LTCcovid Country Profiles

Responses to 1.14. Pandemic preparedness of the Long-term care sector

The LTCcovid International Living report is a “wiki-style” report addressing 68 questions on characteristics of Long-Term Care (LTC) systems, impacts of COVID-19 on LTC, measures adopted to mitigate these impacts and new reforms countries are adopting to address structural problems in LTC systems and to improved preparedness for future events. It was compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project moderated the entries and edited as needed. It was updated regularly until the end of 2022.

The report can be read by question/topic (below) or by country: COVID-19 and Long-Term Care country profiles.

To cite this report (please note the date in which it was consulted as the contents changes over time):

Comas-Herrera A, Marczak J, Byrd W, Lorenz-Dant K, Patel D, Pharoah D (eds.) and LTCcovid contributors.  (2022) LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science.

Copyright is with the LTCCovid and Care Policy and Evaluation Centre, LSE.



The Organisation for Economic Co-Operation and Development (OECD) found that, while most OECD countries had some form of emergency preparedness systems, many of these overlooked the Long-Term Care (LTC) sector. They also found that only just over 50% of OECD countries had guidelines on infection control in the Long-Term Care sector, prior to the pandemic. However, this has changed in response to the pandemic: in 2021, 84% of countries have national guidelines on infection control in LTC. (Source: Rocard E., Sillitti P. and Llena-Nozal A (2021) COVID-19 in long-term care: impact, policy responses and challenges. OECD Health Working Paper No. 131).


The LTC sector in the United States was unprepared for the pandemic; some reports have described it as disastrous and staggering. One key challenge during COVID-19 faced by the LTC sectors was the fundamental (mis)structuring of financial arrangements, which determine the reimbursement, regulatory framework, and design of the services delivered. These arrangements determine which sectors would have enough resources and systems in place (e.g. PPE, infection control training) to respond to the pandemic (source: Dawson et al., 2021; NYTimes).

Lessons on pandemic preparedness can be drawn from experiences from natural disasters, according to authors of a recent study (Peterson et al., 2021). This study explored the experiences of LTC facilities: Nursing Homes (NH) and Assisted Living Communities (ALCs) in Florida, following hurricane Irma in 2017. The findings showed that despite federal disaster preparedness regulations and experience with disasters like hurricanes, NHs and ALCs in Florida experienced issues that highlighted response gaps, highlighting that adequate preparedness goes beyond simply putting in place regulations. The study highlights the importance of lLTC organisations building and maintaining connections with those who can provide support, including relationships with emergency managers and community organisations.


Dawson, W. D., Boucher, N. A., Stone, R., & Van Houtven, C. H. (2021). COVID-19: The Time for Collaboration Between Long-Term Services and Supports, Health Care Systems, and Public Health Is Now. The Milbank Quarterly, 99(2), 565–594.

Peterson, L. J., Dobbs, D., June, J., Dosa, D. M., & Hyer, K. (2021). “You Just Forge Ahead”: The Continuing Challenges of Disaster Preparedness and Response in Long-Term Care. 5(4), 1–13.

Last updated: February 11th, 2022   Contributors: Daisy Pharoah  |  Joanna Marczak  |  

In a study analysing pandemic preparedness in the context of the 2009 influenza pandemic, researchers found that pandemic plans varied in detail, consistency, completeness, and usability depending on the state that issued it. Crisis communication and pharmaceutical interventions were completely missing in some states (Itzwerth et al., 2018).

Another study found that residential care staff reported issues with infection prevention and control strategies. It identified scepticism towards staff influenza vaccinations, effort required to read national guidelines, and lack of infrastructure to physically separate residents during an outbreak as the three main barriers to the management of outbreaks (Huhtinen et al., 2019)

Overall, the aged care sector in Australia struggled with pandemic preparedness even before COVID-19 – the pandemic only exposed the sector’s vulnerability (source: The Guardian).

In April 2020, the Aged Care Quality and Safety Commission contacted all aged care providers to complete an online self-assessment survey that asked about infection control systems and preparedness for a COVID-19 outbreak. 99.5% of providers claimed that their infection control and respiratory outbreak management plan covered all areas identified in the survey. The same proportion assessed their service’s readiness in the event of a COVID-19 outbreak as either satisfactory (56.8%) or best practice (42.7%). Interviews carried out for the Royal Commission found that, in hindsight, providers who experienced COVID-19 outbreaks did not think their previous self-assessments of preparedness were accurate (Royal Commission, 2020).


Huhtinen E., Quinn E., Hess et al. (2018) Brief Report. Understanding barriers to effective management of influenza outbreaks in residential care facilities. Australasian Journal on Ageing 38(1):60-63. doi: 10.1111/ajag.12595

Itzwerth R, Moa A, MacIntyre C.R. (2018) Australia’s influenza pandemic preparedness plans: an analysis. J Public Health Pol 38:111-124.

Royal Commission into Aged Care Quality and Safety (2020) Aged care and COVID-19: a special report. Commonwealth of Australia. 

Last updated: February 11th, 2022

In a 2020 report, MSF describe the situation in a nursing home in Belgium as a ‘real humanitarian crisis’. The organisation launched an emergency intervention in March 2020 in care homes in the capital city, and later in two other locations (Wallonia and Flanders). The intervention involved an initial inspection of the facilities, followed by recommendations tailored for each care home’s specific circumstances. Continued support was provided subsequently, for example through follow-up visits to train staff, if needed.

During the initial visits, a general lack of preparedness for this kind of emergency was reported by MSF: there was a lack of knowledge and understanding among staff of basic hygiene rules and protocols concerning the use of PPE and testing. Many care homes were expected to perform the duties of hospitals, but lacked the resources to do it – for example, many did not have ample masks and aprons. The reason for this poor preparedness, according to the report, was due to the complex health and social system in Belgium that is structurally underfunded and increasingly privatised. MSF reported that after their intervention, the country was in a better position to face subsequent waves of the pandemic (MSF, 2020).

Last updated: February 11th, 2022   Contributors: Daisy Pharoah  |  

A published practice paper presenting the chronology of events in Quebec leading to excess mortality in long-term care facilities (LTCFs) highlighted the lack of preparation in LTCFs and a critical shortage of staff. The massive transfer of older persons from hospitals to LTCFs, combined with human resources management, and a critical shortage of permanent staff before and during the crisis, generated unhealthy living conditions in LTCFs (Beaulieu et al. 2021).


Beaulieu, M., Cadieux Genesse, J., & St-Martin, K. (2021). High death rate of older persons from COVID-19 in Quebec (Canada) long-term care facilities: chronology and analysis. Journal of Adult Protection23(2), 110–115.

Last updated: February 11th, 2022   Contributors: William Byrd  |  

Information on pre-pandemic prepared in the LTC sector is lacking. However, in terms of Canadian pandemic preparedness for the general population, there is evidence that some lessons were learnt from SARS, which affected Canada more than any other country outside of Asia. While responses differed across provinces, funding for infection control in hospitals increased and legislative changes were made to allow for better collaboration between federal and provincial actors (source:

An independent review of the LTC response to COVID-19 was completed in October 2020 and released to the public in January 2021. The review provides a detailed analysis of the government’s and LTC sector’s preparedness. While quick policy decisions prevented further outbreaks in LTC facilities, the pandemic highlighted issues with staffing and Infection Prevention and Control (IPC) training (source:

Last updated: February 11th, 2022

The health sector was prioritized during the first wave of the pandemic, and therefore there were challenges early on with preventing infections and securing resources to protect care homes. Conversely, adequate measures in LTC facilities have been implemented later on (Rostgaard, 2020).


Rostgaard T. (2020), The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020.

Last updated: February 11th, 2022

Despite a robust Pandemic Preparedness plan in Finland, social welfare units (including care homes) were only briefly mentioned. It was reported that pandemic preparedness in Finland provided insufficient guidance on care of older people during crisis (Ylilnen et al., 2021).


Ylinen, T., Ylinen, V., Kalliomaa-Puha, L., Ylinen, S. (2021). ‘Finland: Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future’. MC Covid Working Paper, Retrieved at: CSIC_covid_FINLANDIA.pdf

Last updated: February 11th, 2022

Following the 2003 heatwave France had mandated the use of ‘blueprints’ in LTC facilities (and other healthcare settings) to prepare against extreme health events, and these were triggered in February 2020. However, many LTCFs did not have any ‘contingency plans’ which could provide operational support to significant pressures such as high levels of staff absence. Care homes and other LTC actors were not integrated into risk simulation exercises (source:, see also Rocard E., Sillitti P. and Llena-Nozal A (2021) COVID-19 in long-term care: impact, policy responses and challenges. OECD Health Working Paper No. 131).

Last updated: October 31st, 2021

Roles & responsibilities

Each of the 16 Länder carries responsibility for pandemic preparedness in their area. At the national level, the Robert Koch-Institute (RKI) takes a key role in infectious disease monitoring and prevention. The Institute also provides pandemic plans. A second federal authority with the task to reduce health related risks is the Federal Office for Civil Protection and Disaster Assistance.


As early as in 2013, the Federal Office for Civil Protection and Disaster Assistance already warned of the risk of a pandemic through a virus of the ‘virus family Coronaviridae’.


Tasked by the government, the RKI has maintained a regularly updated National Pandemic Plan for Influenza since the early 2000s. The pandemic plan includes consideration for residential LTC as well as advice on Personal Protection Equipment (PPE) stockpiling, vaccination and training of staff. This plan has been amended to respond to the COVID-19 pandemic in March 2020.


Despite this systemic preparedness, in practice there has been divergence in handling and applying infection prevention and control plans, the experience has shown that not all LTC settings had developed specific plans or not developed them in sufficient detail and that not all care workers, especially care assistants, had been sufficiently trained, and there has also been a shortage of PPE. The existing shortage in the care workforce posed additional challenges to the response during the pandemic (Lückenbach et al., 2021).

A paper reviewing the implications of the LTC sector due to COVID-19 established that the LTC sector was not adequately prepared for a crisis. It was highlighted that residential care settings that need to operate under economic principles have been particularly unprepared to manage crisis. Consequently, providers have been imposing strict measures to prevent blame and legal claims. The measures have severe implications on people’s self-determination and quality of life. It was also noted that closer interdisciplinary partnership could help to prepare LTC for crisis situations (Kricheldorff, 2020).

A survey conducted among care providers in April/May 2020 found that almost two thirds of care home staff were not specifically prepared for handling a pandemic during their apprenticeships, university degrees or training. Most surveyed institutions (90.7%) have run training on PPE. Among part-residential care settings almost 60% (n=96) stated that they had not been specifically prepared for a pandemic. More than half of these settings responded by setting up crisis teams. Two-thirds of domiciliary care providers surveyed did not report specific pandemic preparedness prior to COVID-19 (Wolf-Ostermann et al., 2020).


Kricheldorff, C. (2020) ‚Gesundheitsversorgung und Pflege für ältere Menschen in der Zukunft – Erkenntnisse aus der Corona-Pandemie’, Zeitschrift fur Gerontologie und Geriatrie53(8), 742–748.

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021. Available at: (Accessed 31 January 2022)

Wolf-Ostermann, K, Rothgang, H., Domhoff, D., Friedrich, A.-C., Heinze, F., Preuß, B., Schmidt, A.,  Seibert, K. & Stolle (2020) Zur Situation der Langzeitpflege in Deutschland während der Corona-Pandemie Ergebnisse einer Online-Befragung in Einrichtungen der (teil)stationären und ambulanten Langzeitpflege. Available at: (Accessed 5 February 2022).

Last updated: February 13th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

After the experience of the SARS epidemic in 2003, which resulted in the deaths of 72 care home residents, the Government published the first “Guidelines on Prevention of Communicable Diseases in Residential Care Homes for the Elderly” in 2004 and required all care home operators to designate an Infection Control Officer to coordinate and implement infection control measures (Lum et al., 2020)


Lum T., Shi C., Wong G. and Wong K. (2020) COVID-19 and Long-Term Care Policy for Older People in Hong Kong, Journal of Aging & Social Policy, 32:4-5, 373-379, DOI: 10.1080/08959420.2020.1773192

Last updated: February 11th, 2022

Preparedness for COVID-19 in Israel was limited, which led to considerable death toll particularly in residential care settings. A broad public outcry about the lack of testing and preparedness, as well as some contradictory directives (e.g. on visitation) ensued. On April 20th 2020, following pressure from family caregivers, and long term care managers and staff, new guidelines were established as part of the “Fathers’ and mothers’ shield” program, which specifically addressed older people in long term care settings (Tsadok-Rosenbluth et al. 2020).


Tsadok-Rosenbluth S, Leibner G, Hovav B, Horowitz G and Brammli-Greenberg S (2020). The impact of COVID-19 on people using and providing Long-Term Care in Israel. Report available at, International Long- Term Care Policy Network, CPEC-LSE, 4 May 2020. Retrieved from Article from

Last updated: February 11th, 2022   Contributors: LIAT AYALON  |  

Italy had formally updated the 2006 National Pandemic Plan for Influenza, only in late February 2020; leading to major shortcomings in the overall management of the COVID-19 outbreak.  The LTC sector was poorly prepared for the pandemic and it was not prioritised after the outbreak (in terms of Personal Protection Equipment and personnel), giving rise to multiple issues within services (high mortality rate, lack of coordination with hospitals, etc.).

The pandemic exacerbated pre-existing weaknesses within the Italian LTC sector, such as lack of coordination between and within care sectors; national and regional investments focused on acute care, neglecting LTC services; the poor management of care personnel and a lack of dedicated workforce; poor connection with other care settings and the functioning of nursing homes as acute care settings, that are neither recognised nor funded as that (Notarnicola et al., 2021).

There are indications of a large number of deaths that occurred in nursing homes during the first wave of the pandemic, and the weak capacity of public policy to provide adequate protection. The Lombardy Region had the highest mortality rate due to COVID-19 in nursing homes in Europe. Researchers argued that the negative impact of COVID-19 results from the poor development of LTC policy and from the marginality of residential institutions within the healthcare system (Arlotti et al., 2021).


Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI:

Arlotti, M., & Ranci, C. (2021). The Impact of COVID-19 on Nursing Homes in Italy: The Case of Lombardy. Journal of Aging and Social Policy33(4–5), 431–443.

Last updated: February 4th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  William Byrd  |  

Japan had well-established routine protocols of prevention and control in Long-Term Care Facilities (LTCFs). Each LTCF has a mandatory infection control committee which meets regularly. Practices such as isolating residents in LTCFs suspected to have a contagious infection, such as flu, were already in place before the COVID-19 pandemic. As soon as threat level was raised (as it would be for new TB outbreak or flu), LTCFs responded rapidly, as they were already familiar with protocols to isolate residents.

At the beginning of the pandemic in 2020 many LTCFs were in full or semi-lockdown already due to seasonal flu-outbreaks in January and February, this may have inadvertently helped protect care homes from COVID-19 outbreaks (Estevez-Abe and Ide, 2021)


Estévez-Abe M. and Ide H. (2021). “COVID-19 and Japan’s Long-Term Care System.”, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from:


Last updated: February 11th, 2022

The Netherlands had a national pandemic action plan in place as well as various obligations on hospitals and others to have disaster relief plans. However, these were seen as insufficient. It was also criticised that the government had ignored recommendations provided by experts following the 2014 Ebola outbreak and the 2018 influenza epidemic. The national plan had specific appendices for care and nursing homes (Bruquetas-Callejo and Böcker, 2021). Most Dutch Long-Term Care organisations have an Infection Prevention and Control committee (van Tol et al., 2021).


Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021

van Tol LS, Smaling HJA, Groothuijse JM, et al COVID-19 management in nursing homes by outbreak teams (MINUTES) — study description and data characteristics: a qualitative study 

Last updated: February 11th, 2022

The country was poorly prepared to deal with the pandemic, moreover, the shortfalls of the LTC system became more visible during the pandemic (e.g. limited financial resources for LTC system, poor access to tests, PPI, problems with isolating infected individuals (sources: Alert Zdrowotny 2; Alert Zdrowotny 3).

Last updated: December 16th, 2021   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

While Korea faced similar challenges as other countries in terms of initial shortages of PPE and staff, the memory of MERS facilitated a quick and decisive response from government. This prior experience of a pandemic left a legacy which enabled 1) a good level of societal buy-in with infection control measures (eg wearing facemasks); 2) legislation was already in place to allow for close monitoring of personal data.

Last updated: November 25th, 2021

Singapore took the threat of COVID-19 seriously early on and was able to draw on an already existing Disease Outbreak Response System framework, which had been refined based on the experiences from the Severe Acute Respiratory Syndrome (SARS) of 2003 and the H1N1 influenza pandemic of 2009 (Graham and Wong, 2020).

Following the 2003 outbreak, the government established 900 rapid response public health preparedness clinics (PHPCs) across the country, ear-marked for improved response to pandemics and outbreaks. The PHPCs serve as an intermediary between the community and hospitals, screening all patients with flu-like or pneumonia symptoms into low-risk and high-risk groups. The high risk group is referred to an infectious disease hospital for further assessment and management (Kuguyo et al., 2020).

Nursing homes in Singapore started to prepare for COVID-19 early. A case study of a large charitable nursing home’s measures shows that, as soon as news were reported from China, in January, the Nursing home’s Nursing Director and Infection Control Nurse started to work with staff to establish a command centre, setting up a screening counter, reviewing national pandemic guidelines and liaising with the Ministry of Health and the Agency for Integrated Care, and coordinating mask-fitting for all 400 staff (Goh et al., 2022)


Goh, H.S.; Tan, V.; Lee, C.-N.; Zhang, H.; Devi, M.K. (2022) Nursing Home’s Measures during the COVID-19 Pandemic: A Critical Reflection. Int. J. Environ. Res. Public Health 19, 75.

Graham, WCK, Wong, CH. (2020) Responding to COVID-19 in Residential Care: The Singapore Experience. LTCcovid country report, International Long-Term Care Policy Network, CPEC-LSE, 27 July 2020.

Kuguyo O., Kengne A.P., and Dandara C. (2020) Singapore COVID-19 Pandemic Response as a Successful Model Framework for Low-Resource Health Care Settings in Africa OMICS: A Journal of Integrative Biology.Aug 2020.470-478.

Last updated: February 11th, 2022

At the beginning of the COVID-19 pandemic, the protection of care home residents was a global priority. This included preparing clear and efficient action protocols, especially in the face of worsening scenarios.

However, in a study of the institutional and organisational management of the COVID-19 pandemic in Spanish care homes, Del Pino and colleagues identify lack of preparedness, as well as lack of protection resources, as key factors in the slow response. Consequently, the pandemic had especially serious and tragic effects for residents of nursing homes, especially during the first wave.

Prior to COVID-19, the Spanish Ministry of Health had developed a plan in response to Influenza (H5N1), which was used in 2009 during the H1N1 outbreak. There were also plans in place to respond to Ebola, Dengue and Zika, and one for MERS-CoV. The study found that people responsible for regional responses were not aware of these plans, potentially because they had not been in post for long.

None of the plans in place had any provision for interventions in care homes (or any other collective living establishments). Although, in principle, these establishments should form part of the “critical infrastructure”, as most people living in these centres have no other housing alternative.

The fact that Spain ranked very highly in the Global Health Security Index in 2019 may have generated over-confidence in the ability of the health care system to respond. This was compounded by the experience of having “over-prepared” for flu pandemics in the past. There was a lack of recognition of the increased risk COVID-19 posed to care home residents in particular, despite awareness of the impact of flu among the older population (source: DIGITAL.CSIC).

On December 2, 2020, the final report of the COVID-19 and residences working group was released. The report compiled the lessons learned in the field of residential care during the first wave of the pandemic, along with some of the work carried out in previous months in conjunction with the autonomous communities. These included:

  • A common framework for the application in the field of social services of the Early Response Plan (Annex I).
  • A common checklist for contingency plans (Annex II).
  • A compilation and systematization of the measures adopted to ensure socio-health coordination in the different autonomous territories (ANNEX III).
  • Proposal for the systematization of information and adaptation to the European Centre for Disease Prevention and Control (ECDC) (Annex IV).

The report highlighted the factors that helped increase the impact of Covid-19 in residential centres:

  • The pathogen SARS-CoV-2 and the disease COVID-19.
  • The residents of residential centres and their characteristics.
  • Infrastructure, activity and access to means of protection.
  • Care staff and human resources of residential centres.
  • The policies and strategies of isolation and confinement.
  • Intersectoral governance between different administrations.
  • Ageism, ethical dilemmas and legal problems.

The report also provided a table of available evidence, lessons learned and possible measures to help contain, mitigate or annul the above factors. This was compiled through the examination of action plans developed by all the autonomous communities. Many of these measures, if not all, had been adopted by the release of the report.

Improving the response to the pandemic in care homes, involves deciding where there is capacity to act immediately and in the medium term. This is combined with clearly identifying tasks, resources, timings and responsibilities.

It is crucial to learn from what happened in care homes in the first wave of the pandemic, and to implementing improvements. The resulting measures should be adopted in care homes and maintained in the long term, regardless of the efficacy of vaccines.

Last updated: July 4th, 2022   Contributors: Sara Ulla Díez  |  

The Swedish Corona Commission highlighted that there was no overview of preparedness to tackle the pandemic. Although protecting the older population was an objective from early on in the pandemic, little attention was given to the overall lack of preparedness in the municipal social care sector until much later on. One of the factors contributing to the spread of the disease has been the large proportion of untrained casual workers in the sector.

Last updated: February 10th, 2022

Contributors to the LTCcovid Living International Report, so far:

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica BreuerJorge Browne Salas, Jenni Burton, William Byrd, Sara CharlesworthAdelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin HämelNina Hemmings, David Henderson, Kathryn Hinsliff-Smith, Iva Holmerova, Stefania Ilinca, Hongsoo Kim, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, Martina Paulikova, Eleonora Perobelli, Daisy Pharoah, Stacey Rand, Tine Rostgaard, Olafur H. Samuelsson, Maximilien Salcher-Konrad, Benjamin Schlaepfer, Cheng Shi, Cassandra Simmons, Andrea E. SchmidtAgnieszka Sowa-Kofta, Wendy Taylor, Thordis Hulda Tomasdottir, Sharona Tsadok-Rosenbluth, Sara Ulla Diez, Lisa van Tol, Patrick Alexander Wachholz, Jae Yoon Yi, Jessica J. Yu

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.