Abstract
IntroductionWe retrospectively evaluated the impact of COVID-19 testing among residents and staff in adult social care homes in England. MethodsWe obtained 80 million reported polymerase chain reaction (PCR) and lateral flow device (LFD) test results, from 14,805 care homes (residents and staff) in England, conducted between October 2020 and March 2022. These testing data were then linked to care home characteristics, test costs and 24,500 COVID-19-related deaths of residents. We decomposed the mechanism of outbreak mitigation into outbreak discovery and outbreak control and used Poisson regressions to investigate how reported testing intensity was associated with the size of outbreak discovered and to uncover its association with outbreak control. We used negative binomial regressions to determine the factors influencing COVID-19-related deaths subsequent to outbreaks. We performed a cost-effectiveness analysis of the impact of testing for preventing COVID-19-related deaths of residents.ResultsReported testing intensity generally reflected changes in testing policy over time, although there was considerable heterogeneity among care homes. Client type was the strongest determinant of whether COVID-19-related deaths in residents occurred subsequent to testing positive. Higher staff-to-resident ratios were associated with larger outbreak sizes but rapid outbreak control and a decreased risk of COVID-19-related deaths. Assuming our regression estimates represent causal effects, care home testing in England was cost effective at preventing COVID-19-related deaths among residents during the pandemic and approximately 3.5-times more cost effective prior to the vaccine rollout. ConclusionsPCR and LFD testing was likely an impactful intervention for detecting and controlling COVID-19 outbreaks in care homes in England and cost effective for preventing COVID-19-related deaths among residents. In future pandemics, testing must be prioritised for care homes, especially if severe illness and death particularly affects older people or individuals with characteristics similar to care home residents, and an efficacious vaccine is unavailable.Key MessagesEvidence before this studyMass diagnostic testing plays a key role in any pandemic response. COVID-19 testing in the adult social care sector in England was implemented by NHS Test and Trace (later the UK Health Security Agency, UKHSA). Prior to the large-scale evaluation we report here, a pilot testing evaluation programme had been conducted in Liverpool. Added value of this studyThis study represents the first large-scale evaluation of England's COVID-19 testing programme in adult social care homes. It encompasses data from residents and staff from 14,805 adult social care homes in England. Our findings show that testing was an important and useful public health intervention that had a considerable impact. It was also cost effective at preventing COVID-19-related deaths in adult social care home residents.Implications of all the available evidenceOur study has implications for the development of testing policies in adult social care homes in any future pandemic, particularly if it involves a respiratory disease similar to COVID-19. We found that while testing was a crucial public health intervention in adult social care homes, there were also large heterogeneities seen among care homes. Policymakers thus need to consider whether a one-size-fits-all policy for care home testing is the most effective approach to take in the face of any future pandemic.
Competing Interest Statement
This work was funded by the Secretary of State for Health and Social Care acting as part of the Crown through UKHSA, reference number C80260/PRO5331. All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: all authors working for EY and the University of Oxford had financial support from UKHSA for the submitted work; EY LLP London has previously received payment for consultancy and advisory work on the NHS Test & Trace response from the UK Department of Health and Social Care, now known as UKHSA; Susan Hopkins is supported by the National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance (NIHR200915), a partnership between UKHSA and the University of Oxford. The views expressed are those of the authors and not necessarily those of NIHR, UKHSA, or the Department of Health and Social Care. All authors declare no other competing interests.
Clinical Protocols
https://www.medrxiv.org/content/10.1101/2022.10.27.22281604v3
Funding Statement
This work was funded by the Secretary of State for Health and Social Care acting as part of the Crown through UKHSA, reference number C80260/PRO5331. All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: all authors working for EY and the University of Oxford had financial support from UKHSA for the submitted work; EY LLP London has previously received payment for consultancy and advisory work on the NHS Test & Trace response from the UK Department of Health and Social Care, now known as UKHSA; Susan Hopkins is supported by the National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance (NIHR200915), a partnership between UKHSA and the University of Oxford. The views expressed are those of the authors and not necessarily those of NIHR, UKHSA, or the Department of Health and Social Care. All authors declare no other competing interests.
Author Declarations
I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.
Yes
The details of the IRB/oversight body that provided approval or exemption for the research described are given below:
The study protocol for the evaluation project, which this research fed into, was granted ethics approval by the UKHSA Research Ethics and Governance Group, reference number NR0347. All relevant ethics guidelines were followed throughout.
I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.
Yes
I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).
Yes
I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.
Yes
Data Availability
The data supporting the findings of this study are available within the paper and its supplementary materials. The data were made available by UKHSA to the manuscript's authors as part of a retrospective evaluation of England's COVID-19 testing programme. The authors cannot make the underlying datasets publicly available for ethical and legal reasons, particularly given the sensitive nature of the information included. Applications for access to the anonymised data should be submitted to UKHSA.
