Abstract

The COVID-19 pandemic poses difficulties for long-term care institutions for the elderly, with increased mortality rates for the residents. This study aims to estimate the impact of COVID-19 on mortality of institutionalized elderly in Brazil. Estimates of the percentage of elderly deaths occurring in care homes were calculated for Brazil, States and Regions using estimates for the total number of deaths. The estimation was based upon information available for other countries. The weighted percentage was 44.7% and 107,538 COVID-19 deaths were estimated for the elderly in these institutions in Brazil in 2020. Higher numbers of deaths were expected in the Southeast Region (48,779 deaths), followed by the Northeast Region (28,451 deaths); São Paulo was the most affected State (24,500 deaths). The strong impact of COVID-19 on the elderly population living in long-term care facilities is clear. Estimates for the country exceeded 100,000 elderly people, potentially the most fragile and vulnerable, and are based upon a conservative number of total deaths, in view of other estimates and the alarming situation of death growth in Brazil from COVID-19.

Key words
Coronavirus infections; Simulation; Health of institutionalized elderly; Frail elderly; Cross-sectional studies

Introduction

High fatality rates due to SARS-CoV-2 have been associated with elderly patients or with the presence of comorbidities in these patients¹1 Barra RP, EN Moraes EN, Jardim AA, Oliveira KK, Bonatti PCR, Issa AC. A importância da gestão correta da condição crônica na Atenção Primária à Saúde para o enfrentamento da COVID-19 em Uberlândia, Minas Gerais. APS em Revista 2020; 2(1):38-43.

2 Lloyd-Sherlock P, Ebrahim S, Geffen L, McKee M. Bearing the brunt of covid-19: older people in low and middle income countries. BMJ 2020; 368:m1052 [acessado 2020 Abr 30]. Disponível em: https://www.bmj.com/content/368/bmj.m1052
https://www.bmj.com/content/368/bmj.m105... ^-33 Lai CC, Wang JH, Ko WC, Yen MY, Lu MC, Lee CM, Hsueh PR; Society of Taiwan Long-term Care Infection Prevention and Control. COVID-19 in long-term care facilities: An upcoming threat that cannot be ignored. J Microbiol Immunol Infect 2020; 53(3):444-446.. Among those infected (who are above 80 years), more than one fifth die: these percentages are 21.9% in China and 20.2% in Italy³3 Lai CC, Wang JH, Ko WC, Yen MY, Lu MC, Lee CM, Hsueh PR; Society of Taiwan Long-term Care Infection Prevention and Control. COVID-19 in long-term care facilities: An upcoming threat that cannot be ignored. J Microbiol Immunol Infect 2020; 53(3):444-446.. The COVID-19 pandemic is a challenge for long-term care institutions for the elderly (care homes), given that their institutionalized members belong to the COVID- 19 most susceptible groups⁴4 D’Adamo H, Yoshikawa T, Ouslander JG. Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of COVID-19. J Am Geriatr Soc 2020; 68(5):912-917..

Care homes concentrate people who have adverse outcome risks for COVID-19 that are above the average risks and, also, the fact that they live very close together can act as a worsening factor in the spread of SARS-CoV-2 infections²2 Lloyd-Sherlock P, Ebrahim S, Geffen L, McKee M. Bearing the brunt of covid-19: older people in low and middle income countries. BMJ 2020; 368:m1052 [acessado 2020 Abr 30]. Disponível em: https://www.bmj.com/content/368/bmj.m1052
https://www.bmj.com/content/368/bmj.m105... ^,33 Lai CC, Wang JH, Ko WC, Yen MY, Lu MC, Lee CM, Hsueh PR; Society of Taiwan Long-term Care Infection Prevention and Control. COVID-19 in long-term care facilities: An upcoming threat that cannot be ignored. J Microbiol Immunol Infect 2020; 53(3):444-446.. Although there are estimates of the total deaths of residents of care homes in some countries⁵5 Comas-Herrera A, Zalakain J, Litwin C, Hsu A, Fernandez-Plotka J. Mortality associated with COVID-19 outbreaks in care homes: early international evidence. [acessado 2020 Abr 24]. Disponível em: https://ltccovid.org/wp-content/uploads/2020/05/Mortality-associated-with-COVID-26-April-1.pdf
https://ltccovid.org/wp-content/uploads/... ^,66 Chidambaram P. State Reporting of Cases and Deaths Due to COVID-19 in Long-Term Care Facilities. [acessado 2020 Abr 24]. Disponível em: https://www.kff.org/medicaid/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/
https://www.kff.org/medicaid/issue-brief... , estimates of fatality rates of COVID-19 in elderly persons in care homes were only found for the United States and Singapore. In the United States (King County, Wahshington State)⁴4 D’Adamo H, Yoshikawa T, Ouslander JG. Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of COVID-19. J Am Geriatr Soc 2020; 68(5):912-917., the fatality rate was 33.7% and, in Singapore⁷7 Tan L, Seetharaman S. COVID-19 outbreak in nursing homes in Singapore. J Microbiol Immunol Infect [acessado 2020 Jun 16]. Disponível em: https://doi.org/10.1016/j.jmii.2020.04.018
https://doi.org/10.1016/j.jmii.2020.04.0... , the estimate was indirect, but indicated that deaths by COVID-19 of institutionalized elderly people accounted for about 14% of the general fatality rate⁷7 Tan L, Seetharaman S. COVID-19 outbreak in nursing homes in Singapore. J Microbiol Immunol Infect [acessado 2020 Jun 16]. Disponível em: https://doi.org/10.1016/j.jmii.2020.04.018
https://doi.org/10.1016/j.jmii.2020.04.0... .

A few of countries have attempted to estimate the impact of mortality at care homes⁵5 Comas-Herrera A, Zalakain J, Litwin C, Hsu A, Fernandez-Plotka J. Mortality associated with COVID-19 outbreaks in care homes: early international evidence. [acessado 2020 Abr 24]. Disponível em: https://ltccovid.org/wp-content/uploads/2020/05/Mortality-associated-with-COVID-26-April-1.pdf
https://ltccovid.org/wp-content/uploads/... ^,66 Chidambaram P. State Reporting of Cases and Deaths Due to COVID-19 in Long-Term Care Facilities. [acessado 2020 Abr 24]. Disponível em: https://www.kff.org/medicaid/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/
https://www.kff.org/medicaid/issue-brief... , however, in Brazil, the number of elderly residents in long-term care facilities is not known, nor to what extent COVID-19 has affected the mortality of residents. Thus, the present study aims to estimate the impact of COVID-19 on the mortality of institutionalized elderly in Brazil.

Methods

This is a cross-sectional and simulation study. The estimates were calculated in two stages. In the first stage, total COVID-19 deaths were estimated for the elderly; in the second stage, a weighted percentage, which was obtained based on proportional mortality indicators from official death data in care homes, were applied to these deaths.

In the first stage of the estimation process, the total COVID-19 deaths for the elderly were adopted from the lowest estimated values suggested by Martinez et al.⁸8 Martinez R, Loyd-Sherlock P, Souza LE, Giacomin K. Estimativas do impacto do Covid-19 na mortalidade no Brasil. [acessado 2020 Abr 11]. Disponível em: https://www.abrasco.org.br/site/outras-noticias/ saude-da-populacao/estimativas-do-impacto-da- covid-19-na-mortalidade-no-brasil/46151/
https://www.abrasco.org.br/site/outras-n... , who used the Corona-older platform⁹9 Corona-older.com. Information and tools about coronavirus and older people in developing countries. [acessado 2020 Abr 11]. Disponível em: https://www.corona-older.com/tool
https://www.corona-older.com/tool... . This platform made it possible to estimate the number of deaths expected by COVID-19, by age, for Brazil, States and the Federal District, based on population estimates for 2020. It also allows researchers to work with variable rates of infection and case fatality based on what happened in countries like China, Italy or South Korea. In this study we based our the estimates on Martinez et al.⁸8 Martinez R, Loyd-Sherlock P, Souza LE, Giacomin K. Estimativas do impacto do Covid-19 na mortalidade no Brasil. [acessado 2020 Abr 11]. Disponível em: https://www.abrasco.org.br/site/outras-noticias/ saude-da-populacao/estimativas-do-impacto-da- covid-19-na-mortalidade-no-brasil/46151/
https://www.abrasco.org.br/site/outras-n... , who selected an infection rate of 10.0% and fatality rates by age groups as observed in China, thus obtaining a total number of deaths of 240,281. These estimates may be considered reasonable and conservative as compared to the estimate of 452,694 by Dowd et al.¹⁰10. Dowd JB, Andriano L, Brazel DM, Rotondi V, Block P, Ding X, Liu Y, Mills MC. Demographic science aids in understanding the spread and fatality rates of COVID-19. [acessado 2020 Jun 11]. Disponível em: https://www.pnas.org/content/pnas/early/2020/04/15/2004911117.full.pdf
https://www.pnas.org/content/pnas/early/... , who studied, in detail, not only the behavior of the epidemic, but also the Brazilian age structure.

In relation to the second stage of the estimation approach, COVID-19 death estimates for elderly living in care homes, using data from recent international research on COVID-19: official data came from eleven different countries as published by Comas-Herrera et al.⁵5 Comas-Herrera A, Zalakain J, Litwin C, Hsu A, Fernandez-Plotka J. Mortality associated with COVID-19 outbreaks in care homes: early international evidence. [acessado 2020 Abr 24]. Disponível em: https://ltccovid.org/wp-content/uploads/2020/05/Mortality-associated-with-COVID-26-April-1.pdf
https://ltccovid.org/wp-content/uploads/... . Estimates, as well as their temporal and geographical location⁵5 Comas-Herrera A, Zalakain J, Litwin C, Hsu A, Fernandez-Plotka J. Mortality associated with COVID-19 outbreaks in care homes: early international evidence. [acessado 2020 Abr 24]. Disponível em: https://ltccovid.org/wp-content/uploads/2020/05/Mortality-associated-with-COVID-26-April-1.pdf
https://ltccovid.org/wp-content/uploads/... , are shown in Table 1.

Table 1 indicates: (i) whenever possible, for each country, we used estimates of confirmed deaths by COVID-19 - this choice was made in order to avoid including false positive individuals for COVID -19 who subsequently died (Belgium and Ireland would have, if the data on probable COVID-19 deaths were used, respectively, figures of 100.0% and 56.9%); (ii) information was obtained for the United States based on data from 38 of the 50 US States⁶6 Chidambaram P. State Reporting of Cases and Deaths Due to COVID-19 in Long-Term Care Facilities. [acessado 2020 Abr 24]. Disponível em: https://www.kff.org/medicaid/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/
https://www.kff.org/medicaid/issue-brief... ; finally, information for Spain was obtained based on six of the 17 autonomous communities and the percentage was calculated directly by the authors of this article based on the information provided in Comas-Herrera et al.⁵5 Comas-Herrera A, Zalakain J, Litwin C, Hsu A, Fernandez-Plotka J. Mortality associated with COVID-19 outbreaks in care homes: early international evidence. [acessado 2020 Abr 24]. Disponível em: https://ltccovid.org/wp-content/uploads/2020/05/Mortality-associated-with-COVID-26-April-1.pdf
https://ltccovid.org/wp-content/uploads/... .

The weighted percentage of care home resident-deaths in relation to the total was estimated as the sum of the number of COVID-19 deaths in countries with available information, multiplied by the proportion of COVID-19 deaths of care homes residents by (N1) in relation to the number of total deaths by COVID-19, for all countries (N3), divided by the sum of (N1) for all countries:

For care home elderly COVID-19 deaths, we used 95.0% confidence intervals for the averages.

Results

Estimates by States, Federal District, Regions and Brazil are in Table 2. Out of the 240,287 COVID-19 deaths considered, a total of 107,528 deaths would occur in care homes (95.0% confidence interval from 107,269 to 107,788). These deaths make up 61.9% of all 175,435 COVID-19 related deaths for the elderly. The Southeast Region would concentrate the majority of deaths in Brazil, equivalent to 48,779 deaths (95.0% confidence interval of 48,661 to 48,898), followed by the Northeast Region (28,451 deaths; 95.0% confidence interval of 28,382 to 28,520), according to Figure 1.

Regarding States (Figure 2), São Paulo, Minas Gerais, Rio de Janeiro, Bahia and Rio Grande do Sul, would be those with the highest number of COVID-19 deaths (at all ages and in care homes).

Discussion

Findings of the present study indicated that almost half (44.7%) of COVID-19 will take place among elderly who live in care homes. More than 100,000 elderly people in care homes (107,528 deaths) are expected to die from the disease.

Limitations of the present study may have affected the results, since the estimate of COVID-19 deaths among the elderly in care homes did not consider age structure or the number of beds in these institutions, which vary among Regions in Brazil. Thus, a higher number of elderly deaths due to COVID-19 are expected to come from care homes in the Southeast Region due to its larger population, a high proportion of the elderly (16.1%) in relation to the total population¹¹11 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico 2010. Projeções da população [Internet]. IBGE; 2011. [acessado 2020 Jun 17]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/9109-projecao-da-populacao.html?=&t=resultados
https://www.ibge.gov.br/estatisticas/soc... , the higher percentage of institutionalized elderly people and, finally, due to the number of total deaths due to COVID-19 that has been observed in the last epidemiological weeks in this region¹²12 Brasil. Covid-19. 2020 [acessado 2020 Jun 16]. Disponível em: https://brasil.io/dataset/covid19/caso_ full/
https://brasil.io/dataset/covid19/caso_ ... . Hence, adjustments in the estimates will be needed to assess whether these initial estimates agreed with what actually happened. Also, studies to assess COVID-19 case fatality rates in care homes in Brazil are also necessary.

Another limitation refers to the unavailability of data on the number of elderly residents in institutions as well as official statistics on mortality in care homes. In fact, accurate data on care home elderly residents are scarce: other places, such as the United Kingdom, also consider estimates instead of a more precise figure¹³13 How big is the problem in care homes? BBC news 2020 Abr 30; [acessado 2020 Maio 10]. Disponível em: https://www.bbc.com/news/health-52284281
https://www.bbc.com/news/health-52284281... . Considering this drawback, our option, therefore, was to estimate only the number of deaths.

Our simulation indicates the devastating impact of COVID-19 on institutionalized elderly people, as has occurred in other countries such as in Italy¹⁴14 Parodi E. Uncounted among coronavirus victims, deaths sweep through Italy’s nursing homes. Reuters 2020 Mar 18; [acessado 2020 Jun 16]. Disponível em: https://www.reuters.com/article/us-health-coronavirus-italy-homes-insigh/uncounted-among-coronavirus-victims-deaths-sweep-through-italys-nursing-homes-idUSKBN2152V0
https://www.reuters.com/article/us-healt... and in United States⁴4 D’Adamo H, Yoshikawa T, Ouslander JG. Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of COVID-19. J Am Geriatr Soc 2020; 68(5):912-917..

Cabrero¹⁵15 Cabrero GR. La crisis del coronavirus y su impacto en las residencias de personas mayores en España. Cien Saude Colet 2020; 25(6):1996., based on Spain experience, points out that there are causes for the impact of the COVID-19 pandemic on institutionalized elderly, namely negligence and discrimination caused in part by the overload of the pandemic in health services; insufficient human and material resources; lack of control and legislation aimed at the elderly people living in care homes at the beginning of the crisis. Thus, measures are recommended to promote risk reduction as restriction of visitors to institutions; screening to identify symptoms in any individual who needs to go inside care homes; use of personal protective equipment and, finally, increase testing in these institutions. These measures were implemented in Singapore⁷7 Tan L, Seetharaman S. COVID-19 outbreak in nursing homes in Singapore. J Microbiol Immunol Infect [acessado 2020 Jun 16]. Disponível em: https://doi.org/10.1016/j.jmii.2020.04.018
https://doi.org/10.1016/j.jmii.2020.04.0... , a country that was successful in containing COVID-19 outbreaks in care homes⁷7 Tan L, Seetharaman S. COVID-19 outbreak in nursing homes in Singapore. J Microbiol Immunol Infect [acessado 2020 Jun 16]. Disponível em: https://doi.org/10.1016/j.jmii.2020.04.018
https://doi.org/10.1016/j.jmii.2020.04.0... .

Discrimination and stigma of institutionalized elderly people are likely to happen and this should also be a concern of policy makers. United Nations report from May 2020¹⁶16 United Nations (UN). Policy Brief: The Impact of COVID-19 on older persons. 2020. [acessado 2020 Maio 10]. Disponível em: https://unsdg.un.org/sites/default/files/2020-05/Policy-Brief-The-Impact-of-COVID-19-on-Older-Persons.pdf
https://unsdg.un.org/sites/default/files... draws attention to public discourse and social media, emphasizing that in these times of the COVID-19 pandemic, expressions of intergenerational resentment have occurred. Policies, programs and communication should provide a differentiated, but not distorted, picture of the pandemic impact on the elderly, promoting broader community involvement with elderly issues, their differentiated risks, and, especially, drawing attention to those who live in care homes. This programmatic attitude can promote intergenerational solidarity, which is fundamental for unity among people, especially in times of crisis¹⁶16 United Nations (UN). Policy Brief: The Impact of COVID-19 on older persons. 2020. [acessado 2020 Maio 10]. Disponível em: https://unsdg.un.org/sites/default/files/2020-05/Policy-Brief-The-Impact-of-COVID-19-on-Older-Persons.pdf
https://unsdg.un.org/sites/default/files... .

The findings of the present study can be used by other researchers so that they can make estimates of the number of deaths due to COVID-19 in elderly people in other countries. Simulation and projections are extremely important in critical moments, where there is data shortage, thus, allowing for planning of public policy, guidance and actions.

References

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