Risk factors for outbreaks of SARS-CoV-2 infection at retirement homes in Ontario,Canada: a population-level cohort study

BACKGROUND:The epidemiology of SARS-CoV-2 infection in retirement homes (also known as assisted living facilities) is largely unknown. We examined the association between home-and community-level characteristics and the risk of outbreaks of SARS-CoV-2 infection in retirement homes since the beginning of the first wave of the COVID-19 pandemic.METHODS:We conducted a population-based, retrospective cohort study of licensed retirement homes in Ontario, Canada, from Mar. 1 to Dec. 18, 2020. Our primary outcome was an outbreak of SARS-CoV-2 infection (≥ 1 resident or staff case confirmed by validated nucleic acid amplification assay). We used time-dependent proportional hazards methods to model the associations between retirement home– and community-level characteristics and outbreaks of SARS-CoV-2 infection.RESULTS:Our cohort included all 770 licensed retirement homes in Ontario, which housed 56 491 residents. There were 273 (35.5%) retirement homes with 1 or more outbreaks of SARS-CoV-2 infection, involving 1944 (3.5%) residents and 1101 staff (3.0%). Cases of SARS-CoV-2 infection were distributed unevenly across retirement homes, with 2487 (81.7%) resident and staff cases occurring in 77 (10%) homes. The adjusted hazard of an outbreak of SARS-CoV-2 infection in a retirement home was positively associated with homes that had a large resident capacity, were co-located with a long-term care facility, were part of larger chains, offered many services onsite, saw increases in regional incidence of SARS-CoV-2 infection, and were located in a region with a higher community-level ethnic concentration.INTERPRETATION:Readily identifiable characteristics of retirement homes are independently associated with outbreaks of SARS-CoV-2 infection and can support risk identification and priority for vaccination.

Frail older adults living in congregate care settings have been at the centre of the COVID-19 pandemic in Canada and internationally.^1,2 Long-term care facilities — whose residents are the congregate living population most affected by COVID-19 — have been the subject of immense scientific and public interest during the pandemic.³ Retirement homes (often known as assisted living facilities) have received far less examination despite also housing many vulnerable older adults.^4–7 In contrast to long-term care facilities, retirement homes are private residential complexes that provide a range of supportive care and lifestyle services that are purchased out of pocket by residents or their families.⁸ Although residents of retirement homes access supportive care services, they are substantially less frail and dependent than residents of long-term care homes.⁵ Inconsistent regulation of these facilities throughout Canada and the United States has limited research into the epidemiology of SARS-CoV-2 infection in retirement homes.⁹There are 770 licensed retirement homes in Ontario, Canada’s most populous province, that house more than 50 000 older adults, a population size that approaches the number of Ontario residents of long-term care homes.¹⁰ Since the onset of the COVID-19 pandemic in Ontario, the number of positive cases and deaths in retirement homes has continued to grow. As of Apr. 11, 2021, retirement home residents accounted for about 8% of deaths from COVID-19 in Ontario (596/7552).¹¹ Outbreaks of SARS-CoV-2 infection surged in retirement homes during the first and second waves in Canada and the US,^11,12 and there has been limited examination in the literature beyond early reports of case surveillance.¹³We examined the association between home- and community-level characteristics and the risk of outbreaks of SARS-CoV-2 infection during the first wave of the COVID-19 epidemic in Ontario’s retirement homes. Consistent with our previous population-level work in Ontario long-term care homes,^2,14 we hypothesized that home size and regional incidence of SARS-CoV-2 infection would be associated with the risk of an outbreak.