To the best of our knowledge, this is the first review of RACF COVID-19 outbreaks in Australia. We took advantage of all available outbreak data collected by WBPHU during 2022, which provided a clear overview of the RACF outbreaks associated with the three COVID-19 waves in Queensland to date.
The number and severity of RACF outbreaks generally reflected the extent of COVID-19 transmission within the community. (24) The overall attack rate of 26% for residents concurred with previous findings which established a pooled attack rate of 28%. (25–26) Furthermore, the lower case fatality rates in aged care during subsequent COVID-19 waves is also consistent with international literature, where the contribution of COVID-19 deaths from aged care to total mortality reduced in subsequent waves of the pandemic. (27–28) Previous studies have identified an association between facility size and COVID-19 attack rate, which was also replicated in our comparatively smaller sample. (29)
This review provides practical learning points for PHUs to support RACFs in future outbreaks. Most notably, it promotes the need for communication efficiency and regularity between RACFs and external stakeholders. While some RACFs notify the PHU of outbreaks early and provided daily updates via email and phone, delayed contact with facilities renders timely public health intervention a significant challenge. (30–31) Relationships between RACFs and PHUs have likely been strained throughout 2022, particularly when public health advice differed from facility outbreak guidelines. A goal for PHUs work towards rebuilding relationships with RACFs for ongoing engagement in not only COVID-19 outbreak management, but all communicable disease control and health promotion. (31)
Prompt case detection is imperative to prevent further spread, especially when exposed staff or residents may act as a conduit to further cases. prompt symptom monitoring is crucial and RACFs should remain vigilant following exposure as symptoms may develop up to 14 days following exposure. (32) While some literature has suggested the role of surveillance testing outside of outbreaks (33–34), this has limited efficacy to justify the time burden and staff testing protocols vary between facility. It is important RACFs understand what constitutes symptom monitoring, while also recognising the possibility of asymptomatic cases. (9, 19)
Aged care across Australia has a workforce deficit at baseline (35–36), so this is further exacerbated when large numbers of staff are furloughed due to COVID-19. (37) Reliance on agency staff is suboptimal for both staff transmission (38) and resident outcomes (39) but even this resource was limited during the peak of each COVID-19 wave, with multiple facilities facing concurrent staffing shortages. (40) While this is a systemic issue beyond the scope of PHUs (8, 41), it is crucial to remain mindful of both acute and chronic staffing concerns, given the implications it has on the feasibility of desired risk mitigation strategies.
Shared breaks among staff were another common occurrence among facilities, which posed the risk of further propagating transmission. During an active COVID-19 outbreak, staff should be encouraged to take breaks alone, to ensure their PPE remains in situ during all interactions within the facility. (42) The risk of staff infections has been shown as greater during an outbreak when compared to a COVID-19 ward, which may be in part associated with hand hygiene and PPE compliance (43). The attack rate is higher for staff who work closely with residents, such as personal care workers or nursing assistants, when compared to other healthcare workers. (44, 11) While PHUs often advise on the specific PPE required, there is clearly a need to encourage education on donning and doffing protocols, as well as reinforcing the importance of regular and adequate hand hygiene. (45, 16)
With cessation of the requirement for close contacts to isolate on the 28th of April 2022 (46), management of COVID-19 exposed residents and staff became a key responsibility of RACFs. Few RACFs had the resources to furlough close contact staff during their incubation period, with exposed staff largely required to attend work which thus posed a risk of internal transmission. RACFs who allocated staff to work within a single area were often able to prevent spread to multiple areas. (45, 16) Interestingly, some facilities have adopted staff cohorting as a permanent practice to effectively contain any COVID-19 transmission within limited sections of the facility.
Equally, cohorting exposed residents was another common strategy, although raises ethical concerns regarding the imposition of movement restrictions on liberty. Public health, especially communicable disease control, balances risk and benefit, so outbreak management must consider quality of life, freedom and in the context of circulating infections. (12, 13) Failure to recognise the utmost importance of resident social interaction can have a detrimental impact on elderly mental health, particularly if visitors are limited during outbreaks. (47) Consultation to identify those most at risk of social isolation and physical decline (48), COVID-19 safe methods to facilitate physical activity and implementing ‘lifestyle’ staff to engage with residents using appropriate precautions has been a novel and efficacious strategy to support wellbeing. (49)
Poor resident compliance with isolation and wandering behaviours propagates further transmission and a likely contributor to the frequency of outbreaks among dementia units. (38) Indeed, dementia is a risk factor for contracting COVID-19 due to impaired cognition and memory preventing adequate understanding of the outbreak. (14) This can result in poor compliance with recommended public health intervention, such as poor hand hygiene, social distancing, wandering and delayed recognition of symptoms. (50–53)
Strengths
The long timeframe covered in this study allows for a well-rounded analysis of barriers and enablers to outbreak management across multiple different time points and how these evolved with the different COVID-19 waves in Queensland.
Despite the context of this review situated in regional Queensland, there are no identified nuances of these outbreaks, and the findings are likely generalisable to other RACFs across Australia.
Limitations
As a retrospective review, the main limitation encountered was incomplete documentation. PHU documentation varied between clinical staff which resulted in some missing values across some themes. This review also only captures those outbreaks reported to the PHU and therefore any outbreaks that went unreported will be missed creating a reporting bias. While we initially planned to collect data on resident hospitalisation rates, complete records of this information for all RACFs were not readily available to the WBPHU. Initially all positive cases were referred to the COVID-19 virtual ward, however with the availability of antivirals on the Pharmaceutical Benefits Scheme (PBS), the majority of RACF residents now receive medical follow up through their regular general practitioner.
Vaccination status was only available during the third wave. While this review did not focus on vaccination data, it would be remiss to acknowledge its importance as an enabler of effective outbreak management. (26, 54) This is especially important for the elderly, who have a weaker vaccine response lending to breakthrough infections, as well as newer COVID-19 variants deemed to be capable of evading vaccine immunity. (54)
Moreover, the findings in this review are derived solely from a PHU perspective, without any external stakeholder consultation. Further research would be beneficial, with input from RACFs to assess if their perspectives corroborate these findings as important aspects of COVID-19 outbreak management.