環境感染誌

Vol. 37 no. 5, 2022

〈報 告〉Actual Conditions of COVID-19 Infection Control in Nursing Homes
Di WANG
Department of Infection Control Nursing, Graduate School of Health Care and Nursing, Juntendo University(Received: April 8, 2022; Accepted: June 13, 2022)
Abstract
This study aimed to clarify the actual conditions of COVID-19 infection control in Japanʼs nursing homes (NH). An anonymous self-administered questionnaire survey was conducted among
500 facility managers from 500 randomly selected NH. Of the 66 returned questionnaires, 64 hadvalid responses (12.8%). Medical qualifications were not observed in 56.3% of the respondents.
Additionally, the responses “There is a manual available to detect and manage a resident withsuspected COVID-19,” “Training on COVID-19 measures for staff,” and “Staff training participation rate” accounted for 81.3%, 67.2%, and 67.1%, respectively. However, 64.1% answered “Thereis a countermeasure for staff who cannot participate in infectious disease control training.” “Infection control specialists” were few, and the “Infection control status” varied between facilities. Establishing a system that facilitates access to support from infection control specialists and training infection control personnel in NH is necessary.
Key words: Nursing Homes, COVID-19 Infection Control

cult.

Introduction

In this study, we aimed to determine the actual situ-

Geriatric welfare facilities reported 1310 cases of１）

COVID-19 in Japan . Also, many COVID-19 cases in２）ation of COVID-19 infection control in NH in the Kanto

NH have been reported in the United States . While

Region, where the number of COVID-19 cases in Japansome are severe, most of these cases and its diseaseis high. Through this assessment, suggestions for effec-

onset are mild to moderate. Elderly people aged above

tive control methods will be provided.

60-years old and those with comorbidities are at ahigher risk of developing a severe disease when in-Material and methods

fected with COVID-19３）. In fact, many COVID-19-

Design２，
４）

related deaths in NH have been reported . Asympto-

This research is a cross-sectional study, which con-matic subclinical infection can occur even after resolv-

ducts an anonymous self-administered questionnaireing SARS-CoV-2 infection; sub-clinically infected indi-

survey.
Setting and participantsviduals carry SARS-CoV-2, and they serve as a source
５）

of infection . Considering that COVID-19 is transmitted

The target research facilities were determinedfrom infected and subclinically-infected poeple several

through the Elderly Welfare Facility Information Post-

days before the disease onset, the infection unknow-

ing Page on the homepages of 47 prefectures nation-

ingly spreads from presymptomatic-facility staff orwide; this page is linked to the Welfare and Medical

asymptomatic-infected residents to other residents６）. In

Service Network System７）. We randomly selected 500

addition, daily care often forces staff to be in close con-facilities from 2631 facilities listed in the NH list of thetact with residents, and it is difficult to require hygi-

abovementioned prefectures. Our participants wereenic behavior from residents with cognitive decline.

composed of 500 facility managers, each from the 500

Due to the aforementioned factors, the implementation

research facilities.

of infection control measures in NH is considered diffi― 204 ―環境感染誌
Table 1Vol. 37 no. 5, 2022

Sample characteristics (N ＝64)

Characteristics

Mean±SD (Range)

Qualification
Physician
Nurse
Certified care worker
OthersYears of work experience
Years of experience as a facility manager
Living room type
Completely private room type
Mixed type of private room/multi-bedroom
Completely multi-bedroom type
Facility daily capacity
Number of residents
Number of daycare users
Number of regularly employed nurses and care workers
Number of nurses
Number of certified care workers
Number of long-term care staff who do not have a certified care workers
Employs foreign nurses and care workers
Number of foreign nurses and care workers

n (%)
0 (0.0)18 (28.1)
10 (15.6)
36 (56.3)

21.8±9.5 (2‒41)5.7±4.7 (1‒21)30 (46.9)
29 (45.3)
5 (7.8)105.6±32.8 (47‒216)
16.8±17.0 (0‒60)
5.9±2.7 (2‒18)33.5±12.3 (10‒84)15.3±8.9 (2‒59)
35 (54.7)
2.1±2.6 (0‒10)

SD: standard deviation

Date collection

and the return of answered questionnaires indicatedFrom September 1 to December 31 in 2021, we con-participantsʼ consent to participate. The ethics commit-

ducted an anonymous self-administered questionnairetee of our university approved this study (Approval

survey via mail.

Number: Jun kan Rin No.2021-29).

Survey item
The questionnaire has 65 survey items, comprising

Results

the basic attributes (8 items) and COVID-19 infection

Out of 500 participants, only 66 returned the ques-control items (57 items). The COVID-19 infection con-tionnaires (response rate 13.2%). Among them, 64

trol items were developed according to the World(without defects) had valid responses (12.8%). The basic

Health Organizationʼs COVID-19 Infection Prevention

attributes are as shown in Table 1.
We found that all participants (64 [100%]) reported

and Control Preparedness Checklist for Long-Term
８）

and the infection control issues related“There is an infection control manual,” whereas 52

to COVID-19 countermeasures, noticed by two certi-(81.3%) claimed “There is a manual available to detect

fied infection control nurses during the cluster re-and manage a resident with suspected COVID-19.”

sponse in the destination countries. To ensure the con-Moreover, 54 (84.4%) participants answered “Ensure

tent validity of the questionnaire, we examined it withprocesses are available to detect and manage a resi-

two infection control specialists. We also conducted adent with suspected COVID-19,” and 37 participantspretest together with five facility managers to exam-

answered “Establish a flexible shift schedule to coverine the surface validity of the questionnaire items.

enough staff to care for residents with suspected orCare Facilities

Analysisconfirmed COVID-19.” We also found 29 (45.3%) partici-

All items were summarized by descriptive statistics.

pants who reported that their facilities “Develop andPercentages were calculated for nominal and ordinalmaintain a contact list of healthcare facilities where

variables; means and standard deviations for continu-

suspected cases can be referred for emergency,” butous variables. SPSS for Windows (version 21.0) was

only few “Ensure that guidelines on IPC for safe man-used for the statistical analysis.

agement of deceased residents in the context of
COVID-19 are available” (9 [14.1%]) (Table 2).

Ethical considerations
The questionnaires were anonymously answered,― 205 ―

Regarding health management, all 64 participants

環境感染誌

Vol. 37 no. 5, 2022
Table 2

Organization and planning (N ＝64)

Characteristics

Mean±SD (Range)

Assign a COVID-19 preparedness planning team
Annual frequency of meetings on infection control
Assign a staff in charge of IPC
Number of staff in charge of IPC
There is an infection control manual
There is a manual available to detect and manage a resident with suspected COVID-19
Ensure processes are available to detect and manage a resident with suspected
COVID-19
Establish a flexible shift schedule to cover enough staff to care for residents withsuspected or confirmed COVID-19
Develop a surge capacity plan for extra staff, personal protective equipment andconsumables required for IPC
Develop and implement a screening and documentation process for all persons entering
the facility
There are infection prevention measures in shared spaces
Establish criteria to discharge residents from isolation
Secure space in the facility to isolate residents suspected of COVID-19
Ensure that guidelines on IPC for safe management of deceased residents in thecontext of COVID-19 are available
There are rules for infectious disease control regarding the acceptance of short-term
residents
Develop and maintain a contact list of healthcare facilities where suspected cases canbe referred for emergency
Prepare a communications plan for what events will trigger communication withresidents and their families in an event of a COVID-19 outbreak
Ensure emergency contact name, addresses, and telephone numbers for residentsʼ
family is up to daten (%)
64 (100)

13.6±12.1 (4‒52)
63 (98.4)
4.9±4.8 (0‒18)64 (100)
52 (81.3)
54 (84.4)
37 (57.8)
64 (100)
57 (89.1)
59 (92.2)
59 (92.2)
49 (76.6)
9 (14.1)
59 (92.2)
29 (45.3)
54 (84.4)
51 (79.7)

IPC: infection prevention and control; SD: standard deviation(100%) answered that their facilities “Assess all staff

Discussion

and residents daily for symptoms suggestive ofIn this study, approximately 20% of the facilities

COVID-19,” and 57 (89.1%) claimed that they “Keep a

could not make a manual on COVID-19 and only 14.1%

record of all people who enter the facility for contact

answered “Ensure that guidelines on IPC for safe man-tracing.” Regarding infection prevention measures,

agement of deceased residents in the context of“Ensure good ventilation” and “Cleaning staff should

COVID-19 are available.” NHʼs physicians, nurses, andclean and disinfect the environment at least daily, fo-

infection control specialists is understaffed. Therefore,cusing on frequently touched surfaces” were the most

preparing a manual for COVID-19 according to thecommon (100%). The least common was “Reduce thestructural aspects of the facility and the characteristic

number of shared items between residents” (6 [9.4%])of the user is difficult. Consequently, creating an envi-(Table 3).

ronment where all facilities can easily consult with in-

Regarding education on COVID-19 measures, “Train-

fection control specialists for manual preparation is

ing on COVID-19 measures for staff” was implemented

necessary so that all facilities can prepare a manual onin 43 (67.2%) facilities. The participation rate of the

COVID-19.

training was 67.1±28.9 (range: 10-100), and 41 partici-

Most NH are not prepared for a SARS-CoV-2 pan-pants (64.1%) reported “There is a countermeasure fordemic９）. In this study, approximately 20% of the facili-

staff who cannot participate in infectious disease con-ties did not confirm the feasibility of COVID-19 coun-

trol training.” Additionally, 31 (48.4%) “Ensure opportu-

termeasures in their own facilities. When an infectious

nities for staff to share concerns and worries regu-

disease occurs, a prompt response may not be possible.

larly,” Meanwhile, “Advice on coping with stress andTherefore, the feasibility of COVID-19 infection control

staying healthy” was only implemented by 23 (35.9%)

from normal times should be confirmed, and a systemfacilities, lower than other items (Table 4).

that allows easy consultation with infection control specialists should be established. NH also experienced per― 206 ―環境感染誌
Table 3Vol. 37 no. 5, 2022

Measures to protect a safe working environment and management of goods (N ＝64)
Characteristics

Mean±SD (Range)

Assess all residents daily for symptoms suggestive of COVID-19
Assess all staff daily for symptoms suggestive of COVID-19
Keep a record of all people who enter the facility for contact tracing
Ensure good ventilation
Cleaning staff should clean and disinfect the environment at least daily, focusing on
frequently touched surfaces
Ensure that all gatherings in crowded or close-contact places are minimized or cancelled
Ensure adequate supplies of PPE and other hygiene/cleaning items
Ensure hand hygiene materials are available in every resident room and all other careand common areas
Ensure informative posters are placed around the facility on hand hygiene andtransmission-based precautions
Ensure that all resident personal equipment and belongings are labelled
Clean and disinfect shared items after every use between residents
Ensure dedicated equipment for the care of isolated residents
Reduce the number of shared items between residents
The facilityʼs infection control manual contains instructions on how to handle
contaminated linen
Instructed to wear PPE when disposing of contaminated linens
The facilityʼs infectious disease control manual includes instructions on how to disposeof infectious waste
Instructed to wear PPE when disposing infectious wastes
Implement infectious disease countermeasures in staff break rooms
Implement infectious disease control in staff changing rooms
Implement infectious disease control in smoking areas
Take measures against infectious diseases in the nap room
Frequent contact surface cleaning frequency
Toilet cleaning frequencyn (%)
64 (100)
64 (100)
57 (89.1)
64 (100)
64 (100)59 (92.2)
64 (100)
63 (98.4)
58 (90.6)
59 (92.2)
60 (93.8)
56 (87.5)
6 (9.4)54 (84.4)
63 (98.4)
61 (95.3)
62 (96.9)
61 (95.3)
53 (82.8)
47 (73.4)
40 (62.5)

1.98±0.97 (1‒5)
1.54±0.58 (1‒3)

PPE: personal protective equipment; SD: standard deviation

Table 4

Education and training about COVID-19 (N ＝64)

Characteristics

Mean±SD (Range)

Training on COVID-19 measures for the staff
Annual frequency of training
Staff training participation rate
Educate staff on what to do if they are diagnosed or suspected of having COVID-19
Educate staff members on what to do if they are diagnosed or suspected of having
COVID-19
There is a countermeasure for staff who cannot participate in infectious disease
control training
Educate them to wash their uniforms on every shift
Have daily communication between administers, IPC focal point, and the staff
Ensure opportunities for the staff to share concerns and worries regularly
Advice on coping with stress and staying healthy
Ensure COVID-19 information is visible for residentsʼs family
Ensure COVID-19 information is visible for visitors
Provide COVID-19 information for residents
Encourage and support residents to communicate with their family using methods oftelecommunications, when visits are not allowed or limitedn (%)
43 (67.2)

3.1±2.98 (0‒12)67.1±28.9 (10‒100)
56 (87.5)
52 (81.3)
41 (64.1)
41 (64.1)
55 (85.9)
31 (48.4)
23 (35.9)
29 (45.3)
41 (64.1)
37 (57.8)
61 (95.3)

IPC: infection prevention and control; SD: standard deviation

sonnel shortage due to the spread COVID-19 infec-

enough staff to care for residents with suspected ortion４，１０）. In this study, approximately 50% of the respon-

confirmed COVID-19 during the COVID-19 outbreak.

dents established a flexible shift schedule to coverCreating a work plan for business continuity according― 207 ―

環境感染誌

Vol. 37 no. 5, 2022

to the facilityʼs characteristics is necessary. 9.4% of theConclusions

respondents chose “reduce the number of shared items

The preparation of a manual on COVID-19 and theamong residents.” NH have no additional long-term

implementation status of infection-prevention educa-care fee for infection prevention measures, and the in-tion and mental health care were varied. This variation

troduction of disposable products puts pressure on thewill affect the effectiveness of implementing COVID-19

financial side, making the purchase of medical equip-

measures and may lead to infection of users and thement and goods for infection prevention measures diffi-

staff. Establishing a system to easily receive the sup-cult. Therefore, additional infection control measures in

port of infection control specialists in NH and develop-

facilities need to be considered.

ing human resources for infection control in NH re-

67.2% of the respondents answered that their facili-

main a challenge.

ties conducted “Training on COVID-19 measures forthe staff.” However, only 41 (64.1%) answered that they
had measures for employees who cannot participate in

Acknowledgments: I am sincerely thanks all the participantsin this study.

the infectious disease control training. COVID-19 is an
emerging infectious disease, and education on COVID19 countermeasures is challenging in NH considering

Funding: This work was supported by Japan Grants-in-Aid for
Scientific Research KAKENHI [Grant Number: 21K17441].

the few specialists in infectious disease countermeasures. In addition, the staff have different occupations

Declarations of interest: None.

with different backgrounds on education on infectious
diseases; hence, the status of understanding and imple-

References

mentation of infectious disease countermeasures weredifferent between occupations１１）. Support for infectious
disease control education by infection control specialists, training of infection control education personnel atfacilities, and methods for dealing with staff who could
not participate remain as issues.
The NH staff have been physically and mentallyburdened during the course COVID-19 pandemic,
which led to burnout１２）. In this study, “Advice on coping with stress and staying healthy” was 35.9%, which
tended to be lower than other items. Although mental
health care for employees in NH with few infection
control specialists is difficult to implement, a support
system for mental health care should still be established and maintained.
Limitations
The response rate for this survey was low, whichhave resulted in response bias. Many respondents
were non-medical professionals, which may affect thevalidity of their responses. Furthermore, the survey
items did not include experience in accepting or clustering COVID-19 patients; thus, cannot be generalized.
However, we believe that the survey results clarified
the actual situation and practical problems of infection
control regarding COVID-19 in NH.

― 208 ―

1）Ministry of Health, Labour and Welfare: Visualizing thedata: information on COVID-19 infections: https://covid19.
mhlw.go.jp/en/. accessed March 14, 2022.
2）Centers for Medicare and Medicare Services: COVID-19
nursing home data: https://data.cms.gov/covid-19/covid-1
9-nursing-home-data. accessed March 14, 2022.
3）Matsunaga N, Hayakawa K, Terada M, Ohtsu H, Asai Y,
Tsuzuki S, et al.: Clinical epidemiology of hospitalized patients with coronavirus disease 2019 (COVID-19) in Japan:
report of the COVID-19 Registry Japan. Clin Infect Dis
2021; 73(11): e3677-89.
4）Fisman DN, Bogoch I, Lapointe-Shaw L, McCready J, Tuite AR: Risk factors associated with mortality among residents with coronavirus disease 2019 (COVID-19) in longterm care facilities in Ontario, Canada. JAMA Netw Open
2020; 3: e2015957.
5）Oran DP, Topol EJ: The proportion of SARS-CoV-2 infections that are asymptomatic: a systematic review. Ann Intern Med 2021; 174: 655-62.
6）Bayle C, Cantin D, Vidal JS, Sourdeau E, Slama L, Dumesges N, et al.: Asymptomatic SARS COV-2 carriers among
nursing home staff: a source of contamination for residents? Infect Dis Now 2021; 51: 197-200.
7）Welfare And Medical Service Network System: https://www.wam.go.jp/content/wamnet/pcpub/top/whatwamnet/
ca00b11.html. accessed August 30, 2021.
8）World Health Organization: COVID-19 infection prevention and control: preparedness checklist for long-term carefacilities: https://www.who.int/publications/i/item/WPR-D
SE-2020-028. accessed March 14, 2022.
9）Bernabeu-Wittel M, Ternero-Vega JE, Nieto-Martín MD,
Moreno-Gaviño L, Conde-Guzmán C, Delgado-Cuesta J, etal.: Effectiveness of a on-site medicalization program fornursing homes with COVID-19 outbreaks. J Gerontol A
Biol Sci Med Sci 2020; 1-9.
10）Ouslander JG, Grabowski DC: COVID-19 in nursing homes:
calming the perfect storm. J Am Geriatr Soc 2020; 68:
2153-62.

環境感染誌
11）Wang D, Kawakami K, Kudo A, Iwabuchi K: Current
status and issues of learning norovirus infection control of
the three types of staff members who work at special elderly nursing home. Japanese Journal of Infection Prevention and Control 2020; 35: 168-74.
12）Navarro Prados AB, Jiménez García-Tizón S, Meléndez JC:
Sense of coherence and burnout in nursing home workers
during the COVID-19 pandemic in Spain. Health Soc CareVol. 37 no. 5, 2022

Community 2022; 30: 244-52.
〔Reprint request:
Di Wang, Department of Infection Control Nursing, Graduate
School of Health Care and Nursing, Juntendo University,
TakasuE-mail: t-ou@juntendo.ac.jp〕

特別養護老人ホームにおける COVID-19 感染管理の実態
王迪

順天堂大学大学院医療看護学研究科
要旨
本研究の目的は特別養護老人ホーム（特養）における Coronavirus Disease 2019（COVID-19）に関する感染管理の実態を明らかにすることである．
日本の関東地方にある特養から無作為に抽出した 500 施設の施設責任者 1 名を対象とし，2021
年 9 月〜12 月に自記式質問紙調査を行った．
64 名（12.8%）の回答を分析対象とした．医師・看護師・介護福祉士の資格を持っていない者が多かった（56.3％）．「COVID-19 に関するマニュアルがあり」が 81.3%．「COVID-19 感染症対策に関する職員教育を行った」が 67.2%，職員の研修参加率は 67.1% であったが，「研修に参加できな
い職員への対応方法があり」が 64.1% であった．気軽に感染管理の専門家の支援を受けられる体制の整備および特養における感染管理の人材育成が課題となった．感染管理に関する教育プログラムの開発が必要と考えられる．
Key words：特別養護老人ホーム，COVID-19 感染管理
〔連絡先：〒279-0023 千葉県浦安市高洲 2-5-1
順天堂大学医療看護学部 王迪E-mail: t-ou@juntendo.ac.jp〕― 209 ―