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Summary: We reviewed all genomic epidemiology studies on COVID-19 in long-term care facilities (LTCFs) that had been published to date. We found that staff and residents were usually infected with identical, or near identical, SARS-CoV-2 genomes. Outbreaks usually involved one predominant cluster, and the same lineages persisted in LTCFs despite infection control measures. Outbreaks were most commonly due to single or few introductions followed by a spread rather than a series of seeding events from the community into LTCFs. The sequencing of samples taken consecutively from the same individuals at the same facilities showed the persistence of the same genome sequence, indicating that the sequencing technique was robust over time. When combined with local epidemiology, genomics allowed probable transmission sources to be better characterised. The transmission between LTCFs was detected in multiple studies. The mortality rate among residents was high in all facilities, regardless of the lineage. Bioinformatics methods were inadequate in a third of the studies reviewed, and reproducing the analyses was difficult because sequencing data were not available in many facilities.

Summary: Background: SARS-CoV-2 infection represents a major challenge for long-term care facilities (LTCFs) and many residents and staff are seropositive following persistent outbreaks. We aimed to investigate the association between the SARS-CoV-2 antibody status at baseline and subsequent infection in this population. Methods: We did a prospective cohort study of SARS-CoV-2 infection in staff (aged 65 years) at 100 LTCFs in England between Oct 1, 2020, and Feb 1, 2021. Blood samples were collected between June and November, 2020, at baseline, and 2 and 4 months thereafter and tested for IgG antibodies to SARS-CoV-2 nucleocapsid and spike proteins. PCR testing for SARS-CoV-2 was done weekly in staff and monthly in residents. Cox regression was used to estimate hazard ratios (HRs) of a PCR-positive test by baseline antibody status, adjusted for age and sex, and stratified by LTCF. Findings: 682 residents from 86 LCTFs and 1429 staff members from 97 LTCFs met study inclusion criteria. At baseline, IgG antibodies to nucleocapsid were detected in 226 (33%) of 682 residents and 408 (29%) of 1429 staff members. 93 (20%) of 456 residents who were antibody-negative at baseline had a PCR-positive test (infection rate 0·054 per month at risk) compared with four (2%) of 226 residents who were antibody-positive at baseline (0·007 per month at risk). 111 (11%) of 1021 staff members who were antibody-negative at baseline had PCR-positive tests (0·042 per month at risk) compared with ten (2%) of 408 staff members who were antibody-positive staff at baseline (0·009 per month at risk). The risk of PCR-positive infection was higher for residents who were antibody-negative at baseline than residents who were antibody-positive at baseline (adjusted HR [aHR] 0·15, 95% CI 0·05–0·44, p=0·0006), and the risk of a PCR-positive infection was also higher for staff who were antibody-negative at baseline compared with staff who were antibody-positive at baseline (aHR 0·39, 0·19–0·82; p=0·012). 12 of 14 reinfected participants had available data on symptoms, and 11 of these participants were symptomatic. Antibody titres to spike and nucleocapsid proteins were comparable in PCR-positive and PCR-negative cases. Interpretation: The presence of IgG antibodies to nucleocapsid protein was associated with substantially reduced risk of reinfection in staff and residents for up to 10 months after primary infection. Funding: UK Government Department of Health and Social Care.

Summary: Background: Outbreaks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have occurred in long-term care facilities (LTCFs) worldwide, but the reasons why some facilities are particularly vulnerable to outbreaks are poorly understood. We aimed to identify factors associated with SARS-CoV-2 infection and outbreaks among staff and residents in LTCFs. Methods: We did a national cross-sectional survey of all LTCFs providing dementia care or care to adults aged 65 years or older in England between May 26 and June 19, 2020. The survey collected data from managers of eligible LTCFs on LTCF characteristics, staffing factors, the use of disease control measures, and the number of confirmed cases of infection among staff and residents in each LTCF. Survey responses were linked to individual-level SARS-CoV-2 RT-PCR test results obtained through the national testing programme in England between April 30 and June 13, 2020. The primary outcome was the weighted period prevalence of confirmed SARS-CoV-2 infections in residents and staff reported via the survey. Multivariable logistic regression models were fitted to identify factors associated with infection in staff and residents, an outbreak (defined as at least one case of SARS-CoV-2 infection in a resident or staff member), and a large outbreak (defined as LTCFs with more than a third of the total number of residents and staff combined testing positive, or with >20 residents and staff combined testing positive) using data from the survey and from the linked survey–test dataset. Findings: 9081 eligible wLTCFs were identified, of which 5126 (56·4%) participated in the survey, providing data on 160 033 residents and 248 594 staff members. The weighted period prevalence of infection was 10·5% (95% CI 9·9–11·1) in residents and 3·8% (3·4–4·2) in staff members. 2724 (53·1%) LTCFs reported outbreaks, and 469 (9·1%) LTCFs reported large outbreaks. The odds of SARS-CoV-2 infection in residents (adjusted odds ratio [aOR] 0·80 [95% CI 0·75–0·86], p