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CONFRONTING CORONAVIRUS

Some Swedish care homes have had no cases of Covid-19 – what did they do right?

At least 234 of Sweden's 290 municipalities have elderly care homes with confirmed or suspected coronavirus cases. But a handful seem to have been able to protect residents from Covid-19, in some cases despite staff being infected. So what did they do differently, and could their strategies be applies elsewhere?

Some Swedish care homes have had no cases of Covid-19 – what did they do right?
An elderly care home in Nödinge allows distanced family visits. Photo: Thomas Johansson/TT

“I think the debate on the flaws in elderly care has been lacking nuance. I don't think there have been sufficient efforts to try to describe the underlying reasons for why the spread of infection has been great in different regions. There are almost 60 municipalities which have had better success,” Ebba Gierow, head of social affairs in the Ale municipality, told the TT newswire.

This is one of the municipalities which by late June had not recorded any cases of coronavirus in its five municipal care homes.

Ale is located in Västra Götaland, a region where the spread arrived later and more slowly than for example Stockholm – partly due to the timing of spring school holidays in both regions.

Gierow said that this meant care homes in Västra Götaland had the chance to improve their hygiene routines and make sure that all employees who showed symptoms stayed at home, two of the factors that have long been identified by authorities as decisive in limiting the spread.

Equipment

Beyond this proactive attitude, another tangible factor which has helped certain care homes in preventing or slowing down the spread of the coronavirus in their facilities has been the access to protective clothing.

Gierow explained that Ale decided that “they couldn't sit around and wait for national channels to provide us with equipment”.

Instead, they immediately drove to construction warehouses and other stores to stock up on equipment, and continually kept stock to ensure their supplies would not run out and source more protective clothing. 


Photo: Fredrik Sandberg/TT

Accessing protective equipment when it was in such high demand not only in Sweden but internationally was one of the major challenges for the care sector.

Greger Bengtsson, head of elderly care at the umbrella association for Sweden's municipalities and regions (SKR), told The Local that “we knew we should protect staff and residents, but we didn't have the necessary materials”, which instead went to Sweden's hospitals in the first instance.

“Not until about a month ago did care homes start to receive adequate supplies,” Bengtsson said.

And in Ale, the investment in protective equipment was not only a way to keep staff and residents safe, but also to boost perceived safety.

“It was a challenge, but protective equipment gives a feeling of security. You can't expect staff to go out and do their job well if they're scared. We put a lot of money into this in Ale. We did an evaluation and decided that was the right thing to do,” she said. 

A recent report published by SKR on the situation in care facilities stated that more equipment is not always the best option. For example, certain high grade face masks have valves which mean that, while the wearer is protected, their exhaled air is released unfiltered into their surroundings. Infected but asymptomatic staff wearing this kind of mask could therefore put elderly residents at increased risk. 

Another problem was that funds varied between municipalities, so in early April SKR began acting as a purchaser on behalf of all Sweden's municipalities, as a way to ensure it could act on the world market and ensure equipment was distributed where needed.


Photo: Fredrik Sandberg / TT

Early visitor bans

According to Bengtsson, another major obstacle in protecting care home residents was legislation.  

It was only on April 1st that the government declared a visitors' ban for all municipal care homes. Some municipalities had prohibited visits days or even weeks earlier. This meant they may have broken the law on accessibility of these facilities, which are intended to be an open part of society, but in doing so they may have saved lives.

One of the quickest to act, Luleå, which banned visits on March 20th, has cited this as a factor behind the municipality reporting only one care home death from Covid-19. And the Skåne region, where 85 percent of homes reported no infection at all, introduced a visitor ban 10-12 days before the national one.

However, this was only one of several measures in Skåne which may have had an effect, with others including more widespread testing of staff and residents in care homes than other regions, multilingual information campaigns about the coronavirus from an early stage, and a deal which means specialised hygiene nurses hired by the region work in care homes.

Signs on a care home entrance warning of a visitor ban. Photo: Anders Wiklund / TT

Fewer hourly staff

Another factor which has repeatedly surfaced in the debate on how the virus spread in Sweden's care homes so quickly is the high proportion of temporary staff, who often work in multiple facilities. On hourly contracts, these workers were not protected by extended sick pay legislation, which may have given them less incentive to follow national guidelines in staying home if showing the slightest cold or flu symptoms.

A relatively low proportion of hourly workers is a factor common to Ale and other municipalities which have not reported any cases of coronavirus, including Stenungssund and Alingsås. However, it's hard to assess the direct impact of this, partly because in the hard hit care homes, it's almost impossible to know how the infection entered the facility and spread.

Speaking to reporters in early May, the Public Health Agency's Head of the Department for Antibiotics and Infection Control Malin Grape said there was no clear common factor that pointed to how the infection got into affected care homes in Stockholm and Sörmland.

Some of the possibilities the Public Health Agency has pointed to after speaking with care homes include new arrivals to the homes or residents returning from hospital stays, family visits, or asymptomatic staff, as well as a high proportion of hourly workers. 

It is not possible to pinpoint the exact actions that determined why some municipalities avoided outbreaks in their care homes – and luck will have played some part.

But in order to give staff the necessary support and training, provide the right equipment in sufficient quantities, and take further measures as needed to protect staff and residents, quick reaction and adaptation to a fast-moving and unprecedented situation was essential. That can only come from an engaged leadership.

In Ale, Gierow says the strategy was hands-on from the start. 

“Managers have worked with a close leadership. They've spent a lot of time on the ground, answering questions, supporting staff and simply being around,” she said. “This provides support and security, which means a lot for staff being able to manage” with the pressure of protecting the most vulnerable group in society from the virus.

With reporting by Anne Grietje Franssen and TT's Petronella Uebel

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COVID-19 RULES

Germany should prepare for Covid wave in autumn, ministers warn

German health ministers say that tougher Covid restrictions should come back into force if a serious wave emerges in autumn.

Germany should prepare for Covid wave in autumn, ministers warn

Following a video meeting on Monday, the health ministers of Germany’s 16 states said tougher restrictions should be imposed again if they are needed. 

“The corona pandemic is not over yet – we must not be deceived by the current declining incidences,” said Saxony-Anhalt’s health minister Petra Grimm-Benne, of the Social Democrats, who currently chairs the Conference of Health Ministers (GMK).

According to the GMK, new virus variants are expected to appear in autumn and winter. Over the weekend, federal Health Minister Karl Lauterbach (SPD) also warned that the more dangerous Delta variant could return to Germany. “That is why the federal Ministry of Health should draw up a master plan to combat the corona pandemic as soon as possible and coordinate it with the states,” Grimm-Benne said.

Preparations should also include an amendment of the Infection Protection Act, ministers urged. They want to see the states given powers to react to the infection situation in autumn and winter. They called on the government to initiate the legislative process in a timely manner, and get the states actively involved.

The current Infection Protection Act expires on September 23rd this year. Germany has loosened much of its Covid restrictions in the last months, however, face masks are still compulsory on public transport as well as on planes. 

READ ALSO: Do people in Germany still have to wear Covid masks on planes?

The health ministers said that from autumn onwards, it should be possible for states to make masks compulsory indoors if the regional infection situation calls for it. Previously, wearing a Covid mask was obligatory in Germany when shopping and in restaurants and bars when not sitting at a table. 

Furthermore, the so-called 3G rule for accessing some venues and facilities – where people have to present proof of vaccination, recovery, or a negative test – should be implemented again if needed, as well as other infection protection rules, the ministers said. 

Bavaria’s health minister Klaus Holetschek, of the CSU, welcomed the ministers’ unanimous call for a revision of the Infection Protection Act. “The states must be able to take all necessary infection protection measures quickly, effectively, and with legal certainty,” he said.

North Rhine-Westphalia’s health minister Karl-Josef Laumann (CDU) warned that no one should “lull themselves into a false sense of security”.

“We must now prepare for the colder season and use the time to be able to answer important questions about the immunity of the population or the mechanisms of infection chains,” he said.

On Tuesday, Germany reported 86,253 Covid infections within the latest 24 hour period, as well as 215 Covid-related deaths. The 7-day incidence stood at 437.6 infections per 100,000 people. However, experts believe there could be twice as many infections because lots of cases go unreported. 

READ ALSO: Five things to know about the Covid pandemic in Germany right now

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