Transmission, control, and mortality of infectious diseases in vulnerable populations: norovirus and SARS-CoV-2 in long-term care facilities and the wider community Pubblico
Adams, Carly (Spring 2022)
Abstract
The burden of norovirus and COVID-19 in long-term care facilities (LTCFs) is substantial, and the COVID-19 pandemic is an urgent threat to public health in both LTCFs and the wider community. This research aimed to inform data-driven norovirus and COVID-19 outbreak prevention and control in LTCFs, and to examine trends in COVID-19 case fatality in the general population.
In Aim 1, we conducted a systematic review and meta-analysis to assess associations between norovirus outbreak control measures and outbreak outcomes in hospitals and LTCFs globally. We used regression analyses stratified by setting (hospital/LTCF) to compare the size and duration of outbreaks in which control measures were reported to be implemented to those in which they were not. Control measures were associated with smaller and shorter outbreaks in hospitals but larger and longer outbreaks in LTCFs. In LTCFs, control measures were likely implemented in response to larger and longer outbreaks, rather than causing them.
In Aim 2, we examined SARS-CoV-2 transmission in Fulton County, Georgia LTCFs from March 2020 to September 2021. We estimated the time-varying reproduction number, R(t), and used linear mixed regression models to examine its association with LTCF role (resident or staff) and vaccination status. Transmission declined rapidly after vaccines were first distributed to LTCFs (December 2020) and remained low until September 2021. Staff-cases were substantially more infectious than resident-cases. Results suggest that infection prevention and control measures improved over time, and that staff are driving SARS-CoV-2 transmission in LTCFs.
In Aim 3, we used multivariable logistic regression, adjusted for age and other individual-level characteristics, to examine associations between report month and mortality among COVID-19 cases in Georgia from March 2, 2020 to March 31, 2021. After adjusting for factors associated with COVID-19 death, we observed lower mortality risk from November 2020 to March 2021 compared to August 2020, suggesting that improved clinical management may have contributed to improved survival.
Through this research, we can inform data-driven guidelines for the prevention and control of norovirus and COVID-19 outbreaks in LTCFs. Moreover, we can gain a better understanding of COVID-19 mortality risk among cases in the general population.
Table of Contents
Chapter 1: Background 1
1.1 Infectious disease outbreaks in long-term care facilities 1
1.2 Norovirus outbreaks in long-term care facilities 2
1.3 The COVID-19 pandemic 4
1.3.1 COVID-19 in long-term care facilities 6
1.3.2 The time-varying reproduction number, R(t) 9
1.3.3 COVID-19 mortality in the general population 13
1.4 Summary 15
Chapter 2: Study rationale and specific aims 16
2.1 Study rationale 16
2.2 Specific aims overview 17
Chapter 3: Data sources 21
3.1 Published outbreak reports 21
3.2 GDPH COVID-19 surveillance data 21
3.2.1 COVID-19 Surveillance Dataset 22
3.2.2 COVID-19 Facility Dataset 24
3.2.3 COVID-19 Vaccine Breakthrough Dashboard Dataset 24
3.2.4 COVID-19 Testing Dataset 25
3.3 Publicly available data 25
3.3.1 COVID-19 Reported Patient Impact and Hospital Capacity by State Timeseries dataset 25
3.3.2 U.S. Census Bureau dataset 26
Chapter 4: Aim 1 – Norovirus control measures in healthcare settings 27
4.1 Abstract 27
4.2 Background 28
4.3 Methods 30
4.3.1 Systematic Review 30
4.3.2 Meta-analysis 33
4.4 Results 39
4.4.1 Systematic Review 39
4.4.2 Meta-analysis 44
4.5 Discussion 52
4.6 Conclusions 57
4.7 Supplementary File 58
Chapter 5: Aim 2 – SARS-CoV-2 transmission in long-term care facilities 83
5.1 Abstract 83
5.2 Background 84
5.3 Methods 85
5.3.1 Data 85
5.3.2 Cases and outbreak characteristics 87
5.3.3 Time periods examined 88
5.3.4 SARS-CoV-2 transmissibility 89
5.4 Results 92
5.4.1 Case and outbreak characteristics 92
5.4.2 Time-varying reproduction number and R(t) 99
5.4.3 Associations between case characteristics and R(t) 99
5.5 Discussion 103
5.6 Conclusions 106
5.7 Acknowledgements 106
5.8 Supplementary File 108
Chapter 6: Aim 3 – Trends in COVID-19 case-fatality in Georgia, USA 127
6.1 Abstract 127
6.2 Background 128
6.3 Methods 129
6.3.1 Data description 129
6.3.2 Risk factors for COVID-19 death: all cases 130
6.3.3 Risk factors for COVID-19 death: hospitalized cases 131
6.4 Results 132
6.4.1 Risk factors for COVID-19 death: all cases 141
6.4.2 Risk factors for COVID-19 death: hospitalized cases 146
6.4.3 Evidence for interactions: all cases and hospitalized cases 147
6.5 Discussion 147
6.6 Conclusions 151
6.7 Declarations 151
6.8 Supplementary File 153
Chapter 7: Conclusions and Public Health Implications 181
7.1 Overview 181
7.2 Contributions of each specific aim 181
7.2.1 Aim 1 – Norovirus control measures in healthcare settings 181
7.2.2 Aim 2 – SARS-CoV-2 transmission in long-term care facilities 184
7.2.3 Aim 3 – Trends in COVID-19 case-fatality in the general population 185
7.3 Reflections 188
7.4 Summary 190
Chapter 9. References 191
Chapter 10. Appendix 224
10.1 Abbreviations 224
10.2 Publications, presentations, and funding-related activities 226
10.2.1 Peer Reviewed Publications 226
10.2.3 Presentations 227
10.2.4 Grants 228
About this Dissertation
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