number of infections and deaths amongst staff and residents. To date, high quality research in this population has been limited due to logistical issues. However, key differences between the care home population and community living age match controls have made this research a priority. Understanding the mechanisms behind the high risk of transmission of infectious pathogens within care homes, will inform preventive strategies to optimise their effectiveness in this setting. Findings from COVID-19 research can be translated in future to prevent other communicable disease outbreaks. Thank you for listening. I have included my acknowledgments on this slide.
References and additional reading can be found in the ‘see also’ section below.

In this video Dr Maria Krutikov discusses the impact of the COVID-19 pandemic within care homes.

COVID-19 has impacted millions of lives, however, care homes have been very badly affected within England. 25% of all COVID-19 deaths have occurred within care homes since the start of the pandemic. The disproportionate risk towards those in care homes indicates the need for surveillance, prevention and information about the SARS-CoV-2 virus in this setting.

The large risk towards residents and staff in care homes is unknown but likely to be multifactorial. Residents are often elderly and frail which has shown to be a particular factor that increases the risk of COVID-19. Regular surveillance of staff and residents was implemented but only 4 months into the pandemic. Other issues involve viral exposure of new admissions into the care homes and isolating infected patients which is extremely challenging within this setting. Studies and data collection rarely include care home residents due to challenges with logistics and consent.

These factors emphasise the importance of understanding the impact of COVID-19 in care homes. In June 2020 the VIVALDI study was set up which recruited staff and patients from 350 care homes from around England to investigate COVID-19 seroprevalence, immunity and duration in care homes. It consists of multiple blood tests, results of frequent PCR testing of throat and nose swabs and the collection of epidemiological data from each care home and will finish in 2022. This study hopes to produce data in an under-represented area of research which will provide understanding of transmission and preventative measures in care homes that will inform national policy for controlling COVID-19 and other infectious diseases within care homes.

To find out more check out the VIVALDI study website.

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