Evaluating the role played by care homes and nursing facilities in shaping the dynamics of transmission and the overall burden of Covid-19 has assumed unprecedented urgency. There is growing policy and even judicial scrutiny over the practices adopted by these facilities during the Covid-19 outbreak. Recent reports have indeed suggested that the hazard of care homes was not limited to their residents, but also extended to the staff and to visiting relatives.
Italy was the first western country to experience a severe Covid-19 outbreak. Excess deaths in Lombardy’s care homes are at the centre of media and policy attention, and judicial enquiries point to a lack of clear rules on containment practices, such as the reception of patients with Covid-19-related symptoms, testing, availability of protective gear, and contact with visitors. And it’s not only in Italy: for example, a major political controversy has erupted in New York State over the same issue. The living conditions of the elderly in nursing and care homes are the subject of rapidly rising attention amidst dramatic reports of death rates in long-term residential and nursing facilities, described as “besieged castles,” during the pandemic. In several of these facilities, lack of adequate protocols for containment may have led to a rapid and lethal spread of the virus. Furthermore, the fact that most care homes do not have an infrastructure for treating acute illness may have exacerbated the crisis.
In the epidemiological literature there is consensus about the role played by the environment, including the environments of health and long-term care, in determining the spread of infectious diseases; but non-anecdotal evidence on how care homes might have added to the burden of Covid-19 is currently lacking. In a recent study, we provide an assessment of the role of care homes in the overall burden of Covid-19 in Northern Italy. We estimate the concentration of excess mortality in municipalities with care homes as local hotspots in the diffusion of the pandemic. We use registry-based daily mortality records from Lombardy (Italy), among the areas hardest-hit by the pandemic worldwide, and match those with a novel geolocated dataset of care homes and their population. We estimate differences in excess mortality between municipalities with and without care homes, compared to the average of the previous five years.
Our analyses show that total excess mortality in the population was significantly higher in municipalities with at least one care home, reaching up to 12 additional daily excess deaths per 100,000 inhabitants in March 2020. Overall, the presence of a care home accounts for 43% of the excess deaths recorded at the population level, and for 39% of the excess deaths among the elderly (70 years old and older). This increase in excess death is not explained by the size of the care home population nor by the local share of people aged over 70. The results suggest that, for whatever reasons, transmission of Covid both within and from contacts with care homes was a major source of the vector of Covid-19.
© Caterina Alacevich, Nicolò Cavalli, Osea Giuntella, Raffaele Lagravinese, Francesco Moscone, Catia Nicodemo
Caterina Alacevich is a post-doctoral research fellow at the Department of Primary Care at the University of Oxford, UK
Nicolò Cavalli is an assistant professor at Bocconi University, Italy
Osea Giuntella is assistant professor of economics at the University of Pittsburgh, USA, and a Research Fellow of IZA
Raffaele Lagravinese, is a senior lecturer in economics at Universita’ di Bari, Italy
Francesco Moscone is an associate professor of economics at the University of Venice (Ca’ Foscari), Italy
Catia Nicodemo is a research fellow in the Department of Primary Care at the University of Oxford, UK and a Research Fellow of IZA
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