LTCcovid Country Profiles

Responses to 1.13 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 is compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project are moderating the entries and editing as needed.

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, Pharoah D (eds.) and LTCcovid contributors. 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 health sector was prioritized first and therefore there were challenges early on with preventing infections and securing resources to protect care homes, however, the characteristics of the care system seem to have supported the implementations of measures later on (source:

Last updated: January 6th, 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 (source:

Last updated: January 6th, 2022

Each of the 16 Federal States carries responsibility for the pandemic in their area. On a national level, the Robert Koch-Institute (RKI) takes a key role in infectious disease monitoring and prevention. The Institute also provides pandemic plans. 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 PPE stockpiling, vaccination and training of staff. This plan has been amended to respond to the COVID-19 pandemic in March 2020. 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, it already warned of the risk of a pandemic through a virus of the ‘virus family Coronaviridae’. Despite this systemic preparedness, in practice there has been divergence in handling and applying hygiene plans, the experience that not all LTC settings had developed specific plans or not developed them in sufficient detail and that not all care workers, especially assistants, had not been sufficiently trained as well as a shortage of protective equipment. The existing shortage in the care workforce posed additional challenge to the response during the pandemic. While the government has taken some measures to increase the attractiveness of working in the LTC sector and the quality of care provided, more needs to be done (source:

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 (source:

A survey conducted among care providers in April/May 2020 found that almost two thirds of care home 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 institutions that did not have training the proportion of those that have been more severely affected by outbreaks was higher. 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 (source:

Last updated: January 6th, 2022

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 (source:

Last updated: January 6th, 2022

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 (sources:;

Last updated: January 6th, 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 (source:–/view).

Most Dutch Long-Term Care organisations have an Infection Prevention and Control committee (van Tol et al., 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: January 6th, 2022

Singapore drew many lessons from the SARS-CoV outbreak of 2002, which exposed the ill-preparedness of the country to deal with pandemics. Following the 2002 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 (

Last updated: January 6th, 2022

The LTC sector in the United States was unprepared for the pandemic; some reports have described it as disastrous and staggering. One key systemic 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 in the midst of 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 long-term care facilities – Nursing Homes (NH) and Assisted Living Communities (ALCs) – in Florida, following hurricane Irma in 2017. The findings showed that like pandemics, natural disasters create disruptions at organisational, community, and societal levels. Despite federal disaster preparedness regulations and ample experience with disasters like hurricane Irma, NHs and ALCs in Florida experienced issues that highlighted response gaps, illustrating that adequate preparedness goes beyond simply establishing regulations. The study highlights the importance of long-term care organisations building and maintaining connections with all those who can provide support, beyond the residents and facilities in which they live. This includes relatinonships with emergency managers, stakeholders, and – importantly – 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: January 6th, 2022   Contributors: Daisy Pharoah  |  Joanna Marczak  |  

In a study analysing pandemic preparedness in 2009, 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.

Another study published in 2018 found issues with infection prevention and control strategies and cited 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.

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%). This survey suggests that providers believed that they were more prepared than they were. The commission also found that most providers required further Infection Prevention and Control (IPC) and PPE training throughout the pandemic (sources: Aged Care and COVID-19 report; ACQSC).

Last updated: December 22nd, 2021

Among the ten Canadian provinces, Quebec has experienced the most significant excess mortality of older persons during COVID-19. A published practice paper presents the chronology of events leading to this excess mortality in long-term care facilities (LTCFs) and a comprehensive analysis of the phenomenon. Two findings emerge: 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, 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: November 30th, 2021   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. Data availability presents a key challenge in managing pandemic, for example, lack of baseline data made it difficult to calculate excess staffing needs and costs during COVID-19 (source:

Last updated: November 6th, 2021

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

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.


Last updated: December 5th, 2021   Contributors: LIAT AYALON  |  

Italy had only formally updated the 2006 National Pandemic Plan for Influenza, causing major shortcomings in the overall management of the COVID-19 outbreak in late February 2020.

The LTC sector was poorly prepared to 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, namely: absence 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.

A published article focuses on the 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 them with adequate protection. The analysis focuses on the case of the Lombardy Region, where the mortality rate due to COVID-19 in nursing homes was the highest in Europe. In the search for possible causes, they investigate the situation of such facilities before the pandemic. Two aspects are analysed: their institutional embeddedness and recent trends in their management. They conclude by arguing that the negative impact of COVID-19 stems from the poor development of long-term care policy and from the marginality of residential institutions within the healthcare system.


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: December 4th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  William Byrd  |  

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

In a study of the institutional and organisational management of the COVID-19 pandemic in care homes, Del Pino and colleagues identify lack of preparedness in care homes, as well as lack of protection resources, as key factors in the slow response. Prior to COVID-19, the Spanish Ministry of Health had a plan in place that had developed to respond 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 those 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 infrastructures”, as for most people living in these centres there is no other housing alternative and these centres are needed to maintain basic social, health and wellbeing of the people living there. 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, coupled with the experience of having “over-prepared” for the flu pandemic in the past. There was a lack of recognition of the increased risk this virus posed to care home residents in particular, despite awareness of the impact of flu among the older population (source: DIGITAL.CSIC).

Last updated: November 23rd, 2021

Overall, the Corona Commission highlighted that there was no overview of preparedness to tackle the pandemic, protecting the older population was a stated objective from the beginning, but there was no attention to the lack of preparedness and shortcomings in the municipal social care sector until later. The large proportion of casual and untrained care workers in the social care sector has been seen as contributing to the spreading of the disease (source:

Last updated: November 23rd, 2021

Contributors to the LTCcovid Living International Report, so far:

this list is regularly updated to reflect contributions to the report, if you’d like to contribute please email

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Jorge 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, Stefania Ilinca, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, 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, 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.