Pandemic to endemic: New strategies needed to limit the impact of COVID-19 in long-term care facilities (LTCFs)

Residents of long-term care facilities (LTCFs) are particularly vulnerable to the coronavirus disease 2019 (COVID-19).^{1, 2} Globally, COVID-19 deaths in LTCFs account for 30%–70% of mortality in developed countries.³ In Singapore, LTCFs accounted for 0.03% of cases but 14% of COVID-19 deaths in 2020.

Having achieved a high vaccination rate of over 80% in August 2021, Singapore pivoted to an endemic COVID-19 strategy.⁴ This middle path approach involves cautiously opening up economically and socially while aiming to avoid high mortality rates. There were only 42 deaths in total at the start of the pivot toward an endemic COVID-19 policy in August 2021. Yet within weeks of opening up, COVID-19 infections and mortalities have risen in tandem. Vulnerable populations such as LTCFs and acute hospitals had an unprecedented total ban on visitors imposed on September 13, 2021. This ban, at the time of writing, has been further extended for another month.⁴ The rise of new variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), particularly the delta variant (B.1.617.2), has necessitated a review of strategies that had previously worked to contain COVID-19, even in a highly vaccinated country.

Within a month of embarking on an endemic COVID-19 strategy, nearly 25% of LTCFs across the country had detected COVID-19 cases. COVID-19 numbers in local LTCFs have increased exponentially less than 50 cases prior to the visitor ban to approximately 800 cases even with the ban in place. This begets several important considerations when COVID-19 becomes endemic:

1. Visitor bans on LTCF residents do not achieve total containment of COVID-19 and are not sustainable in the long run. The evidence shows that visitor bans do not prevent COVID-19 infections as staff movement contributes to transmission, especially with an endemic situation.⁵ Sharing of best practices and the development of robust protocols to facilitate safe visiting of LTCF residents are integral to maintain the welfare of residents.^{6, 7} Telehealth should continue to be developed and is already being deployed, however these cannot fully replace in-person interactions.⁸
2. High vaccination rates will attenuate, but not eliminate COVID-19 mortalities. LTCF residents will continue to be disproportionately affected. Singapore practices an age-based triage strategy with home recovery as the default for fully vaccinated persons aged 12–79 years old. The majority of LTCF residents who are older and more frail are transferred to acute hospitals or community treatment facilities, as has been practiced since the start of the pandemic.⁴ This is not practical with healthcare facilities increasingly strained by the rapid surge of cases due to the delta variant. Instead, careful risk stratification and scaling up LTCFs to manage stable COVID-19 cases is a more sustainable long-term solution. In addition, LTCF residents should receive priority and be encouraged to take booster vaccinations against COVID-19 where indicated.⁹
3. Evidence has shown that the incidence of influenza has fallen dramatically due to social distancing measures. Natural immunity to influenza may have diminished among LTCF residents during this COVID-19 pandemic. In an endemic phase of COVID-19 and with the resumption of visitors, LTCFs must prepare for the resurgence of influenza and other viral epidemics that may have been suppressed with social distancing measures. Strict hygiene measures should be practiced while simultaneously encouraging vaccinations against both COVID-19 and influenza.
4. Data on COVID-19 cases in LTCFs should be clear, transparent, and available to inform public policy and opinion. In Singapore, due to the massive outbreak among dormitory workers in 2020, data are presented on daily cases in the community and in dormitories. Data on infections and mortalities of LTCF residents are not available alongside community and dormitory data. Given the disproportionate impact on LTCF residents even and especially in an endemic situation, it is essential that data on LTCF infections are prioritized and monitored.
5. Frailty is an important predictor for poor healthcare outcomes, and there is a high prevalence of frailty among LTCF residents. The COVID-19 pandemic has highlighted the importance of frailty as a tool for assessment and prognostication, especially in older persons and in LTCFs.^{1, 10} Frailty is still often not part of routinely collected clinical data in acute healthcare settings and even more so in LTCFs. Accurate and rapid assessment of frailty and targeted interventions can help to attenuate the impact of endemic COVID-19 and other transmissible viruses in LTCFs.

Despite the rapid development of vaccinations, new SARS-CoV-2 variants continue to pose challenges to mitigating the toll from COVID-19. New and sustainable strategies are needed to minimize the impact of an endemic COVID-19.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

AUTHOR CONTRIBUTIONS

Li Feng Tan and Min Feng Tan both conceptualized and wrote the manuscript. Both authors were involved in the literature review, conceptualization, writing, and critical review of the manuscript.

SPONSOR'S ROLE

No sponsorship was received for this study.