The pandemic shut down wide swaths of the world in 2020. In Canada, where mask-wearing and physical distancing would become a way of life, schools, stores, restaurants and companies closed for months. With no vaccine to protect people from catching the novel coronavirus, and no reliable cure or treatment for it, prevention has been the only means available to stop its spread from one human host to another.
Yet a wholesale social lockdown ranks as the last resort of prevention efforts, given the economic, psychological and social hardships it brings. Only when community spread is so extensive that nearly everyone must be isolated from each other does it become unavoidable. Lockdowns and shutdowns are an admission that far more targeted, palatable efforts have failed to contain the virus.
At the heart of any successful containment strategy is the ability to quickly identify those who are infected. It allows people with COVID-19 to be properly cared for and isolated. It makes it possible to trace their recent history and contacts, and quarantine those who may have caught the virus from them. It also reveals where disease is spreading, enabling communities to step up prevention efforts if cases rise. None of this can happen without tests to diagnose an infection, and, to date, testing remains the sharpest weapon humanity has in its war against COVID-19.
Scientists developed the first test for the new virus even before the pathogen was given a name. A lab- performed, genetic-based assessment, it continues to be the gold standard for diagnosing the disease. Canada used the technique to confirm the country’s first known case on January 27, and each province since then has decided how best to roll out testing for its own populations.
Yet the Revera Expert Advisory Panel found that the vulnerable elderly living in congregate settings were largely overlooked in those decisions by provincial healthcare systems. Early in the pandemic, although it was widely understood that long term care homes and retirement residents faced an extremely high risk of serious complications and death from COVID-19, and so had much to gain from testing, they and the staff who look after them, were not prioritized for testing within the system.
In Ontario, for instance, where COVID-19 had killed more than 1,800 residents by the end of August – a tally that accounts for nearly 30 per cent of all the country’s deaths in long term care – the testing strategy utterly failed seniors living in congregate settings. Testing in the province focused on people with symptoms who showed up at hospital emergency departments or the COVID-19 assessment centres that sprang up on hospital grounds. But the possibility of sending sick residents from long term care homes to be tested at these sites was limited by local health authorities, who discouraged the transfer of these residents in order to protect hospitals’ capacity to handle the expected surge in coronavirus patients from the community.
As a result, screening of residents and staff became the imperfect substitute. Screening is used to identify someone who may be unwittingly infected, or who may have mild COVID-19 symptoms. It involves querying the individual about potential contact with anyone known to have the virus, or about the presence of symptoms. In the early days, only three symptoms were assessed: fever, dry cough and shortness of breath. Screening for symptoms related to loss of taste or smell, muscle aches, fatigue, diarrhea or other gastrointestinal upsets started much later.
Before long term care homes and retirement residences restricted visitors in early March, screening questions also focused on a person’s recent travels. At the time, the prime concern was that the virus might enter a home by way of visitors who had been overseas. No one realized then that it had already begun its quiet spread through communities in Canada.
Yet even after the first outbreaks began to claim lives in long term care homes and retirement residences – and infections could be traced back to community spread – the testing of residents remained totally inadequate. In part, this reflected a general shortage of the supplies needed to conduct the gold standard test in the pandemic’s early days, along with a lack of knowledge that the disease could be spread by those without symptoms.
Other than in Ontario – where the government introduced surveillance testing of staff and essential family caregivers and visitors for social reasons at the end of May in response to the industry’s request – low testing levels in long term care homes and retirement residences persisted throughout the pandemic’s first wave, while botched logistics added to the problem. Public health’s reporting of positive test results often took far too long. At one of Revera’s long term care homes, samples sent to a public health lab for testing were lost; in another case, test results were returned with confusing and incomplete information, factors that impeded efforts to contain further spread.
Meanwhile, most of this occurred in a policy vacuum. Not until May 31, for example, did it become mandatory in Ontario for long term care home and retirement residence staff, and essential family caregivers, to be regularly tested – nearly three months after homes had been locked down. And not until mid-June did surveillance for the disease include routine testing for all staff and essential family caregivers in long term care. By then, however, the worst of the first wave was over. The country was reopening as cases declined, and the death toll in long term care had already passed its staggering peak.
The industry advocated for surveillance testing of workers and residents as early as April. If this had occurred, infected residents could have been identified, treated and isolated sooner to prevent further spread to other residents and staff. Identifying infected staff members would have allowed them to receive faster medical care and kept them from continuing to work and spreading the virus further. Access to quicker testing would also have revealed a home’s rising caseload in time to recognize the urgent and critical need to improve infection control practices and boost training for staff.
In all, the COVID-19 catastrophe makes it clear that screening, testing and tracing must be as stringent in long term care homes and retirement residences as they are in the acute-care settings of hospitals. Improving both testing and infection control in long term care will demand time and investment. But enough meaningful steps can be taken in the short term to ensure that residents are better protected as the pandemic rages on.
A Blunt Instrument
Screening seemingly healthy people for mild symptoms of infection can help curb the spread of any contagion. It indicates who might pose a potential risk, and who should undergo further testing. But screening lacks the precision of a diagnosis and in the context of COVID-19, it’s an especially blunt instrument: Up to 30 per cent of those infected with the new coronavirus have no symptoms, and, unlike most respiratory infections, the new coronavirus is a sneaky microbe that is highly contagious when people are pre-symptomatic. Studies find that infected people often spread it for two to four days before they start to show symptoms.
Screening older people for COVID-19 symptoms adds a layer of complexity. The novel coronavirus can produce dramatically different symptoms in different people, and among older adults, those symptoms tend to be highly ambiguous: They might sleep more or eat less, speak differently or not at all, become increasingly dizzy, confused or disoriented – all clues that can be easily missed or misdiagnosed in long term care settings, where 90 per cent of residents live with dementia or other cognitive impairments.
But family caregivers who might have noticed these subtle behavioural changes in their loved ones were no longer allowed to visit when disease first broke in long term care homes and retirement residences. At the same time, the number of personal support, nursing and other healthcare workers familiar with the residents, who might also have been able to recognize vague signs of trouble, was dwindling as employees fell ill themselves and absences rose.
In Ontario, before March 12, screening of staff had been a passive undertaking. Employees were asked to stay home if they had COVID-like symptoms or felt unwell. But after that date, daily active screening became the norm with questionnaires and temperature checks. It proved, however, to be a preventive measure that simply could not measure up to the goal of containment. Staff members who caught the virus in their communities but were asymptomatic or pre-symptomatic slipped through these screening protocols and became the unwitting source of outbreaks in long term care homes and retirement residences.
Yet with no diagnostic tests available to identify cases early, infected staff and residents often remained undetected until their illness was full-blown. By then, efforts to isolate sick residents from the healthy became increasingly challenging. Cognitively impaired residents, prone to wandering, were difficult to isolate, especially in homes that lacked the extra space to do so, and especially in outdated long term care homes where shared bedrooms and bathrooms were common (an issue to be explored further in Chapter 5).
By late April, the outbreaks had spiralled into a health management crisis, and one that underscored critical differences between the infection control standards of acute care settings like hospitals and chronic care environments like long term care homes. In hospitals, procedures to ensure the isolation of those infected, and practices to contain spread (such as using single rooms to isolate sick patients, intense cleaning and disinfection of common surfaces, frequent handwashing, and the safe, regular use of personal protective equipment – gloves, gowns, masks), are second nature and routinely audited. In contrast, given the different nature of long term care, homes have not historically had the same infection control practices in place as hospitals. While these practices were seen as appropriate in the pre-COVID environment, it became apparent that increased measures were needed to combat the spread of this novel, highly virulent disease.
Throughout April and May – when most infections and deaths were occurring in long term care settings – public health had limited capacity in their testing systems, and long term care residents were not prioritized.
The few exceptions involved those unusual instances when sick residents were transferred to hospital emergency departments for testing, and in homes where outbreaks became so severe that external supervisors – including the military and local hospitals – took over the home’s management. Otherwise, in Ontario, it was not until early June that public health officials began visiting homes to provide regular testing to residents and staff in non-outbreak situations.
Long term care advocates – including home operators, doctors, residents and families – had pushed public health authorities to distribute diagnostic tests sooner. But the severe lack of testing was not unique to long term care; it was emblematic of a national shortfall. During the pandemic’s first wave, testing lagged across Canada, as it did in several countries. The new virus had appeared without warning, and the capacity to detect it in the human body required a sudden and massive rallying of lab resources that few jurisdictions had on hand or could ramp up quickly.
Shortfalls, Backlogs and Blind Sides
At the end of January, the World Health Organization began shipping a quarter of a million test kits around the globe to diagnose COVID-19. But Canada was among the industrialized nations with the capacity to develop its own tests. It did so in mid-January, shortly after scientists in Wuhan shared online the genetic code of the novel coronavirus that had surfaced in their city.
Having the pathogen’s precise genetic sequence is the foundation of the gold standard test for COVID-19. But taking the test can be an uncomfortable experience. A healthcare worker wearing protective gear must insert and rotate a long, flexible brush-tipped swabbing device up into the nostril to the back of the throat to gather cells and mucus that may contain the virus. The samples collected by these nasopharyngeal swabs are then sealed in saline-filled containers and sent to a lab where they are analyzed for genetic traces of the virus.
The technique used in testing the collected sample is called PCR, short for Polymerase Chain Reaction. It involves the use of certain chemicals, known as reagents, formulated to bind to the specific genetic code of the virus being hunted. The reagents are added to the samples, which then undergo an automated series of temperature-changing cycles in highly specialized machines.
Unlike the double helix of DNA, which encodes instructions to build and operate an organism, the novel coronavirus has only RNA, a single-stranded molecule that conveys instructions. If the virus’s RNA is present in a sample, the PCR process amplifies it a billion times over, like a molecular photocopier. A positive result means the viral RNA was found in the sample, and that the person it came from has an active infection. If no trace of viral RNA is found, the test result is negative.
But no test is perfect. Logistical problems can arise while collecting the nasopharyngeal specimen, or in labelling samples, processing them and reporting results. And while the PCR technique is lauded as the most sensitive and specific diagnostic available, it can fail if the virus does not happen to be present in the sample collected, or if the virus has yet to replicate in high enough concentrations to be detectable – which is a major cause of false-negative COVID-19 tests.
While the novel coronavirus is highly contagious, studies show that most people who have been infected will receive a negative result if they are tested the day after being exposed. This is because it can take several days for the virus to incubate and replicate in high enough quantities to be detected, even by a PCR test. In fact, false-negative results continue to be likely for about three or four days after an exposure. Not until eight days after exposure is the result most likely to be accurate. At that point, roughly a week later, the chance of receiving a false-negative test drops to 20 per cent. Understanding this is critical in long term care homes, since a false-negative test may result in a resident who has been exposed remaining in a shared room, or continuing to eat in a common dining room and taking part in group activities, increasing the risk of spreading the disease further.
In rare cases, a PCR test can also return false-positive results. In a small portion of people who have had COVID-19, the gold standard test can continue to pick up genetic traces of dead virus for up to three months after symptoms have disappeared. While false-positives occur in less than one per cent of samples tested, in long term care it may result in residents remaining unnecessarily isolated or quarantined, causing undue emotional distress to them and their family. A false-positive may also prevent staff members who have cleared an infection from returning to work – further contributing to the chronic labour shortages in long term care settings which exacerbated the scope of outbreaks.
Even still, none of these issues with the leading diagnostic test for COVID-19 proved as devastating to the long term care sector as the simple lack of access to it. As with the shortage of personal protective equipment, resources for testing were prioritized for hospitals as demand dramatically outstripped supply.
When the pandemic was declared in March, the country was not only running low on the specific swabs needed to perform nasopharyngeal collections, but also the reagents required to run the PCR test for the new virus. Public health labs also faced a shortage of technicians, capacity, and the specialized machines needed to test the sudden daily flood of samples they were receiving.
On March 28, a few weeks into the pandemic’s first wave, Ontario’s network of public health labs was performing only about 3,400 tests per day for the entire province, a mere fraction of its 20,000-tests- per-day goal. The number increased to 5,500 tests a day by mid-April, and about 10,000 tests a day at the end of April, but that was still half the number public health authorities considered optimal for the size of the provincial population.
Meanwhile, as demand for tests continued to outpace lab capacity, the gap created backlogs and stalled the reporting of positive test results by days, and in some cases a week or more. In turn, this delayed efforts to trace contacts, quarantine those who may have been infected and contain further spread.
The health system’s testing woes continued to cause issues for the long term care sector. Not only did the lack of access prevent the timely diagnosis of residents and staff, the province-wide testing shortages also hid the fact that as early as March the virus was spreading widely in Canadian communities – communities where long term care staff worked and lived and became infected. If testing levels had been higher, they would have revealed that the greatest viral threat to long term care at the time was not from returning travellers, but rather from local spread of the contagion. Instead, the sector was blindsided.
Research conducted since has also found that COVID-19 outbreaks in long term care homes are likely to arise after the virus has become prevalent in the community outside its doors and particularly in those areas where its staff members reside. In fact, Revera’s internal case tracking shows that when cases increased in the community, a similar spike followed in neighbouring long term care homes about two weeks later, essentially shadowing the trajectory of infection in the community.
In an effort to slow community spread, the World Health Organization recommends that lockdowns should be considered when the test positivity rate in a given area climbs above five per cent, or, put another way, when at least five per cent of a region’s test results come back positive. By that definition, the whole of Ontario had teetered on the brink of utter disaster in the pandemic’s first wave: 10 per cent of COVID-19 tests conducted in the province at the beginning of April were positive. On April 11, the positivity rate peaked at 20 per cent – meaning one in every five people tested was infected with the novel coronavirus. But it was the long term care sector, its residents, staff and connected families that paid the highest price of not knowing the scope and location of viral transmission.
By the end of May, thanks in part to diligent physical distancing, improved testing capacity and mask-wearing, Ontario managed to dramatically reduce to four per cent the proportion of tests coming back positive, and that figure dropped to roughly one per cent in June.
Testing, or the lack of it, can clearly have a profound impact on the course of an outbreak when physical distancing is the only way to stall the spread of disease. The urgent issue on the horizon is how best to conduct a rapid, robust and accessible testing program for long term care homes and retirement residences, where residents face the greatest risk of dying from a pathogen so tricky to detect.
The Gold and Silver: A Tale of Two Tests
The notion that the gold standard test to diagnose COVID-19 could be offered on a regular basis to the senior living sector is an impractical and unwieldy proposition. In Ontario alone, about 144,000 people live in long term care and retirement residences, which employ roughly an equal number of staff. To provide PCR tests for these 288,000 people on a bi-weekly basis would require labs in the province to perform 20,000 tests a day – a threshold it never came close to meeting during the pandemic’s first wave, and a tally that doesn’t include testing anyone else in Ontario.
While no other diagnostic so far beats the sensitivity or accuracy of a PCR test, the gold standard technique is too cumbersome for frequent use in long term care. It takes too long to be a timely or meaningful way to identify visitors who may be infected. A nasopharyngeal swab to collect samples for testing is also too uncomfortable for residents to undergo on a regular basis. As one Revera leader noted, many of its long term care residents who took the test suffered nosebleeds as a result. For healthcare workers who must don PPE to gather nasopharyngeal tissue samples, the test is both risky and time-consuming – samples have to be collected, properly labelled and shipped to a public health lab.
Results can also take far too long to be returned, particularly as testing demands rise with the reopening of schools and businesses. Reporting of results can also present challenges. When testing finally became available in long term care, paper-based test results were generally faxed to residences by the stack for staff to sort through and decipher. At one Revera home, a set of results came through the fax machine with only case numbers – no names – attached to the reports, leaving staff to puzzle over precisely who was infected and who was not.
For all these reasons, a rapid, point-of-care screening test would be much better suited to meet the unique demands of helping to diagnose COVID-19 in long term care homes and retirement residences. During the pandemic’s first wave, none were available in Canada.
Unlike lab testing, which can take days to produce results and requires dedicated healthcare workers and technicians to perform, rapid screening tests – such as at-home pregnancy tests – produce easy-to-read visual results within minutes, and people can often perform these tests on themselves.
Some rapid screening tests evaluate a saliva sample or throat swab for the presence of specific proteins (known as antigens) produced by the virus. If the antigens are found, the test is positive. Other rapid diagnostic tests screen samples for traces of viral RNA using a toaster-sized desktop machine that can produce results in about 15 minutes.
In October, Health Canada approved ID NOW, a version of this genetic testing device from the U.S.- based Abbott Labs, making it the first, and long-awaited, rapid point-of-care test to receive the national go-ahead for use in this country. Earlier in the year, the U.S. Food and Drug Administration had approved Abbott’s BinaxNow, a rapid antigen diagnostic test, which may also eventually be available in Canada. Neither test is officially approved to detect COVID-19 in those who have no symptoms at the time of writing.
There is no doubt that rapid tests are generally less sensitive and specific than the gold standard lab evaluations – the false-negative rate can be as high as 30 per cent in some products. But what they lack in accuracy, they may make up for in speed, which could be critical to slowing the spread of disease in the future. At the very least, rapid screening can swiftly pinpoint who should have their results confirmed through the gold standard method. Not only would this lighten the testing load on over-burdened labs, it would also allow the long term care sector to finally wield its own on-the-spot detection weapon against COVID-19, independent of any government bodies or agencies.
No More Flying Blind
In the face of a global pandemic that has claimed a million lives and counting, the availability of smart, swift and sustainable testing programs is essential to containing the spread of COVID-19. With no vaccine, treatment or cure currently available to even slow transmission of the novel coronavirus, a three-pronged containment strategy based on screening, diagnostic testing and contact tracing is the best hope of prevention.
If containment efforts fail, and community spread goes unchecked, a lockdown – and all the economic and psychosocial burdens that come with it – becomes the regrettable alternative. As the spring wave clearly demonstrated, when low testing levels failed to reveal the prevalence of community spread in Canada, there was no way for the long term care sector to recognize the root source of infections. The Revera Expert Advisory Panel found that the testing shortage ranks among the top contributors to the scope of the COVID-19 tragedy.
As the pandemic continues to wreak havoc in Canada and around the world, the hope is that the hard- won lessons learned about the importance of testing through the spring of 2020 will make a meaningful difference for the winter ahead.
1) Standards involving IPAC in long term care must be brought to the levels expected in hospitals. This must include, at a minimum, training in hand hygiene; hand hygiene auditing; and the safe, effective use of PPE, including donning and doffing, and a focus on appropriate cleaning methods.
Revera Response: Implementation of recommendation is in progress.
We have well-established IPAC education and training from a clinical team that includes the chief medical officer, a consultant infectious disease physician, and a manager of clinical support, who has a Certificate of Infection Control from IPAC Canada. We have purchased and implemented a digital tool for auditing hand hygiene that provides results of audits in real-time for identification of homes/staff that require additional training. The frequency of hand hygiene and PPE donning and doffing audits has been increased during the pandemic. We have put an IPAC champion in each home and hired four regional IPAC specialists in Ontario. In the western provinces, we have increased the number of regional managers to improve IPAC education and support the homes’ IPAC champions. Similar resources are planned for the retirement residences.
2) Staff must be trained in the management of infectious residents, including isolation procedures, contact and droplet precautions, and methods to be used to protect against airborne transmission.
Revera Response: Recommendation already implemented.
IPAC training had already been in place prior to COVID-19 in both long term care and retirement residence settings to manage other infections. Given the novelty of the COVID-19 virus and its transmission, we put in place additional IPAC tools, training and audits to ensure sustainment of IPAC measures. As we recruit new staff, we are retraining constantly to ensure that, as much as possible, good IPAC procedures are followed.
3) Each long term care home and retirement residence must establish screening protocols for staff and visitors.
Revera Response: Recommendation already implemented.
We have established active screening for staff and visitors in each home. Each province has different specific wording and direction; we have consolidated those provincial rules so that all our homes across Canada follow the highest level of screening. In addition, we have made additional investments in an IPAC surveillance software provider that allows our sites to track signs and symptoms for residents, monitor outbreaks and conduct hand hygiene audits. This solution was previously deployed in long term care homes in 2019. Over the summer, we partnered with the vendor to develop two new modules that allow our sites to: (1) track lab results for resident and staff; and (2) track staff symptoms and infections. These modules allow us to have a single source of truth for tracking of test results and manage all infection cases in a site through one application.
4) Staff should be trained in how to obtain various samples for testing.
Revera Response: Recommendation already implemented.
In Ontario, we have worked with Public Health to administer weekly or bi-weekly surveillance testing for our staff . This includes a playbook and operating procedures for testing, which included training on specimen collection (currently nasopharyngeal in Ontario) as well as tools and support for test result tracking. In the western provinces, we have not yet been able to secure surveillance testing from Public Health, so we are working with a private laboratory chain to conduct surveillance testing clinics for our employees, including training on specimen collection using the bilateral nasal method. We are also in the process of securing alternate testing modalities such as antigen testing and, at the right time, will train our staff on specimen collection for those tests.
5) Education related to assessment of patients with respiratory infections should be available for all staff.
Revera Response: Recommendation already implemented.
Education related to respiratory infections had been previously available to our staff. At the onset of COVID-19, we developed specific education related to its symptoms and transition, and continue to update the education to staff as our knowledge of the virus evolves.
6) Management should familiarize itself with the residential areas of staff members and monitor community spread in those neighbourhoods to determine when there is a higher likelihood of staff becoming infected. Screening and testing procedures should be increased during times of high community prevalence. Consideration should also be given to providing private transportation options for staff.
Revera Response: Recommendation already implemented.
Revera has created an interactive dashboard that tracks outbreak risk, including community spread, for its sites. Additional precautions are taken when community spread poses a greater risk for a site. This includes heightened IPAC measures and audits, additional surveillance testing, and additional education on IPAC to staff and visitors as well as reminders on how to reduce risk of infection outside of work. Additionally, we have been providing transportation vouchers/reimbursements for staff.
7) Isolating infectious residents is difficult in older long term care homes. Homes should consider having temporary transitional facilities available on-site that will allow for true isolation of residents who develop COVID-19.
Revera Response: Implementation of recommendation is not feasible.
Currently, long term care homes add 1:1 support for those residents who require isolation and are unable to self-isolate. Adding transition facilities brings in new risks: how to staff the additional unit, ensure safety protocols are in place or meet licensing requirements. Additionally, moving residents to these transitional facilities would create significant and potentially unsettling change for residents. Moreover, given occupancy decreases, we are better able to create isolation areas within our homes.
8) Until routine testing of asymptomatic residents and staff is available, homes should continue regular testing with PCR detection of viral RNA. The frequency of asymptomatic testing should vary with the prevalence of disease in the geographic area around a home, and the prevalence in the communities where staff members reside.
Revera Response: Recommendation already implemented.
Revera conducts weekly or bi-weekly staff surveillance testing (lab-based PCR) at all of its Ontario sites through collaboration with Public Health. In the western provinces, Revera has secured a partnership with a private laboratory chain and is rolling out twice-monthly surveillance testing at sites with higher community spread.
9) Revera should continue to track the availability and sensitivity of point-of-care rapid testing products, either those that are antigen based or those that detect the virus’s genetic material. It should consider rolling rapid tests into screening protocols for staff and visitors whenever spread increases in local communities. Rapid tests approved to date by Health Canada (ID Now) are not currently approved for use in asymptomatic individuals; however, this situation is expected to change quickly. Revera should stay knowledgeable about what types of tests are available and approved by Health Canada in order to provide the best option for regular cost-effective screening for staff, residents and visitors.
Revera Response: Implementation of recommendation is in progress.
Revera continues to pursue rapid point-of-care solutions as part of our testing strategy. In general, vendors in this space continue to have challenges bringing products to market, securing government approvals and making commitments to meaningful product quantities. However, we do have commitments from a couple of providers for a small quantity of kits that we can pilot at our sites. For the time being, we will continue to use lab-based PCR testing and, as we gain more confidence in antigen testing, we will show preference for this modality given speed, simplicity and cost.
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This report is dedicated to Revera’s employees, residents, their families, and all those on the front lines of the senior living sector who are working through the worst pandemic in living history.
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