Risk Factors Associated With SARS-CoV-2 Breakthrough Infections in Fully mRNA-Vaccinated Individuals: Retrospective Analysis

BackgroundCOVID-19 messenger RNA (mRNA) vaccines have demonstrated efficacy and effectiveness in preventing symptomatic COVID-19, while being relatively safe in trial studies. However, vaccine breakthrough infections have been reported.ObjectiveThis study aims to identify risk factors associated with COVID-19 breakthrough infections among fully mRNA-vaccinated individuals.MethodsWe conducted a series of observational retrospective analyses using the electronic health records (EHRs) of the Columbia University Irving Medical Center/New York Presbyterian (CUIMC/NYP) up to September 21, 2021. New York City (NYC) adult residences with at least 1 polymerase chain reaction (PCR) record were included in this analysis. Poisson regression was performed to assess the association between the breakthrough infection rate in vaccinated individuals and multiple risk factors—including vaccine brand, demographics, and underlying conditions—while adjusting for calendar month, prior number of visits, and observational days in the EHR.ResultsThe overall estimated breakthrough infection rate was 0.16 (95% CI 0.14-0.18). Individuals who were vaccinated with Pfizer/BNT162b2 (incidence rate ratio [IRR] against Moderna/mRNA-1273=1.66, 95% CI 1.17-2.35) were male (IRR against female=1.47, 95% CI 1.11-1.94) and had compromised immune systems (IRR=1.48, 95% CI 1.09-2.00) were at the highest risk for breakthrough infections. Among all underlying conditions, those with primary immunodeficiency, a history of organ transplant, an active tumor, use of immunosuppressant medications, or Alzheimer disease were at the highest risk.ConclusionsAlthough we found both mRNA vaccines were effective, Moderna/mRNA-1273 had a lower incidence rate of breakthrough infections. Immunocompromised and male individuals were among the highest risk groups experiencing breakthrough infections. Given the rapidly changing nature of the SARS-CoV-2 pandemic, continued monitoring and a generalizable analysis pipeline are warranted to inform quick updates on vaccine effectiveness in real time.     

Multistate Outbreak of SARS-CoV-2 Infections,Including Vaccine Breakthrough Infections,Associated with Large Public Gatherings,United States

During July 2021, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) B.1.617.2 variant infections, including vaccine breakthrough infections, occurred after large public gatherings in Provincetown, Massachusetts, USA, prompting a multistate investigation. Public health departments identified primary and secondary cases by using coronavirus disease surveillance data, case investigations, and contact tracing. A primary case was defined as SARS-CoV-2 detected <14 days after travel to or residence in Provincetown during July 3–17. A secondary case was defined as SARS-CoV-2 detected <14 days after close contact with a person who had a primary case but without travel to or residence in Provincetown during July 3–August 10. We identified 1,098 primary cases and 30 secondary cases associated with 26 primary cases among fully and non–fully vaccinated persons. Large gatherings can have widespread effects on SARS-CoV-2 transmission, and fully vaccinated persons should take precautions, such as masking, to prevent SARS-CoV-2 transmission, particularly during substantial or high transmission.     

SARS-CoV-2 Breakthrough Infections after introduction of 4 COVID-19 Vaccines,South Korea, 2021

We conducted a nationwide retrospective cohort study to estimate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) breakthrough infection among recipients of 4 different vaccines in South Korea. Age-adjusted breakthrough infection rate per month was highest for Janssen (42.6/100,000 population), followed by AstraZeneca (21.7/100,000 population), Pfizer-BioNTech (8.5/100,000 population), and Moderna (1.8/100,000 population).     

Cross-Variant Neutralizing Serum Activity after SARS-CoV-2 Breakthrough Infections

To determine neutralizing activity against the severe acute respiratory syndrome coronavirus 2 ancestral strain and 4 variants of concern, we tested serum from 30 persons with breakthrough infection after 2-dose vaccination. Cross-variant neutralizing activity was comparable to that after 3-dose vaccination. Shorter intervals between vaccination and breakthrough infection correlated with lower neutralizing titers.     

Factors Associated With Antimicrobial Use in Nursing Home Residents With Advanced Dementia

ObjectivesWidespread antimicrobial misuse among nursing home (NH) residents with advanced dementia raises concerns regarding the emergence of multidrug-resistant organisms and avoidable treatment burden in this vulnerable population. The objective of this report was to identify facility and resident level characteristics associated with receipt of antimicrobials in this population.DesignCross-sectional analysis of baseline data from the Trial to Reduce Antimicrobial use in Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD).Setting and ParticipantsTwenty-eight Boston area NHs, 430 long stay NH residents with advanced dementia.MeasuresThe outcome was the proportion of residents who received any antimicrobials during the 2 months prior to the start of TRAIN-AD determined by chart review. Multivariable logistic regression was used to identify resident and facility characteristics associated with this outcome.ResultsA total of 13.7% of NH residents with advanced dementia received antimicrobials in the 2 months prior to the start of TRAIN-AD. Residents in facilities with the following characteristics were significantly more likely to receive antimicrobials: having a full time nurse practitioner/physician assistant on staff [adjusted odds ratio (aOR) 3.02; 95% confidence interval (CI), 1.54, 5.94], fewer existing infectious disease practices (eg, antimicrobial stewardship programs, established algorithms for infection management) (aOR, 2.35; 95% CI 1.14, 4.84), and having fewer residents with severely cognitively impaired residents (aOR 1.96; 95% CI 1.12, 3.40). No resident characteristics were independently associated with receipt of antimicrobials.Conclusions and ImplicationsFacility-level characteristics are associated with the receipt of antimicrobials among residents with advanced dementia. Implementation of more intense infectious disease practices and targeting the prescribing practices of nurse practitioners/physician assistants may be critical targets for interventions aimed at reducing antimicrobial use in this population.     

SARS-CoV-2 Breakthrough Infections among US Embassy Staff Members,Uganda, May–June 2021

The SARS-CoV-2 Delta variant emerged shortly after COVID-19 vaccines became available in 2021. We describe SARS-CoV-2 breakthrough infections in a highly vaccinated, well-monitored US Embassy community in Kampala, Uganda. Defining breakthrough infection rates in highly vaccinated populations can help determine public health messaging, guidance, and policy globally.     

Breakthrough Infections of SARS-CoV-2 Gamma Variant in Fully Vaccinated Gold Miners,French Guiana, 2021

An outbreak of severe acute respiratory syndrome coronavirus 2 caused by the Gamma variant of concern infected 24/44 (55%) employees of a gold mine in French Guiana (87% symptomatic, no severe forms). The attack rate was 60% (15/25) among fully vaccinated miners and 75% (3/4) among unvaccinated miners without a history of infection.     

Previous SARS-CoV-2 Infection,Age, and Frailty Are Associated With 6-Month Vaccine-Induced Anti-Spike Antibody Titer in Nursing Home Residents

ObjectivesOlder nursing home residents make up the population at greatest risk of morbidity and mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. No studies have examined the determinants of long-term antibody responses post vaccination in this group.DesignLongitudinal cohort study.Setting and ParticipantsResidents from 5 nursing homes assessed before vaccination, and 5 weeks and 6 months post vaccination, with the BNT162b2 messenger RNA SARS-CoV-2 vaccine.MethodsComprehensive clinical assessment was performed, including assessment for comorbidity, frailty, and SARS-CoV-2 infection history. Serum nucleocapsid and anti-spike receptor binding domain (RBD) antibodies were analyzed at all timepoints. An in vitro angiotensin-converting enzyme (ACE2) receptor-spike RBD neutralization assay assessed serum neutralization capacity.ResultsOf 86 participants (81.1 ± 10.8 years; 65% female), just under half (45.4%; 39 of 86) had evidence of previous SARS-CoV-2 infection. All participants demonstrated a significant antibody response to vaccination at 5 weeks and a significant decline in this response by 6 months. SARS-CoV-2 infection history was the strongest predictor of antibody titer (log-transformed) at both 5 weeks [β: 3.00; 95% confidence interval (CI): 2.32–3.70; P < .001] and 6 months (β: 3.59; 95% CI: 2.89–4.28; P < .001). Independent of SARS-CoV-2 infection history, both age in years (β: ?0.05; 95% CI: ?0.08 to ?0.02; P < .001) and frailty (β: ?0.22; 95% CI: ?0.33 to ?0.11; P < .001) were associated with a significantly lower antibody titer at 6 months. Anti-spike antibody titers at both 5 weeks and 6 months significantly correlated with in vitro neutralization capacity.Conclusions and ImplicationsIn older nursing home residents, SARS-CoV-2 infection history was the strongest predictor of anti-spike antibody titers at 6 months, whereas age and frailty were independently associated with lower titers at 6 months. Antibody titers significantly correlated with in vitro neutralization capacity. Although older SARS-CoV-2 naïve nursing home residents may be particularly vulnerable to breakthrough SARS-CoV-2 infection, the relationship between antibody titers, SARS-CoV-2 infection, and clinical outcomes remains to be fully elucidated in this vulnerable population.     

Factors Associated With the Quality of Life of Nursing Home Residents During the COVID-19 Pandemic: A Cross-Sectional Study

ObjectivesQuality of life (QoL) of nursing home (NH) residents is critical, yet understudied, particularly during the COVID-19 pandemic. Our objective was to examine whether COVID-19 outbreaks, lack of access to geriatric professionals, and care aide burnout were associated with NH residents' QoL.DesignCross-sectional study (July to December 2021).Setting and ParticipantsWe purposefully selected 9 NHs in Alberta, Canada, based on their COVID-19 exposure (no or minor/short outbreaks vs repeated or extensive outbreaks). We included data for 689 residents from 18 care units.MethodsWe used the DEMQOL-CH to assess resident QoL through video-based care aide interviews. Independent variables included a COVID-19 outbreak in the NH in the past 2 weeks (health authority records), care unit-levels of care aide burnout (9-item short-form Maslach Burnout Inventory), and resident access to geriatric professionals (validated facility survey). We ran mixed-effects regression models, adjusted for facility and care unit (validated surveys), and resident covariates (Resident Assessment Instrument–Minimum Data Set 2.0).ResultsRecent COVID-19 outbreaks (β = 0.189; 95% CI: 0.058–0.320), higher proportions of emotionally exhausted care aides on a care unit (β = 0.681; 95% CI: 0.246–1.115), and lack of access to geriatric professionals (β = 0.216; 95% CI: 0.003–0.428) were significantly associated with poorer resident QoL.Conclusions and ImplicationsPolicies aimed at reducing infection outbreaks, better supporting staff, and increasing access to specialist providers may help to mitigate how COVID-19 has negatively affected NH resident QoL.     

SARS-CoV-2 and Wisconsin Nursing Homes: Temporal Dynamics During the COVID-19 Pandemic

ObjectivesEvidence suggests that quality, location, and staffing levels may be associated with COVID-19 incidence in nursing homes. However, it is unknown if these relationships remain constant over time. We describe incidence rates of COVID-19 across Wisconsin nursing homes while examining factors associated with their trajectory during 5 months of the pandemic.DesignRetrospective cohort study.Setting/ParticipantsWisconsin nursing homes.MethodsPublicly available data from June 1, 2020, to October 31, 2020, were obtained. These included facility size, staffing, 5-star Medicare rating score, and components. Nursing home characteristics were compared using Pearson chi-square and Kruskal-Wallis tests. Multiple linear regressions were used to evaluate the effect of rurality on COVID-19.ResultsThere were a total of 2459 COVID-19 cases across 246 Wisconsin nursing homes. Number of beds (P < .001), average count of residents per day (P < .001), and governmental ownership (P = .014) were associated with a higher number of COVID-19 cases. Temporal analysis showed that the highest incidence rates of COVID-19 were observed in October 2020 (30.33 cases per 10,000 nursing home occupied-bed days, respectively). Urban nursing homes experienced higher incidence rates until September 2020; then incidence rates among rural nursing homes surged. In the first half of the study period, nursing homes with lower-quality scores (1-3 stars) had higher COVID-19 incidence rates. However, since August 2020, incidence was highest among nursing homes with higher-quality scores (4 or 5 stars). Multivariate analysis indicated that over time rural location was associated with increased incidence of COVID-19 (β = 0.05, P = .03).Conclusions and ImplicationsHigher COVID-19 incidence rates were first observed in large, urban nursing homes with low-quality rating. By October 2020, the disease had spread to rural and smaller nursing homes and those with higher-quality ratings, suggesting that community transmission of SARS-CoV-2 may have propelled its spread.     

Breakthrough Infections of E484K-Harboring SARS-CoV-2 Delta Variant,Lombardy, Italy

The Delta variant of concern of severe acute respiratory syndrome coronavirus 2 is dominant worldwide. We report a case cluster caused by Delta sublineage B.1.617.2 harboring the mutation E484K in Italy during July 11–July 29, 2021. This mutation appears to affect immune response and vaccine efficacy; monitoring its appearance is urgent.     

T-Cell Mediated Response after Primary and Booster SARS-CoV-2 Messenger RNA Vaccination in Nursing Home Residents

ObjectivesNursing home (NH) residents have been significantly affected by the coronavirus disease 2019 (COVID-19) pandemic. Studies addressing the immune responses induced by COVID-19 vaccines in NH residents have documented a good postvaccination antibody response and the beneficial effect of a third booster vaccine dose. Less is known about vaccine-induced activation of cell-mediated immune response in frail older individuals in the long term. The aim of the present study is to monitor messenger RNA SARS-CoV-2 vaccine-induced T-cell responses in a sample of Italian NH residents who received primary vaccine series and a third booster dose and to assess the interaction between T-cell responses and humoral immunity.DesignLongitudinal cohort study.Setting and ParticipantsThirty-four residents vaccinated with BNT162b2 messenger RNA SARS-CoV-2 vaccine between February and April 2021 and who received a third BNT162b2 booster dose between October and November 2021 were assessed for vaccine-induced immunity 6 (prebooster) and 12 (postbooster) months after the first BNT162b2 vaccine dose.MethodsPre- and postbooster cell-mediated immunity was assessed by intracellular cytokine staining of peripheral blood mononuclear cells stimulated in vitro with peptides covering the immunodominant sequence of SARS-CoV-2 spike protein. The simultaneous production of interferon-γ, tumor necrosis factor-α, and interleukin-2 was measured. Humoral immunity was assessed in parallel by measuring serum concentration of antitrimeric spike IgG antibodies.ResultsBefore the booster vaccination, 31 out of 34 NH residents had a positive cell-mediated immunity response to spike. Postbooster, 28 out of 34 had a positive response. Residents without a previous history of SARS-CoV-2 infection, who had a lower response prior the booster administration, showed a greater increase of T-cell responses after the vaccine booster dose. Humoral and cell-mediated immunity were, in part, correlated but only before booster vaccine administration.Conclusions and ImplicationsThe administration of the booster vaccine dose restored spike-specific T-cell responses in SARS-CoV-2 naïve residents who responded poorly to the first immunization, while a previous SARS-CoV-2 infection had an impact on the magnitude of vaccine-induced cell-mediated immunity at earlier time points. Our findings imply the need for a continuous monitoring of the immune status of frail NH residents to adapt future SARS-CoV-2 vaccination strategies.     

Dilemmas With Restrictive Visiting Policies in Dutch Nursing Homes During the COVID-19 Pandemic: A Qualitative Analysis of an Open-Ended Questionnaire With Elderly Care Physicians

ObjectivesTo mitigate the spread of COVID-19, a nationwide restriction for all visitors of residents of long-term care facilities including nursing homes (NHs) was established in the Netherlands. The aim of this study was an exploration of dilemmas experienced by elderly care physicians (ECPs) as a result of the COVID-19 driven restrictive visiting policy.Setting and ParticipantsECPs working in Dutch NHs.MethodsA qualitative exploratory study was performed using an open-ended questionnaire. A thematic analysis was applied. Data were collected between April 17 and May 10, 2020.ResultsSeventy-six ECPs answered the questionnaire describing a total of 114 cases in which they experienced a dilemma. Thematic analysis revealed 4 major themes: (1) The need for balancing safety for all through infection prevention measures versus quality of life of the individual residents and their loved ones; (2) The challenge of assessing the dying phase and how the allowed exception to the strict visitor restriction in the dying phase could be implemented; (3) The profound emotional impact on ECPs; (4) Many alternatives for visits highlight the wish to compensate for the absence of face-to-face contact opportunities. Many alternatives for visits highlight the wish to compensate for the absence of face-to-face opportunities but given the diversity of NH residents, alternatives were often only suitable for some of them.Conclusions and ImplicationsECPs reported that the restrictive visitor policy deeply impacts NHs residents, their loved ones, and care professionals. The dilemmas encountered as a result of the policy highlight the wish by ECPs to offer solutions tailored to the individual residents. We identified an overview of aspects to consider when drafting future visiting policies for NHs during the COVID-19 pandemic.     

Staffing Shortages,Staffing Hours,and Resident Deaths in US Nursing Homes During the COVID-19 Pandemic

ObjectivesStaffing shortages at nursing homes during the COVID-19 pandemic may have impacted care providers' staffing hours and affected residents’ care and outcomes. This study examines the association of staffing shortages with staffing hours and resident deaths in nursing homes during the COVID-19 pandemic.DesignThis study measured staffing hours per resident using payroll data and measured weekly resident deaths and staffing shortages using the Centers for Disease Control and Prevention's National Healthcare Safety Network data. Multivariate linear regressions with facility and county-week fixed effects were used to investigate the association of staffing shortages with staffing hours and resident deaths.Setting and Participants15,212 nursing homes.MeasuresThe primary outcomes included staffing hours per resident of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) and weekly total deaths per 100 residents.ResultsBetween May 31, 2020, and May 15, 2022, 18.4% to 33.3% of nursing homes reported staffing shortages during any week. Staffing shortages were associated with lower staffing hours per resident with a 0.009 decrease in RN hours per resident (95% CI 0.005-0.014), a 0.014 decrease in LPN hours per resident (95% CI 0.010-0.018), and a 0.050 decrease in CNA hours per resident (95% CI 0.043-0.057). These are equivalent to a 1.8%, 1.7%, and 2.4% decline, respectively. There was a positive association between staffing shortages and resident deaths with 0.068 (95% CI 0.048-0.088) total deaths per 100 residents. This was equivalent to an increase of 10.5%.Conclusion and ImplicationsOur results showed that self-reported staffing shortages were associated with a statistically significant decrease in staffing hours and with a statistically significant increase in resident deaths. These results suggest that addressing staffing shortages in nursing homes can save lives.     

Clinical characteristics and outcome of hospitalized elderly patients with COVID- 19 after vaccine failure

We described clinical characteristics and outcome of 160 patients over 65 years (01 September to 31 August 2021) who had a first positive SARS-CoV-2 PCR- test more than 14 days after full vaccination and were hospitalized with COVID-19. Median age of included patients was 84 years, 61.2% were over 80 years; 50.6% were male and most (82.5%) has at least one comorbidity. Up to 84% received specific treatment against COVID-19, including 76.9% low-flow oxygen therapy. We found that overall mortality was 25.6% and 30.6% in those older than 80 years. A higher mortality was significantly associated with older age and treatment with tocilizumab. Our data showed that although COVID-19 vaccines continue protecting elderly patients against hospitalization and death and might improve the prognosis after hospitalization in patients with breakthrough infections, mortality in this population -especially in those older than 80 years- remains very high.     

Geographic Variation in Anticoagulant Use and Resident,Nursing Home,and County Characteristics Associated With Treatment Among US Nursing Home Residents

ObjectivesTo quantify geographic variation in anticoagulant use and explore what resident, nursing home, and county characteristics were associated with anticoagulant use in a clinically complex population.DesignA repeated cross-sectional design was used to estimate current oral anticoagulant use on December 31, 2014, 2015, and 2016.Setting and ParticipantsSecondary data for United States nursing home residents during the period 2014-2016 were drawn from the Minimum Data Set 3.0 and Medicare Parts A and D. Nursing home residents (≥65 years) with a diagnosis of atrial fibrillation and ≥6 months of Medicare fee-for-service enrollment were eligible for inclusion. Residents in a coma or on hospice were excluded.MethodsMultilevel logistic models evaluated the extent to which variation in anticoagulant use between counties could be explained by resident, nursing home, and county characteristics and state of residence. Proportional changes in cluster variation (PCVs), intraclass correlation coefficients (ICCs), and adjusted odds ratios (aORs) were estimated.ResultsAmong 86,736 nursing home residents from 11,860 nursing homes and 1694 counties, 45% used oral anticoagulants. The odds of oral anticoagulant use were 18% higher in 2016 than 2014 (aOR: 1.18; 95% confidence interval: 1.14-1.22). Most states had counties in the highest (51.3-58.9%) and lowest (31.1%-41.4%) deciles of anticoagulant use. Compared with the null model, adjustment for resident characteristics explained one-third of the variation between counties (PCV: 34.8%). The full model explained 65.5% of between-county variation. Within-county correlation was a small proportion (ICC < 2.2%) of total variation.Conclusions and ImplicationsIn this older adult population at high risk for ischemic stroke, less than half of the residents received treatment with anticoagulants. Variation in treatment across counties was partially attributable to the characteristics of residents, nursing homes, and counties. Comparative evidence and refinement of predictive algorithms specific to the nursing home setting may be warranted.     

SARS-CoV-2 Vaccine Breakthrough by Omicron and Delta Variants,New York,USA

Recently emerged SARS-CoV-2 variants have greater potential than earlier variants to cause vaccine breakthrough infections. During emergence of the Delta and Omicron variants, a matched case–control analysis used a viral genomic sequence dataset linked with demographic and vaccination information from New York, USA, to examine associations between virus lineage and patient vaccination status, patient age, vaccine type, and time since vaccination. Case-patients were persons infected with the emerging virus lineage, and controls were persons infected with any other virus lineage. Infections in fully vaccinated and boosted persons were significantly associated with the Omicron lineage. Odds of infection with Omicron relative to Delta generally decreased with increasing patient age. A similar pattern was observed with vaccination status during Delta emergence but was not significant. Vaccines offered less protection against Omicron, thereby increasing the number of potential hosts for emerging variants.     

温州地区新冠肺炎抗疫一线医护人员职业暴露危险因素分析

目的 探讨新冠肺炎抗疫一线医护人员职业暴露危险因素,构建职业暴露预测模型.方法 对2020年1-2月温州地区10家医疗机构共计326名新冠肺炎抗疫一线的医护人员进行问卷调查;采用单因素及多因素Logistic回归分析职业暴露的潜在危险因素,构建医护人员职业暴露事件的风险预测模型.结果 (1)通过单因素及多因素回归分析最...     

Increase in Frailty in Nursing Home Survivors of Coronavirus Disease 2019: Comparison With Noninfected Residents

ObjectivesInstitutionalized older adults have a high prevalence of frailty and disability, which may make them more vulnerable to the negative consequences of coronavirus disease 2019 (COVID-19). We investigated the impact of COVID-19 on the level of frailty, physical, and cognitive performance in nursing home residents.DesignNested case-control study.Setting and ParticipantsThe study included nursing home residents who were infected with COVID-19 (case group, n = 76), matched by age to a control group (n = 76).MethodsParticipants’ sociodemographic and medical data were collected, and they were also assessed for physical function (handgrip and walking speed), cognitive performance (Mini-Mental State Examination) and frailty (Frail-NH scale) before the first wave of the COVID-19 pandemic (October to December 2019, pre-COVID-19) and after (June to July 2020, post-COVID-19). COVID-19 symptoms and clinical course were recorded for the cases.ResultsBetween the pre- and post-COVID-19 assessments, we found a 19% greater deterioration in handgrip, a 22% greater decrease in walking speed, and a 21% greater increase in Frail-NH scores in cases compared with controls. In both cases and controls, on the other hand, there was a significant 10% decrease in Mini-Mental State Examination scores over the study period. Multivariable logistic regression showed that COVID-19 survivors had a 4-fold increased chance of developing frailty compared with controls (odds ratio 4.95, 95% confidence interval 1.13–21.6, P = .03), but not cognitive decline.Conclusions and ImplicationsCOVID-19 can accelerate the aging process of institutionalized older adults in terms of physical performance and frailty by around 20%. However, we found similar levels of decline in cognitive performance in both cases and controls, likely because of the burden of social isolation and containment measures on neuropsychological health.