Title: Clinical Features of SARS-CoV-2 Infection in Italian Long-Term Care Facilities: GeroCovid LTCFs Observational Study
Abstract: The burden of COVID-19 in long-term care facilities (LTCFs) was high worldwide. According to an Italian national survey, during the first pandemic wave, of the 33.8% of residents who died with COVID-19–like symptoms, only 7.4% had tested positive to a SARS-CoV-2 swab test because of limitations in accessing diagnostic tests.1Lombardo F.L. Bacigalupo I. Salvi E. et al.Italian National Institute of Health Nursing Home Study GroupThe Italian national survey on Coronavirus disease 2019 epidemic spread in nursing homes.Int J Geriatr Psychiatry. 2021; 36: 873-882Crossref PubMed Scopus (22) Google Scholar The prevalence of frailty, multimorbidity, and dementia,2Abbatecola A.M. Antonelli-Incalzi R. Editorial: COVID-19 spiraling of frailty in older Italian patients.J Nutr Health Aging. 2020; 24: 453-455Crossref PubMed Scopus (68) Google Scholar,3Bielza R. Sanz J. Zambrana F. et al.Clinical characteristics, frailty, and mortality of residents with COVID-19 in nursing homes of a region of Madrid.J Am Med Dir Assoc. 2021; 22: 245-252.e2Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar as well as the frequent atypical or asymptomatic manifestations of COVID-19 in such populations,4Arons M.M. Hatfield K.M. Reddy S.C. et al.Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility.N Engl J Med. 2020; 382: 2081-2090Crossref PubMed Scopus (1512) Google Scholar were some of the factors that contributed to the spread of the infection in this setting. The picture was further complicated by the fact that a substantial number of residents suffered from conditions that mimic SARS-CoV-2 infection.5Rutten J.J.S. van Loon A.M. van Kooten J. et al.Clinical suspicion of COVID-19 in nursing home residents: Symptoms and mortality risk factors.J Am Med Dir Assoc. 2020; 21: 1791-1797.e1Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar In this study, we aimed to investigate the clinical features associated with SARS-CoV-2 infection and mortality due to COVID-19 in Italian LTCFs. A prospective study with a 60-day follow-up was performed in a sample of Italian LTCFs, from March 1, 2020, up to December 31, 2020, as part of the GeroCovid Observational study, a multicenter and multisetting study, evaluating the impact of the COVID-19 pandemic on the health of individuals aged ≥60 years in acute, outpatient, and LTC settings.6Trevisan C. Del Signore S. Fumagalli S. et al.GeroCovid Working GroupAssessing the impact of COVID-19 on the health of geriatric patients: The European GeroCovid Observational Study.Eur J Intern Med. 2021; 87: 29-35Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar The GeroCovid cohort consists of 39 LTCFs from 6 Italian regions, 9 of which reported positive COVID-19 cases. The total number of residents in the facilities involved was 2380; of these, a subsample of 586 aged ≥60 years was enrolled based on the presence of signs and symptoms suspect for COVID-19 or on a judgment of high risk of infection. The residents who had a direct physical contact or a stay in a closed environment with a COVID-19–confirmed case with no suitable personal protective equipment (close contact) were considered at high risk of infection. Furthermore, all new patients admitted to a facility and all residents readmitted after a hospital stay were also considered at high risk of infection. The residents at high risk or with COVID-19–like symptoms underwent SARS-CoV-2 swab testing. Based on the swab results and the above risk factors of infection, we categorized the residents into 3 groups: (1) positive SARS-CoV-2 swab; (2) negative SARS-CoV-2 swab with close contact (asymptomatic); and (3) negative SARS-CoV-2 swab with clinical suspicion (symptomatic). For each participant, we collected data on demographic characteristics, lifestyle, chronic diseases, and clinical outcome in an electronic registry.7Tadic M. Cuspidi C. Grassi G. Mancia G. COVID-19 and arterial hypertension: Hypothesis or evidence?.J Clin Hypertens (Greenwich). 2020; 22: 1120-1126Crossref PubMed Scopus (58) Google Scholar These characteristics were compared among the 3 groups of residents through chi-squared or Fisher exact tests for the categorical variables, and generalized linear model or the Wilcoxon sum-rank test, as appropriate. Multivariate Cox proportional hazard models were used to identify factors associated with death. As reported in Table 1, SARS-CoV-2–positive residents were older compared with both SARS-CoV-2–negative groups. The median number of chronic diseases was 3 among SARS-CoV-2–positive residents, 2 among asymptomatic, and 5 among symptomatic SARSCoV-2–negative residents.Table 1Characteristics of Older Adults Enrolled in the GeroCovid LTCFs Study by SARS-CoV-2 Positive or Negative Swab Test, Clinical Suspicion, and High Risk of InfectionSARS-CoV-2–Positive (n = 179)SARS-CoV-2–NegativeWith Close Contact (Asymptomatic)(n = 203)SARS-CoV-2–NegativeWith Clinical Suspicion (Symptomatic)(n = 121)P ValueAge, y, mean±SD85.6 ± 8.283.5 ± 9.084.8 ± 8.8.05Sex, female, n (%)135 (75.4)156 (76.9)91 (75.2).93Smoking status, n (%).54 Current smoker1 (1.5)3 (3.5)5 (5.3) Ex-smoker14 (20.3)11 (12.9)16 (16.8) Nonsmoker54 (78.3)71 (83.5)74 (77.9)Chronic diseases, n (%)‡Information before COVID-19 incidence. Arterial hypertension82 (46.6)127 (76.5)91 (75.2)<.001 Cardiomyopathy∗Ischemic, valvulopathy, or arrhythmia.75 (42.4)24 (27.0)64 (53.8)<.001 Atrial fibrillation6 (6.1)7 (8.9)16 (14.7).11 Central and peripheral arterial disease68 (38.9)12 (13.3)17 (14.3)<.001 Cardiac failure13 (10.6)13 (16.1)16 (14.6).48 Stroke30 (24.4)9 (11.0)18 (16.5).044 Diabetes (type 1 or 2)47 (27.2)40 (37.7)32 (26.7).12 Depression65 (31.4)47 (42.7)35 (29.7).07 Osteoarthrosis66 (54.1)21 (25.6)71 (67.0)<.001 COPD†Or other bronchopneumopathies.26 (15.1)22 (23.2)26 (21.9).187 Chronic renal failure16 (9.2)6 (6.9)23 (19.8).006 Chronic liver disease10 (5.7)9 (10.3)3 (2.5).06 Obesity14 (12.0)4 (5.4)17 (15.7).10 Poor nutritional status33 (28.0)2 (2.7)42 (38.5)<.001 Psychiatric disorders46 (43.0)77 (48.1)55 (51.4).46 Nervous system disorders73 (68.2)42 (26.4)62 (56.9)<.001 Dementia or cognitive impairment45 (42.5)10 (6.3)35 (33.0)<.001Total number of chronic diseases, median (Q1, Q3)3 (2, 5)2 (1, 3)5 (3, 6).002Chronic diseases, n (%)<.001 0, 1, 220 (11.2)76 (37.4)1 (0.8) 3+159 (88.8)127 (62.6)120 (99.2)Q1, quartile 1; Q3, quartile 3; SD, standard deviation.∗ Ischemic, valvulopathy, or arrhythmia.† Or other bronchopneumopathies.‡ Information before COVID-19 incidence. Open table in a new tab Q1, quartile 1; Q3, quartile 3; SD, standard deviation. Concerning the patterns of chronic diseases, we found that dementia or cognitive impairment and central and peripheral arterial disease were more prevalent in SARS-CoV-2–positive residents compared with SARS-CoV-2–negative groups; arterial hypertension, cardiomyopathy, osteoarthrosis, and poor nutritional status were more prevalent in SARS-CoV-2–negative residents with suspicious symptoms compared to SARS-CoV-2 asymptomatic and SARS-CoV-2–positive residents. The mortality of SARS-CoV-2–positive residents was 21.6%, compared to 10.8% among SARS-CoV-2–negative symptomatic residents [hazard ratio (HR) 0.27, 95% confidence interval (CI) 0.12-0.59, P = .001), and 1.8% among SARS-CoV-2–negative asymptomatic residents (HR 0.07, 95% CI 0.02-0.25, P = .001). Our results are partly in line with those of previous studies. For instance, the frequency of hypertension among patients with COVID-19 who were enrolled in other studies ranged between 15% and 35%.7Tadic M. Cuspidi C. Grassi G. Mancia G. COVID-19 and arterial hypertension: Hypothesis or evidence?.J Clin Hypertens (Greenwich). 2020; 22: 1120-1126Crossref PubMed Scopus (58) Google Scholar In our sample, the lower prevalence of hypertension found among SARS-CoV-2–positive residents compared to symptomatic or asymptomatic SARS-CoV-2–negative individuals, may be interpreted as part of the phenomenon of "reverse epidemiology"; that is, some degrees of hypertension may protect against all-cause mortality.8Ahmadi S.F. Streja E. Zahmatkesh G. et al.Reverse epidemiology of traditional cardiovascular risk factors in the geriatric population.J Am Med Dir Assoc. 2015; 16: 933-939Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar On the other hand, asymptomatic SARS-CoV-2–negative residents with a history of close contact had the lowest prevalence of neurologic diseases, dementia, and malnutrition, whereas SARS-CoV-2–positive individuals appeared to be more likely to present such conditions. As already underlined by previous study, our data support the higher risk that individuals with dementia may have in getting SARS-CoV-2 infection.9Rutten J.J.S. van Kooten J. van Loon A.M. et al.Dementia and Parkinson's disease: Risk factors for 30-day mortality in nursing home residents with COVID-19.J Alzheimers Dis. 2021; 84: 1173-1181Crossref PubMed Scopus (14) Google Scholar Finally, worthy of interest is the high mortality found among SARS-CoV-2–negative symptomatic residents, who were likely to have experienced non–SARS-CoV-2 infections or exacerbations of their chronic conditions. Overall, these findings suggest that attributing death to COVID-19 only based on epidemiologic or clinical criteria, without confirmation by nasopharyngeal swab test, may be misleading and probably contributed to overestimating COVID-19–related mortality in the LTC setting, especially during the first pandemic wave. Angela Marie Abbatecola, MD [RSA INI Città Bianca, Veroli (FR)], Domenico Andrieri, MD [RSA Villa Santo Stefano, S. Stefano di Rogliano (CS)], Francesco Raffaele Addamo, MD [RSA San Giovanni di Dio, Patti (ME)], The GeroCovid LTCFs Working Group members are as follows (in alphabetical order). Rachele Antognoli, MD [RSA Villa Isabella, Pisa], Paola Bianchi, BA [Associazione Nazionale Strutture Territoriali e per la Terza Età, Roma], Carmine Cafariello, MD [RSA Villa Sacra Famiglia, IHG, Roma; I RSA Geriatria, IHG, Guidonia (RM); III RSA Geriatria, IHG, Guidonia (RM); RSA Estensiva, IHG, Guidonia (RM); RSA Intensiva, IHG, Guidonia (RM)], Valeria Calsolaro, MD [RSA Villa Isabella, Pisa], Francesco Antonio Campagna, MD [Centro di Riabilitazione San Domenico, Lamezia Terme (CZ)], Sebastiano Capurso, MD [RSA Bellosguardo, Civitavecchia (RM)], Silvia Carino, MD [RSA San Domenico, Lamezia Terme (CZ); Centro di Riabilitazione San Domenico, Lamezia Terme (CZ); RSA Villa Elisabetta, Cortale (CZ); Casa Protetta Madonna del Rosario, Lamezia Terme (CZ)], Manuela Castelli, MD [ASP Golgi Redaelli, Istituto Geriatrico Camillo Golgi, Abbiategrasso (MI)], Arcangelo Ceretti, MD [ASP Golgi Redaelli, Istituto Geriatrico Camillo Golgi, Abbiategrasso (MI)], Mauro Colombo, MD [ASP Golgi Redaelli, Istituto Geriatrico Camillo Golgi, Abbiategrasso (MI)], Antonella Crispino, MD [RSA Villa Santo Stefano, S. Stefano di Rogliano (CS); RSA Villa Silvia, Altilia Grimaldi (CS)], Roberta Cucunato, MD [RSA Villa Santo Stefano, S. Stefano di Rogliano (CS); RSA Villa Silvia, Altilia Grimaldi (CS)], Ferdinando D'Amico, MD [RSA San Giovanni di Dio, Patti (ME); RSA Sant'Angelo di Brolo (ME)], Annalaura Dell'Armi, MD [III RSA Geriatria, IHG, Guidonia (RM)], Christian Ferro, MD [RSA Sant'Angelo di Brolo (ME)], Serafina Fiorillo, ND [RSA Madonna delle Grazie, Filadelfia (VV); Casa di Riposo Mons. Francesco Luzzi, Acquaro (VV); Casa di Riposo Villa Betania, Mileto (VV); Casa di Riposo Pietro Rosano, Dasà (VV); Casa di Riposo Serena Diocesi, Mileto (VV); Alloggio per Anziani Villa Amedeo, Francavilla Angitola (VV); Casa Albergo Villa Fabiola, Monterosso Calabro (VV); Casa di Riposo Villa Sara, San Nicola da Crissa (VV); Casa di Riposo Don Mottola, Tropea (VV); Casa di Riposo San Francesco, Soriano Calabro (VV); RSA Anziani, Soriano Calabro (VV); Casa di Riposo Suore Missionarie del Catechismo, Pizzo (VV)], Pier Paolo Gasbarri, BS [Associazione Nazionale Strutture Territoriali e per la Terza Età, Roma], Roberta Granata, MD [RSA Villa Sacra Famiglia, IHG, Roma], Nadia Grillo, MD [RSA San Domenico, Lamezia Terme (CZ); Casa di Riposo San Domenico, Lamezia Terme (CZ); RSA Villa Elisabetta, Cortale (CZ)], Antonio Guaita, MD [ASP Golgi Redaelli, Istituto Geriatrico Camillo Golgi, Abbiategrasso (MI)], Marilena Iarrera, MD [RSA Sant'Angelo di Brolo (ME)], Valerio Alex Ippolito, MD [Casa Protetta Villa Azzurra, Roseto Capo Spulico (CS)], Alba Malara, MD [RSA San Domenico, Lamezia Terme (CZ); Casa di Riposo Villa Marinella, Amantea (CS); Casa Protetta Madonna del Rosario, Lamezia Terme (CZ); Casa Protetta Villa Azzurra, Roseto Capo Spulico (CS); Centro di Riabilitazione San Domenico, Lamezia Terme (CZ); RSA Casa Amica, Fossato Serralta (CZ); RSA La Quiete, Castiglione Cosetino (CS); RSA San Domenico, Lamezia Terme (CZ); RSA Villa Elisabetta, Cortale (CZ); RSA Villa Santo Stefano, S. Stefano di Rogliano (CS); RSA Villa Silvia, Altilia Grimaldi (CS)], Irene Mancuso, MD [RSA San Giovanni di Dio, Patti (ME)], Eleonora Marelli, MD [ASP Golgi Redaelli, Istituto Geriatrico Camillo Golgi, Abbiategrasso (MI)], Paolo Moneti, MD [RSA Villa Gisella, Firenze], Fabio Monzani, MD [RSA Villa Isabella, Pisa], Marianna Noale, MSc [RSA AltaVita, Istituzioni Riunite di Assistenza, Padova], Sara Osso, MD [RSA La Quiete, Castiglione Cosentino (CS)], Agostino Perri, MD [RSA La Quiete, Castiglione Cosentino (CS)], Maria Perticone, MD [Casa di Riposo Villa Marinella, Amantea (CS)], Carmine Romaniello , MD [RSA INI Città Bianca, Veroli (FR)]; Marcello Russo, MD [RSA INI Città Bianca, Veroli (FR)], Giovanni Sgrò, MD [RSA Istituto Santa Maria del Soccorso, Serrastretta (CZ); RSA San Vito Hospital, San Vito sullo Jonio (CZ); Casa Protetta Villa Mariolina, Montauro (CZ); Casa Protetta Villa Sant'Elia, Marcellinara (CZ)], Federica Sirianni, MD [Casa di Riposo Villa Marinella, Amantea (CS)], Deborah Spaccaferro, MD [RSA Estensiva, IHG, Guidonia (RM); RSA Intensiva, IHG, Guidonia (RM)], Fausto Spadea, MD [RSA Casa Amica, Fossato Serralta (CZ)], Rita Ursino, MD [I RSA Geriatria, IHG, Guidonia (RM)].