We describe the results of the national program of periodic universal staff screening of all of Israel's LTCFs. Our analysis indicates that implementation of such a weekly screening program for LTCF employees resulted in a substantial reduction in the mortality ratio in the second wave compared to the first wave.
During the COVID-19 pandemic, LTCFs have been a major source of devastating outbreaks in many countries accompanied by high mortality and morbidity, causing a consequential load on national health systems [1, 2]. Root-cause analysis of LTCF outbreaks identified that COVID-19 prevalence in the community is the main factor that is directly associated with the likelihood of COVID-19 entering the facility [11, 18–22]. Accordingly, this program involves primary prevention of outbreak events by identifying asymptomatic HCWs and potentially preventing the outbreak entirely. Additionally, it includes a second line of defense, immediately activating the screening of all residents and employees, where a positive COVID-19 case is identified, enabling us to limit the extent of the outbreak. The PCR test results were reported directly to the LTCF medical directors, within 24 hours, and the response was immediately implemented out by the Senior Shield program headquarters, which stood by ready to take action on a 24/7 basis .
Evaluation of international ability to defend the LTCF sector from COVID-19 mortality is a challenging task due to differences in the number of LTCF beds per population. Israel’s population is significantly younger than in other western countries (Israel has only 11.2% above 65 compared to OECD 18.3% and USA 16.5%) and the number of LTCF residents per million is lower than most OECD countries [15, 24]. An ECDC report showed that general mortality in the LTCF sector seems to be directly correlated with the prevalence of COVID-19 in the country. However, according to this report, even though Israel had a high prevalence of COVID-19 cases, there was very low LTCF mortality per 1000 beds (Fig. 3). Given that health system accessibility as well as medical practice to COVID-19 patients during the course of the pandemic was identical across Israel, the decrease in the mortality ratio of LTCF residents in the second wave, compared to the first wave, can be accounted for by the execution of the LTCF screening plan.
During the COVID-19 pandemic the Ministry of Health defined the national "red line capacity" level of Israel hospital system to be no more than 800 patients hospitalized with severe COVID-19. During the peak of the second wave Israel crossed this red line and had 898 such patients. The activation of this program, with the reduction in LTCF outbreak events and the associated decrease in morbidity and acute hospitalizations, significantly contributed to preventing the national public hospital system from being overwhelmed during the second wave (Table 2). Our experience with this screening program indicated an ability to offer a sustained reduction in overall outbreaks up to a certain level of community spread of COVID-19. However, when the test positivity rate increased above 5%, and above a weekly incidence of 240/1,000,000 in the Israeli population, in the second wave, a bi-weekly screening became mandatory in order to prevent outbreaks and to better defend these vulnerable residents.
Before starting the program there were three main concerns: first that HCWs with negative COVID-19 test results would weaken their compliance with the use of face masks and would not follow mandatory hygiene procedures. Second, the ability to oblige LTCFs to join the program and the HCWs to undergo repeated weekly testing was weak. Interestingly we noticed that the staff's acceptance of screening as an effective way of protecting the LTCF’s residents, resolved this issue rapidly. This is demonstrated by the 100% compliance of facilities in joining the program and the adherence of managers to screening more than 90% of their workers every week. Third, given Israel's strict medical confidentiality laws there were legal obstacles to transferring the employee's medical information (COVID-19 test results) to their direct administrative manager. We were able to resolve this issue by permitting the results to be transferred to the LTCF’s medical director.
This report has some limitations. Bear in mind that this was and continues to be a real-life pandemic situation with all of the confusion and uncertainty engendered by such crises. As such it took one month from initiating the system to reaching full coverage of all LTCFs. Therefore, the results are not as precise as they should be in a well-designed study. However, the dramatic differences in LTCF resident mortality and morbidity in the two waves, which started two weeks after the implementation of the screening program and continued during the second wave – strengthens our impression that such a national or local screening program is effective in reducing morbidity and mortality in this especially vulnerable group of older persons.
In this study we found that by using weekly PCR testing of all employees we were able to protect the LTCF system from outbreaks. Although immunization of LTCF residents and HCW is the ultimate goal in preventing further COVID-19 infection, our research suggests an effective method of protecting LTCF against future outbreaks caused by seasonal respiratory pathogens. We conclude that adopting a program of routine employee screening may reduce LTCF resident mortality and morbidity, and may help prevent national health systems from being overwhelmed.