gms | German Medical Science

Background: The COVID-19 pandemic has highlighted the need to be better prepared for future pandemics. Viral respiratory infections are considered the most likely pathogen to cause the next pandemic-like event. In these events, long-term care facilities (LTCFs) are at high risk: the care needs of residents require high levels of close personal contacts and the underlying health conditions increase the risk for adverse courses of disease. Non-pharmacological interventions (NPIs) are the primary defense mechanism when pharmacological interventions are not (yet) available. However, evidence on effectiveness and adverse consequences of NPIs implemented in LTCFs remain unclear.

Methods: We conducted a systematic review assessing the effectiveness of NPIs implemented in LTCFs to protect residents and staff from viral respiratory pathogens with pandemic potential. We searched the databases Medline, Embase, CINAHL, and two COVID-19 registries in September 2022. Two experienced researchers independently screened records and extracted data. We included (cluster) randomized controlled trials (cRCTs) and non-randomized observational studies of intervention effects (NRSIs). Included studies were appraised in duplicate using ROBINS-I and RoB2 tools. Primary outcomes encompassed number of outbreaks, infections, hospitalizations, and deaths. We synthesized findings narratively using vote-counting, focusing on the direction of effect. Certainty of evidence (CoE) was assessed using GRADE.

Results: We analyzed 13 observational studies and 3 cRCTs assessing intervention effectiveness and 2 NRSIs assessing adverse consequences. All studies were conducted in high-income countries, 15 focused on SARS-CoV-2. We found that multiple-component measures (combination of different measures) as well as improving hand hygiene can be effective in protecting LTCF residents and staff from infection-related outcomes (moderate CoE). Compartmentalization of staff in the LTCF, self-confinement of staff to prevent the introduction of the pathogen into the facility, and routine testing independent of symptoms, among others, may be effective in protecting LTCFs (low CoE). Other measures were found to be potentially effective, but the evidence was very uncertain (very low CoE): among others, restricting shared spaces, serving meals in room, cohorting infected and non-infected residents. Two studies assessed the impact of lockdown measures in combination with countermeasures against adverse consequences of these NPIs. Both found no significant adverse effect on mental health in the specific study context (low CoE). In an evidence gap map, we highlight areas with a lack of evidence on important interventions, including visiting restrictions, pre-entry testing, and air filtration.

Conclusions: We identified several measures which may be effective in protecting LTCFs in future pandemics due to respiratory-transmitted pathogens. While the certainty of evidence was low or very low for most interventions, the implementation of the NPIs identified as potentially effective may often be the sole viable option, particularly prior to the availability of PIs. While these NPIs may have adverse effects, we found that potential adverse effects especially on mental health may be mitigated through appropriate countermeasures. Our evidence-gap map highlighted several relevant evidence gaps regarding the effectiveness of measures underscoring the imperative for more reliable and robust empirical evidence. These gaps need to be addressed to prepare LTCFs for future pandemics.

The authors declare that they have no competing interests.

The authors declare that an ethics committee vote is not required.