Enhanced lateral flow testing strategies in care homes are associated with poor adherence and were insufficient to prevent COVID-19 outbreaks: results from a mixed methods implementation study

Tulloch, John; Micocci, Massimo; Buckle, Peter; Lawrenson, Karen; Kierkegaard, Patrick; McLister, Anna; Gordon, Adam L; Garcı́a-Fiñana, Marta; Peddie, Steve; Ashton, Mark W.; Buchan, Iain; Parvulescu, Paula

doi:10.1093/ageing/afab162

Cited by 28 publications

(69 citation statements)

References 13 publications

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“…A mixed method study by Tulloch et al, (2021) conducted in England, UK, investigated adherence to IPC and lateral flow testing. Rapid lateral flow tests were performed, but protocol adherence was poor, with 8.6% of staff achieving protocol adherence of >75% and 25.3% achieving ≥50%.…”

Section: Resultsmentioning

confidence: 99%

Have infection control and prevention measures resulted in any adverse outcomes for care home and domiciliary care residents and staff?

Spencer

Hartfiel

Hendry

et al. 2022

Preprint

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Background / Aim of Rapid Review Care for older and vulnerable people must sustain core infection prevention and control (IPC) practices and remain vigilant for COVID-19 transmission to prevent virus spread and protect residents and healthcare professionals from severe infections, hospitalisations and death. However, these measures could potentially lead to adverse outcomes such as decreased mental wellbeing in patients and staff. A recent publication by Public Health England examines the effectiveness of IPC practices for reducing COVID-19 transmission in care homes (Duval et al., 2021). We explore evidence relating to adverse outcomes from IPC practices to help inform policy recommendations and identify gaps within the literature where further research can be prioritised. Key Findings Extent of the evidence base 15 studies were identified: 14 primary studies and one rapid review Recency of the evidence base Of the primary studies, six were published in 2020 and eight were published in 2021 The rapid review was published in 2021. Summary of findings This rapid review focuses on adverse outcomes resulting from increased IPC measures put in place during the COVID-19 pandemic. Whilst there is some evidence to show that there may be a link between IPC measures and adverse outcomes, causation cannot be assumed. During the COVID-19 restrictions, the cognition, mental wellbeing and behaviour of residents in care homes were negatively affected Increased IPC procedures during the COVID-19 pandemic increased stress and burden among care staff because of increased workload and dilemmas between adhering well to IPC procedures and providing the best care for the care recipients COVID-19 IPC procedures were not well developed at the beginning of the COVID-19 pandemic, but evidence from 2021 suggests that good adherence to IPC measures can enable visitations by family members and medical professionals into care homes Only one study investigating domiciliary care was found. Therefore, it is difficult to make conclusions related specifically to this care setting No published studies have reported on the costs or cost-effectiveness of IPC measures or have explored the cost implications of adverse outcomes associated with IPC measures Best quality evidence Only one study was deemed as high quality based on the quality appraisal checklist ranking. This was a mixed methods study design (Tulloch et al., 2021). Policy Implications Since March 2020, there have been many changes to government guidelines relating to procedures to keep the population safe from COVID-19 harm. Policies vary according to country, even within the UK. Important issues such as care home visitation policies have changed in such a way that care home staff have felt it difficult to keep up with the changes, which in itself increased the burden on those staff. The following implications were identified from this work: IPC policies should be clear, concise and tailored to care homes and domiciliary care settings Increased attention to workforce planning is needed to ensure adequate staffing and to reduce individual burden Restrictions (e.g. visitation) for care home residents needs to be balanced by additional psychological support Further research with robust methods in this area is urgently needed especially in the domiciliary care setting Strength of Evidence One limitation is the lack of high-quality evidence from the included studies. Confidence in the strength of evidence about adverse outcomes of COVID-19 IPC procedures was rated as low overall. Whilst the majority of studies achieved a moderate score based on the quality appraisal tools used, due to the nature of the methods used, the overall quality of evidence is low.

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Section: Resultsmentioning

confidence: 99%

Have infection control and prevention measures resulted in any adverse outcomes for care home and domiciliary care residents and staff?

Spencer

Hartfiel

Hendry

et al. 2022

Preprint

View full text Add to dashboard Cite

show abstract

“…We also do not differentiate between agents that have received a single or several vaccination doses and we do not consider the time-dependence of vaccination efficacy. Furthermore, adherence rates to voluntary testing schemes can depend on the test technology used [ 59 , 60 ]. We do not model different adherence rates to voluntary testing and assume a 100% adherence rate in all scenarios.…”

Section: Discussionmentioning

confidence: 99%

Agent-based simulations for protecting nursing homes with prevention and vaccination strategies

Lasser

Zuber

Sorger

et al. 2021

J. R. Soc. Interface.

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Due to its high lethality among older people, the safety of nursing homes has been of central importance during the COVID-19 pandemic. With test procedures and vaccines becoming available at scale, nursing homes might relax prohibitory measures while controlling the spread of infections. By control we mean that each index case infects less than one other person on average. Here, we develop an agent-based epidemiological model for the spread of SARS-CoV-2 calibrated to Austrian nursing homes to identify optimal prevention strategies. We find that the effectiveness of mitigation testing depends critically on test turnover time (time until test result), the detection threshold of tests and mitigation testing frequencies. Under realistic conditions and in absence of vaccinations, we find that mitigation testing of employees only might be sufficient to control outbreaks if tests have low turnover times and detection thresholds. If vaccines that are 60% effective against high viral load and transmission are available, control is achieved if 80% or more of the residents are vaccinated, even without mitigation testing and if residents are allowed to have visitors. Since these results strongly depend on vaccine efficacy against infection, retention of testing infrastructures, regular testing and sequencing of virus genomes is advised to enable early identification of new variants of concern.

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“…Ag-RDT screening is widely used in healthcare settings, but there is limited empirical evidence demonstrating efficacy for SARS-CoV-2 transmission prevention. 17 Despite a range of studies reporting efficacy for case identification, 18–20 interventional trials are needed to understand impacts on nosocomial spread. Our comparison of apparent and real screening efficiency demonstrates why case identification may be a poor proxy measure for actual health and economic benefit.…”

Section: Discussionmentioning

confidence: 99%

Rapid antigen testing as a reactive response to surges in nosocomial SARS-CoV-2 outbreak risk

Duval

Zahar

et al. 2021

Preprint

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Background: Surges in community SARS-CoV-2 incidence increase risk of importation and subsequent transmission in healthcare facilities. Antigen rapid diagnostic testing (Ag-RDT) is widely used for population screening, but its health and economic benefits as a reactive intervention in healthcare settings are unclear. Methods: We used stochastic, individual-based modelling to simulate SARS-CoV-2 transmission in a long-term care facility with varying COVID-19 containment measures in place (social distancing, face masks, vaccination). In contrast to routine symptomatic testing using reverse-transcriptase polymerase chain reaction (RT-PCR), we evaluated the efficacy and health-economic efficiency of single or repeated population-wide Ag-RDT screening interventions implemented in response to surges in nosocomial outbreak risk. Results: Depending on the baseline containment measures in place, nosocomial SARS-CoV-2 incidence was reduced by up to 40-47% (range of means) with routine RT-PCR testing, 59-63% with the addition of a timely round of Ag-RDT screening, and 69-75% with well-timed two-round screening. For the latter, a delay of 4 to 5 days between the first and second rounds was optimal for transmission prevention. Efficacy varied depending on test sensitivity, subpopulations targeted, and SARS-CoV-2 incidence in the community. Efficiency, however, varied primarily depending on the other containment measures in place: surveillance costs for a combined strategy of routine RT-PCR testing and reactive Ag-RDT screening ranged from a mean €420-€10,260/infection averted across scenarios (default unit costs: €5/Ag-RDT test, €50/RT-PCR test). Interpretation: Reactive Ag-RDT screening complements routine RT-PCR testing, and systematic two-round screening helps overcome limited, time-varying diagnostic sensitivity. Health-economic gains scale significantly with underlying nosocomial outbreak risk.

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Enhanced lateral flow testing strategies in care homes are associated with poor adherence and were insufficient to prevent COVID-19 outbreaks: results from a mixed methods implementation study

Cited by 28 publications

References 13 publications

Have infection control and prevention measures resulted in any adverse outcomes for care home and domiciliary care residents and staff?

Have infection control and prevention measures resulted in any adverse outcomes for care home and domiciliary care residents and staff?

Agent-based simulations for protecting nursing homes with prevention and vaccination strategies

Rapid antigen testing as a reactive response to surges in nosocomial SARS-CoV-2 outbreak risk

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