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May 25, 2021

Most US Nursing Homes Had Multiple, Sustained COVID-19 Outbreaks, GAO Reports

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum and JAMA
JAMA Health Forum. 2021;2(5):e211621. doi:10.1001/jamahealthforum.2021.1621

The majority of US nursing homes experienced 2 or more outbreaks of COVID-19 from May 2020 through January 2021, and many such outbreaks had weeks of sustained transmission, according to a report from the federal government’s Government Accountability Office (GAO).

In addition, two-thirds of the outbreaks began with a staff member who tested positive during the first week of a given outbreak.

The COVID-19 pandemic has had a disproportionate impact on residents in the nation’s more than 15 000 Medicare- and Medicaid-certified nursing homes. “While the introduction of vaccines and the sharp decline in nursing home cases and deaths since their peaks in December 2020 may indicate that nursing homes are seeing a reprieve, little is still known about the frequency and duration of COVID-19 outbreaks in nursing homes at critical points during the pandemic,” the report notes.

Nursing homes are particularly vulnerable to COVID-19 for several reasons. Nursing home residents, typically older adults with high levels of chronic illness and impairment, are especially susceptible to severe complications and mortality from the disease, live in close proximity to other residents, and have regular contact with caregivers who interact with multiple residents and also with other people in the community.

The GAO examined data on COVID-19 reported each week by nursing homes to the Centers for Disease Control and Prevention (CDC) from May 2020 through January 2021, the most recent data available at the time of the agency’s review. The analysis included data from 13 380 Medicare- and Medicaid-certified nursing homes.

Nursing homes experienced an average of about 3 COVID-19 outbreaks each during the review period. The vast majority (12 555 [94%]) had more than 1 outbreak, with 5943 (44%) each experiencing 4 or more. Only 761 (6%) of the facilities had a single outbreak, and just 64 (0.5%) had none.

The GAO also examined outbreak duration, defined as starting the week that a nursing home reported a new case of COVID-19 in a resident or staff member and ending when 2 weeks had elapsed without any new cases. A total of 11 311 nursing homes (about 85%) had long-duration outbreaks lasting 5 weeks or longer, with an average of 56 COVID-19 cases per outbreak.

In addition, 6858 (61%) of the 11 311 nursing homes with long-duration outbreaks had outbreaks lasting between 5 and 10 weeks; the remaining 39% had outbreaks lasting more than 10 weeks.

Short-duration outbreaks that lasted 1 to 4 weeks were reported by 2005 (15%) of nursing homes, with an average of 13 cases per outbreak. Only 267 of nursing homes were able to control their outbreaks after the first week.

Longer outbreaks were more likely to occur in nursing homes with higher bed counts compared with those with fewer beds, the GAO found. About 12% of all nursing homes in the study had fewer than 50 beds; these facilities made up a disproportionately greater share of homes with short-duration outbreaks (28%) and a smaller share of homes with long-duration outbreaks (9%). In contrast, about 44% of the nursing homes reviewed had 100 to 199 beds; they made up 27% of homes with short-duration outbreaks and 47% of homes with long-duration outbreaks.

“In part, this reflects the fact that larger homes will inherently incur a higher risk of having at least one case, given that they have more residents and staff, each of whom could become that case,” the report notes. Also, studies have shown that larger nursing homes with more residents and staff may have a higher risk of exposure to the coronavirus, particularly in areas of high community spread.

However, the duration of outbreaks did not appear to be associated with the type of ownership status—for-profit, nonprofit, or government—or whether a home had been cited before the pandemic for deficiencies in infection control and prevention.

For both long- and short-duration outbreaks, 8720 nursing homes (66%) reported that these outbreaks began with a staff member who tested positive the first week.

One recent account of such an outbreak was reported by the CDC, in which an unvaccinated health care worker set off an outbreak at a nursing home in Kentucky, resulting in 46 COVID-19 cases, including 22 cases among residents and employees who were already fully vaccinated. Cases occurred disproportionately among unvaccinated residents and staff, although there were some breakthrough infections even among those who were fully immunized against COVID-19.

The report notes that interviews with researchers and representatives of national associations and organizations cited several factors that can increase the risk of setting off an outbreak and contributing to its spread in nursing homes, including failure or inability of a nursing home to implement robust infection control practices, a lack of personal protective equipment that increases the risk of staff members becoming infected or infecting others, and inadequate staffing that makes it difficult for nursing homes to adhere to infection control practices.

The GAO is charged (under the Coronavirus Aid, Relief, and Economic Security [CARES] Act enacted in March 2020) with monitoring the federal pandemic response, including reviewing the Centers for Medicare & Medicaid Services’ (CMS’s) oversight of nursing homes during the pandemic.

The agency plans future reports that “will examine more broadly infection prevention and control and emergency preparedness in nursing homes and CMS’s response to the COVID-19 pandemic.”

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Article Information

Published: May 25, 2021. doi:10.1001/jamahealthforum.2021.1621

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Stephenson J. JAMA Health Forum.

Corresponding Author: Joan Stephenson, PhD, Consulting Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).

Conflict of Interest Disclosures: None reported.

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