LTCcovid Country Profiles
Responses to 3.08. Access to testing and contact tracing for people who use and provide Long-Term Care
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. https://doi.org/10.21953/lse.mlre15e0u6s6
Copyright is with the LTCCovid and Care Policy and Evaluation Centre, LSE.
There has sufficient access to COVID-19 tests – testing has been available for all residents and staff in aged care facilities. Testing is typically only done if an individual shows symptoms or is suspected of having COVID-19. Regular testing for all staff and residents has not been introduced (source: DoH).
Last updated: December 22nd, 2021
By 16 April 2020, the Austrian government had announced plans that staff and residents in care homes should be systematically tested. A paper reports some reluctance in the implementation of testing in LTC services, especially in community care. However, it was also reported that residents ‘were scarcely tested’ up to January 2021 and that communication of test results did not always happen in good time (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).
By November 2020, care home staff had to undergo compulsory testing on a weekly basis, but regulation allowed staff to continue working following a positive test if they do not show symptoms, their Ct value is above 30 and they ware an FFP2 mask (https://ltccovid.org/2020/11/27/the-second-wave-has-hit-austria-harder-also-in-care-homes/).
Last updated: September 8th, 2021
For vaccinated residents with symptoms, only a PCR test can be used to detect a possible infection. An antigen rapid test can only be used for non-vaccinated symptomatic residents (symptom duration of maximum five days) and for residents with symptoms just after the first vaccination (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).
Last updated: November 2nd, 2021
In care homes: Initially testing was only completed for symptomatic staff and patients, those experiencing “influenza-like illness (ILI) or respiratory symptoms, clients with fever without known cause, and clients experiencing other symptoms possibly due to COVID-19”. Contact tracing was completed by both public health authorities and the LTC facility itself. Residents who share rooms with the infected resident should be considered as exposed and should be monitored for symptoms at least twice a day for 14 days from last date of exposure (http://www.bccdc.ca/Health-Info-Site/Documents/COVID19_LongTermCareAssistedLiving.pdf). Staff wearing all appropriate PPE are not considered a close contact of a patient who tests positive (http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/testing-and-case-management-for-healthcare-workers).
Last updated: November 6th, 2021
The general strategies for testing have changed a number of times in Denmark, leading to some criticism for lack of transparency or evidence-based practice. The initial test strategy, introduced in early March, was aimed at preventing the disease from spreading, a so-called confinement strategy. This took place by testing persons who might have been exposed to the disease, even if they did not have symptoms. These were typically persons who were exposed during travelling (source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).
As of March 15th, the strategy changed to a mitigation strategy, targeting test measures to alleviate the consequences of the disease. Now only persons with symptoms were tested and following a referral from the GP. This led to concerns being raised such as from the WHO, which generally advised a more aggressive testing strategy. Nationally it sparked a debate that the new test strategy was a pragmatic and not a health-based decision, mainly due to a lack of testing equipment (source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).
Since 27 April 2020, residents and staff without symptoms could also be tested if there was an outbreak in the nursing home. Testing must take place at the nursing home and not in the regional test centres, which are set up in tents (source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).
On May 12th, a new and more aggressive testing strategy was introduced, where persons without symptoms were also tested. The capacity was set to 20,000 persons on a daily basis and the ambition was to increase this number over time. This would make Denmark a country with one of the highest number of tests per inhabitants. There were two tracks in the new strategy:
– A health track, which includes testing of persons with symptoms, as well as employees of hospitals and nursing homes and patients admitted to hospital, even if they do not have symptoms. The test took place at regional hospitals. The capacity for this track was 10,000 daily tests.
– A societal track, which included testing of persons without symptoms. Testing took place in 16 specially set-up tents around the country, some of them with a drive-in facility. The capacity was for an additional 10,000 daily tests. Initially, only those aged 18- 25 years old could asked to be tested. This included around 600,000 persons and 4,500 persons were tested during the first day. During the first week, other age groups were included and, as of 25th May, there were no age limitations. (source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).
Staff, working in the health and elder sector and some parts of the social sector, should be tested twice a week if they are not fully vaccinated. It is essential to implement a systematic, regular solution, which is easily accessible for the staff to secure comprehensive support from the personnel. Fully vaccinated staff can refrain from being tested regularly. This also applies to staff working in nursing homes, assisted living facilities, respite care, and social institutions, and in hospitals and the home care sector. Unvaccinated staff should still be tested regularly (source: https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).
In case of a discovery of a COVID-19 infection among a resident or an employee, all residents, if possible, should be tested within a day after contact with someone infected with COVID-19. The test is then repeated for the residents who are not fully vaccinated, every 7 days, until there are no more instances of COVID-19 at the institution. Personnel, including temporary staff and cleaning staff have to get tested even if they have no knowledge of being in contact with the person concerned and are fully vaccinated. The test must be taken as quickly as possible. Preferably within a day after they have received information, they must get tested. The test must be repeated every days for the personnel who are not fully vaccinated until there are no more outbreaks at the institution. It is a case of extra testing on the basis of caution, and the test does not require self-isolation for the staff member/s who can work while they wait on their test results (source: https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).
Last updated: May 25th, 2023
Access to testing in Finland was at first relatively restricted and has been steadily increasing. Nearly 3.2 million tests for COVID-19 have been conducted as of February 21st, 2021, but the increase in access to test only began in late July 2020 (https://experience.arcgis.com/experience/92e9bb33fac744c9a084381fc35aa3c7).
Last updated: September 8th, 2021
As with guidance, the sector decried that testing for care homes and in the community was made widely available too late – guidance published on 21st March 2020 limited tests only to symptomatic older people. Changes were made in April to grant priority access to testing for care home workers and residents, to test and isolate the first symptomatic care home worker (leading to isolation of all workers) and the first symptomatic older person, and the following three. On 20th April 2020 pressure was raised to extend tests beyond the first three residents as many asymptomatic cases were missed (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). It was only from 6th May that all contacts of symptomatic cases were tested (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). It is unclear how much testing was allowed for domiciliary care workers.
Last updated: September 8th, 2021
The German Federal Ministry of Health has put in place a national testing strategy. Testing is to be provided and paid for by the sickness funds for people with COVID-19 related symptoms, people without symptoms but close contact to a person infected with COVID-19, people in shared social spaces (e.g. schools, day care centres, refugee centres, prisons) if a positive case has been recorded, staff, patients/residents in residential care settings/hospitals following an outbreak, patients/residents before (re)-entering residential or ambulatory care and staff of health and long-term care setting. Some groups/circumstances are only eligible for rapid tests. (https://www.bundesgesundheitsministerium.de/coronatest.html).
Rules vary between federal states, but LTC staff working in residential or domiciliary care settings have to be tested regularly (https://pflegenetzwerk-deutschland.de/fileadmin/files/Corona/210317-Uebersicht-Testfrequenzen-Laender.pdf).
Health authorities are responsible for contact tracing. Earlier in the pandemic teams were expanded to at least 5 people per 20,000 residents. In addition, affected areas received support from additional teams as well as the armed forces. An app was also been issued to facilitate contact tracing. However, rates have been consistently too high to ensure that contact tracing can be done consistently. It is estimated that all contacts can be traced again when a seven-day incidence of 50 new infections per 100,000 people or below is reached again. The federal government is supporting the individual states (https://www.bundesregierung.de/breg-de/aktuelles/bund-laender-beschluss-1841048; https://www.bundesregierung.de/breg-de/aktuelles/bund-laender-beschluss-1744224 ). A new open-source software was due to be issued to local health authorities, however, so far this software does not offer all promised features and has not been consistently taken up by all health authorities. Other associated costs will be covered by the federal ministry of health (https://www.aerztezeitung.de/Politik/Warum-die-einheitliche-Corona-Kontaktnachverfolgung-holpert-416538.html).
Robert Koch Institute guidelines recommend that contact tracing in residential care settings should be prioritised. The guidelines outline the different levels of contacts and outline responsibilities of the health authority (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Kontaktperson/Management.htm; https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFilel).
Two-third of care homes surveyed as part of a study conducted in April/May had implemented clinical monitoring and found that it took on average between 3 and 4 days for care workers and people who use LTC to learn the results of their COVID-19 test (https://www.uni-bremen.de/fileadmin/user_upload/fachbereiche/fb11/Aktuelles/Corona/Ergebnisbericht_Coronabefragung_Uni-Bremen_24062020.pdf).
Last updated: September 8th, 2021
From late March 2020, staff and residents of nursing homes were among the groups prioritised for testing. ‘Assessment and testing pathways’ for residents showing symptoms of COVID-19 in residential care settings were issues by the Health Service Executive. By early April, it was recommended that care home staff should be screened twice a day, and that staff should be prioritised for testing (https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).
Last updated: November 2nd, 2021
Access to testing in Israel was considered slow in Spring 2020, and ramped up by summer with the promise of 20 million tests by the end of 2020.
The national task force for managing the pandemic in the LTCFs (‘The Fathers and Mothers Shield’) changed the testing policy in early May 2020 from testing symptomatic staff and residents to regular screening regardless of known COVID-19 presence. Numbers gathered from these screenings were deemed key figures in determining potential outbreaks, and rates of illness decreased dramatically (and proportionally with the nationwide numbers) by early June 2020.
Last updated: December 5th, 2021 Contributors: Shoshana Lauter |
During the first wave in 2020, testing was not available for Long Term Care Facilities (LTCFs) and this has been considered as one of the main causes of the high mortality rate registered in LTCFs in the first months of 2020. From the second wave onwards, regional guidelines have been implemented that give LTCFs preferential access to testing.
Japan did not pursue a policy of mass testing, instead focusing on the 3Cs (closed space, crowded places, close contacts (https://www.mhlw.go.jp/content/3CS.pdf) and pursuing rigorous retrospective tracing) (https://thediplomat.com/2020/06/japans-pragmatic-approach-to-covid-19-testing/).
Last updated: September 8th, 2021
Access to testing was limited in the beginning of the pandemic and restrictive policies prevented access to testing for care homes. Testing capacity was limited and restrictions lasted until June. 2020. A new testing policy announced on 6th April 2020 allowed all healthcare workers (including LTC staff) to get tested when they developed symptoms (https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf).
Criteria for testing have been broadened over time but testing capacity remained a challenge (https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).
Last updated: September 8th, 2021
South Korea is notable for the speed of their drive to mass test, as early as February/March 2020. The government built hundreds of high-capacity screening clinics and worked closely with the private sector to ensure an adequate supply of tests. This enabled early testing of care home residents and staff. In March 2020, at one care home in Daegu, more than 70 patients and employees tested positive for the contagious disease, including 17 staff (https://world.kbs.co.kr/service/news_view.htm?lang=e&Seq_Code=152108). Diagnostic tests were conducted for 460 inpatients in LTCHs who were being treated for unknown pneumonia, as early as 5th March 2020. According to the Korean Convalescent (long-term care). In October authorities focused COVID-19 testing on all employees and patients of long-term care hospitals, mental health care providers and care homes located in the wider capital area, totalling around 160-thousand people (http://world.kbs.co.kr/service/news_view.htm?lang=e&id=Dm&Seq_Code=156889).
Regarding ‘healthcare workers’ operating across various settings including long-term care centres, there were clusters of outbreaks in Daegu within long term care centres. The government tasked health officials with conducting universal Covid-19 tests by RT-PCR for everyone in those facilities. Confirmed Covid-19 patients were transferred to a designated Covid-19 hospital or a community treatment centre. These centres with outbreaks were reinspected regularly. (https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0159).
The central and local governments respond to infected cases rapidly by tracing each case and isolating contacts. For the epidemiological survey, interviews are conducted with patients, families, and also healthcare workers, if necessary more objective data including medical records, mobile GPS, CCTV, credit card records, etc., may be collected and verified. Information about the travel routes of infected cases is provided on a website run by the government, in which no information that can identify a person is provided.” (https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).
Last updated: September 8th, 2021
In April 2020 Singapore started routine testing of residents who showed COVID-19 relevant symptoms. At the end of April 2020 routine testing of all staff and residents began. Testing and follow-up treatment for those with positive results identified through this surveillance mechanism were provided for free by the government.
In addition, the Ministry of Health and the Agency for Integrated Care have ‘worked with the regional hospitals to train nurses in care facilities and nurses in three home care providers in testing and to support the development of ‘mass swabbing workflows’. The Agency for Integrated Care took on the coordination of sending the samples to the National Public Health Laboratory (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
Last updated: November 2nd, 2021
The Corona Commission and other reports elaborate on shortcomings in testing strategy, particularly a scarcity of testing kits at the beginning of the pandemic. During the peak of the first wave in April, care home residents, homecare users and eldercare staff were not prioritized for testing. The Swedish Public Health Agency’s testing strategy was initially focused on active infection tracing, from mid-March patients who came to the hospital were tested first, followed by hospital employees, and those with community-leading occupations, followed by social care staff. Municipalities and social care providers could buy tests from private companies to test social care staff and service users. However, it was not until June 2020 when the government advocated increased testing activities and promised to cover the costs. The Swedish Public Health Agency was criticised for not giving clear signals earlier to the regions to increase the testing rate and although the agency pointed out that it did not want to overburden the healthcare system, it admitted that testing of, for example, staff in long-term care should have been started earlier. Overall, by the time of the second wave tests are widely available e.g. citizens can test themselves with home test kits delivered to their doors
Last updated: November 23rd, 2021
Limitations on testing capacity meant that the initial workforce testing strategy focused on NHS workers with symptoms. This was extended to social care workers (with symptoms) from April 15, 2020, and on April 28, a policy of one-off whole home testing was announced for all staff and residents of care homes with residents over 65 or with dementia. An online portal was launched on May 11 to help care homes arrange deliveries of test kits.
Although testing capacity was increasing, this was not without problems. The BBC reported that on April 22, 159 out of 210 care providers contacted about testing reported that none of their staff had received a test. On May 12, the Guardian reported that care home operators accused the government of “a complete system failure” regarding the promised testing in care homes. According to this article, only tens of thousands had been tested so far, leaving many vulnerable people at risk. Different government agencies were accused of passing responsibilities to each other. A survey of 43 English care home managers, which was conducted at the end of May and early June 2020, found that only 40% had accessed testing of asymptomatic residents and 50% of asymptomatic staff. At that time, only 36% of residents had been tested, with many describing a chaotic and poorly co-ordinated service, and only 10% of care homes surveyed had successfully tested all residents in their care home (Rajan et al. 2020).
On June 8, 2020, the Government announced that all remaining adult care homes would be able to access whole care home testing for all residents and asymptomatic staff through the digital portal, including adult care homes catering for adults with intellectual disabilities or mental health issues, physical disabilities, acquired brain injuries, and other categories for younger adults under 65 years old. It should be noted that these ‘whole care home’ testing arrangements do not apply to supported living settings, extra-care settings, and domiciliary care. In these situations, individual tests can be applied for through self-referral. From 3 July, care home staff were promised weekly testing, but domiciliary care staff were still only eligible for free testing if symptomatic, as the general population.
In light of advice from the Government’s Scientific Advisory Group for Emergencies (SAGE) and results from the Vivaldi 1 study, regular retesting of staff and residents in care homes for over 65s and those with dementia was announced to be implemented from early July. The Times reported that this had been delayed until September, with promises of new rapid point of care tests, although these had yet to be formally approved and questions remained about the most suitable and safe tests for such a vulnerable setting.
On December 23, the Department of Health and Social Care (DHSC) announced £149 million to support the rollout of Lateral Flow Device (LFD) testing in care homes. Local authorities should pass on 80% of this to care homes on a per bed basis, which must be within the local geographical area. The other 20% should be used to support care providers to implement increased LFD testing, allocated at the discretion of the local authority. Care homes currently have access to 3 tests per week for their staff, with daily testing for 7 days in the event of a positive case. Care homes will have additional LFDs to test individuals working in more than one setting before the start of every shift.
On February 16, 2021, DHSC published guidance announcing that weekly COVID-19 testing is to be made available to personal assistants working in adult social care in England. After testing positive, a person does not need to test again for 90 days unless they become symptomatic. This guidance gives personal assistants responsibility for informing their employers if they receive a positive result.
On January 17, 2021, DHSC announced a £120 million Workforce Capacity Fund to help local authorities to boost staffing levels, so that safe and continuous care is achieved by all providers of adult social care. If the specific way in which staff capacity is strengthened means that they do not have access to routine asymptomatic testing or LFD testing, then it is suggested that the local authority could use their allocation of LFD tests for routine testing.
On March 5, DHSC published guidance on LFD testing in adult social care settings. This stipulated that it is necessary to obtain consent before residents and staff are tested and their results shared. If a person receives a positive result from a LFD, then they will need to take a confirmatory PCR test and immediately self-isolate. With a negative test, the person can stop self-isolating but must continue to follow national and local rules and guidelines.
On March 12, Nuffield Trust released analysis explaining that there was no mention of social care in the budget announced by the Chancellor. Short-term emergency support in the form of the Rapid Testing Fund was crucial in enabling safe visits to occur in care homes, which is due to expire at the end of March.
On March 18, LaingBuisson announced that an extra £341 million was to be provided to support adult social care with the costs of infection prevention control and testing so that visits can be carried out safely. This commitment was for a three-month period. There was no mention of an extension to the Workforce Capacity Fund.
Published on November 3, the Adult social care: COVID-19 winter plan 2021 to 2022 sets out the key elements of national support available for the social care sector for winter 2021 to 2022. A further £388.3 million in further funding to support IPC, testing and vaccination uptake in adult social care settings will be provided. Regular asymptomatic COVID-19 testing will be maintained throughout winter for all staff and unpaid carers in adult social care, as well as more intense testing regimes in settings deemed higher risk, in line with clinical advice. Additionally, £126.3 million will be provided to continue to support the sector to deliver COVID-19 testing from October 2021 to the end of March 2022.
Access to testing: impact on mental health
Nyashanu et al. (2020) collected data through interviews with forty healthcare workers from nursing homes (n = 20) and domiciliary care agencies (n = 20) in the English Midlands in the early phase of the pandemic (before May 2020) to explore triggers of mental health problems. Participants reported experiencing distress and anxiety caused by unreliable testing and delayed or false results. Delayed results meant that healthcare workers who had been tested were delayed in their return to work, which led to further staff shortages – another cause of stress.
Nyashanu, M., Pfende, F., & Ekpenyong, M. S. (2020). Triggers of mental health problems among frontline healthcare workers during the COVID-19 pandemic in private care homes and domiciliary care agencies: Lived experiences of care workers in the Midlands region, UK. Health & Social Care in the Community. https://doi.org/10.1111/HSC.13204
Rajan, S., Comas-Herrera, A. and Mckee, M., 2020. Did the UK Government Really Throw a Protective Ring Around Care Homes in the COVID-19 Pandemic?. Journal of Long-Term Care, (2020), pp.185–195. DOI: http://doi.org/10.31389/jltc.53
Contributors to the LTCcovid Living International Report, so far:
Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica Breuer, Jorge Browne Salas, Jenni Burton, William Byrd, Sara Charlesworth, Adelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin Hämel, Nina 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’Donovan, Camille 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. Schmidt, Agnieszka 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.