CIHI
Snapshot
June 2020

Pandemic Experience in theLong-Term Care Sector
How Does Canada Compare With Other Countries?

Issue
Canada’s long-term care (LTC) sector has been especially hard hit by the COVID-19 pandemic.
More than 840 outbreaks have been reported in LTC facilities and retirement homes, accounting
for more than 80% of all COVID-19 deaths in the country (as of 9 p.m. ET on May 25, 2020).
This short analysis examines the similarities and differences between Canada’s pandemic
experience in LTC and that of other countries in the Organisation for Economic Co-operationand Development (OECD). Specifically, it focuses on 3 areas of comparison:• COVID-19 outcomes in LTC (cases and deaths);• Baseline sector characteristics; and• Policy responses to address the pandemic.
Comparisons must be interpreted with extreme caution due to rapidly evolving
infection case numbers, different definitions of LTC and variations acrosscountries in COVID-19 testing and reporting practices.

How to cite this document:
Canadian Institute for Health Information. Pandemic Experience in the Long-Term Care
Sector: How Does Canada Compare With Other Countries?. Ottawa, ON: CIHI; 2020.Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?

CIHI Snapshot

Key findings
The analysis includes Canada and 16 other OECD countries that had sufficient data for reporting:Australia, Austria, Belgium, France, Germany, Hungary, Ireland, Israel, Italy, the Netherlands, Norway,
Portugal, Slovenia, Spain, the United Kingdom and the United States.

COVID-19 outcomes in LTC• As of May 25, 2020, the number of reported COVID-19 deaths among LTC residents varied

substantially, from 28 in Australia to 30,000 in the United States, with more than 10,000 in France,Italy, Spain and the U.K. The number of LTC residents who had died of COVID-19 in Canada(5,324) was similar to the average of OECD countries.

• While Canada’s overall COVID-19 mortality rate was relatively low compared with the rates in otherOECD countries, it had the highest proportion of deaths occurring in long-term care. LTC residents
accounted for 81% of all reported COVID-19 deaths in Canada, compared with an average of 38%
in other OECD countries (ranging from less than 10% in Slovenia and Hungary to 66% in Spain).

• Variation among Canada’s provinces and territories was greater than variation among OECDcountries. As of May 25, Newfoundland and Labrador, Prince Edward Island, New Brunswick
and the territories had no reported deaths in retirement homes and LTC facilities, whereas LTC
deaths represented over 70% of all COVID-19 deaths in Quebec, Ontario and Alberta and 97%
of all deaths in Nova Scotia. Generally, jurisdictions with lower COVID-19 infection rates in thecommunity reported fewer LTC cases and deaths.

• As a proportion of total COVID-19 cases in Canada, about 1 in 5 (18%) were among LTC residents.
Internationally, this proportion ranged from under 1% of total cases in Australia to 51% in France
and 73% in the U.K.

• The proportion of infected LTC residents who died from the disease also varied considerably acrosscountries, from 4% in Slovenia to 83% in Norway. In Canada, the mortality rate for those infectedwith COVID-19 in LTC was about 35% as of May 25.

• Many countries have reported high rates of infection among health care workers, leading toabsenteeism and staffing shortages. In Canada, more than 9,650 LTC staff members were infectedby COVID-19, representing more than 10% of the country’s total cases. As of May 25, 9 of these
health care workers had died of COVID-19.

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Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?

CIHI Snapshot

Figure 1	COVID-19 deaths as of May 25, 2020, at 9 p.m.
A

Number per million population, total and LTC

900
800
700
600
500
400
300
200
100

B

um

Belgi

ain
SpK.
U.

ly
ItaceansFrrlanddlan

NetheS.

OE

Number of COVID-19
deaths per million population

IreU.

eager

CDavldanaCagartuyan

Poiarm

GeAu

str

yarng

ia
en

HuovaySllrw

NoaeIsrAu

stralia0

Number of LTC COVID-19deaths per million population

Percentage of all COVID-19 deaths, LTC

OECD
Australia Israel Norway Slovenia Hungary Austria Germany Portugal Canada average U.S. Ireland Netherlands France Italy U.K. Spain
285858971934

25

8138

3156

1548

322766

Belgium
50

Notes
OECD: Organisation for Economic Co-operation and Development.
LTC: Long-term care.
The situation is evolving rapidly and this data represents a snapshot of the pandemic in countries reported by May 25, 2020, at 9 p.m. ET.
Reporting of COVID-19 cases and deaths in the LTC sector is not directly comparable due to different testing and reporting standards across countries,
as well as to different definitions of LTC. In many countries, COVID-19 cases in this sector are under-reported.
Data for Italy is available from only 52% of the nursing homes operating in the country.
Sources
World Health Organization. Coronavirus disease (COVID-2019) situation reports. Accessed May 25, 2020.
World Health Organization Europe. Coronavirus disease (COVID-19) outbreak reports: Country information. Accessed May 25, 2020.
United Nations Department of Economic and Social Affairs, Population Division. World Population Prospects 2019. 2019.
European Centre for Disease Prevention and Control. Accessed May 25, 2020.
National Institute on Ageing. NIA Long-Term Care COVID-19 Tracker. Accessed May 25, 2020.
Daily epidemiological summaries produced by each country, where available, March 1 to May 25, 2020 (e.g., Public Health Agency of Canada,
Robert Koch Institute of Germany).
International Long-term care Policy Network. Accessed May 25, 2020.

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Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?

CIHI Snapshot

Baseline sector characteristics• The proportion of seniors (age 65 and older) living in LTC and retirement homes is higher in Canada
than it is in the average of OECD countries. However, results may vary due to different definitions ofLTC across countries.

• Variation in LTC use among seniors also exists within Canada, where a more consistent definitionof LTC is used (see Figure 2).

• Compared with other OECD countries, Canada’s LTC population tends to be older, with 91% of LTCand retirement home residents over age 65 and 74% over age 80.

• Compared with the OECD average, Canada had fewer health care workers (nurses and personal supportworkers) per 100 senior residents of LTC homes in 2018, with a rate that was half as high as the rates in
the Netherlands and Norway.

• OECD countries varied widely in reported patient safety issues prior to the pandemic. Countries withhigher rates of infection and pressure ulcers in LTC in 2019 (Spain, Portugal, Italy) tended to have more
COVID-19 cases and deaths in this sector.

• OECD countries have different models of funding and regulation for LTC. While no clear differencesin pandemic outcomes were observed across funding models (public, private or mixed), countries withcentralized regulation and organization of LTC (e.g., Australia, Austria, Hungary, Slovenia) generally
had lower numbers of COVID-19 cases and deaths.

Figure 2	Percentage of seniors (65+) in LTC by province andterritory, 2018–2019

10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
utav

NorthwestNunritoriesnkoTerYuiambolunrta
behC

Alitis
BrSa

sk

atc

hewa

ba
itoioMantarOnCNe ana
an wfo dad L un
Prab dlainc
e E rad nddw orardIslandNova
Sc
oti
Neaw
Brun
sw
ickQu
eb
ec

0%

Notes
LTC: Long-term care.
Data includes nursing homes, retirement homes and homes for residents with disabilities or mental health needs.
SourceStatistics Canada. Data tables, 2016 Census: Type of collective dwelling (16), age (20) and sex (3) for the populationin collective dwellings of Canada, provinces and territories, 2016 Census — 100% data. Accessed May 25, 2020.

4

Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?

CIHI Snapshot

Policy responses to address the pandemic• Countries that implemented specific, mandatory prevention measures targeted to the LTC sector at the sametime as their stay-at-home orders and closure of public places (Australia, Austria, the Netherlands, Hungary,Slovenia) had fewer COVID-19 infections and deaths in LTC. These prevention measures included immediate
infection control measures, such as broad LTC testing and training, isolation wards to manage clusters,
and additional supports for LTC workers such as surge staffing, specialized teams and personal protective
equipment (PPE) (see Figure 3).

Figure 3	Impact of COVID-19 on LTC residents by level of policy
response at the time of 1,000 COVID-19 cases

60%

Canada, France, Norway,Spain, U.S., U.K.

Israel, Belgium,Italy

Hungary, Portugal,Ireland, Netherlands

Austria, Australia,
Slovenia

Policy response 1• Stay-at-home order• Economic stimulus• Acute care funding

Policy response 2All in response 1 and• LTC visitor restrictions• LTC guidance

Policy response 3
All in response 2 and• Hazard pay• LTC surge staffing• LTC recruitment• PPE funding

Policy response 4
All in response 3 and• LTC isolation wards• Broad LTC testing• LTC infection control
training and audit• LTC rapid response control
and prevention teams

50%
40%
30%
20%
10%0%

COVID-19 deaths in LTC as apercentage of all COVID-19 deaths

COVID-19 deaths in LTC as apercentage of COVID-19 cases

Notes
LTC: Long-term care.
PPE: Personal protective equipment.
Countries are grouped according to which policy interventions were announced as mandatory at the time of a country’s first reported
1,000 COVID-19 cases.
Policy implementation can vary substantially within countries as some of these measures may be applied at the local level only. Each COVID-19
policy response includes the interventions from the previous level.
Specific policies and their implementation differ widely across regions or provinces of a country. For instance, the level of enforcement measures
may vary across regions of a country and may have changed with the evolution of the outbreak in certain regions where more local measures may
have been implemented. Some regions or provinces may have acted earlier than the national announcement in order to better manage their own
outbreaks; however, the category of policy response did not change as a whole for the country.
Sources
World Health Organization. COVID-19 Health System Response Monitor. Accessed May 25, 2020.
International Long-term care Policy Network.
Organisation for Economic Co-operation and Development. AI Policy Observatory.
North American Observatory on Health Systems and Policies.

5Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?

CIHI Snapshot

Notes and limitations
Data for this analysis was sourced from official international publications (from the OECD, World HealthOrganization, etc.), country websites, and the media and published literature. Interpretation of thisinformation needs to consider the following:• The situation is evolving rapidly and this data represents a snapshot as of May 25, 2020, at 9 p.m. ET.
• Data on COVID-19 cases and deaths was collected from official surveillance websites. OECD peer
countries that do not report publicly on their LTC sector were not included.

• Reporting of COVID-19 cases and deaths in the LTC sector is not directly comparable due to different
testing and reporting standards across countries, as well as to different definitions of LTC. In manycountries, COVID-19 cases in this sector are under-reported due to a lack of testing in care homesor lag times in reporting test results.

• The definition of LTC for COVID-19 reporting varies by country. For Canada, Hungary, France andBelgium, LTC includes both residential facilities with 24-hour nursing care and facilities with fewer
services, such as retirement homes and assisted-living facilities. Data for Germany and the Netherlands
includes all communal institutions such as prisons, shelters and homes for residents with disabilities
in addition to assisted-living and residential care facilities. Data for Italy and Israel includes only thoseseniors’ homes with intensive nursing support. Data for Austria includes residences for residents
with disabilities. Data for Australia, Ireland, Norway, Portugal, Spain, Slovenia, the U.K. and the U.S.
includes residential and nursing homes and skilled nursing facilities.

• Information is not available at the country level for many factors that may influence COVID-19 outcomesin LTC. These factors include staff working at multiple sites, the density of the resident population incare homes, hospital transfer policies and access to PPE.

More information can be found in our companion data tables.

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Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?

CIHI Snapshot

Appendix: Text alternative for figures
Figure 1: COVID-19 deaths as of May 25, 2020, at 9 p.m. — Number per million population,
total and LTC

CountryNumber of COVID-19
deaths per million
population

Number of LTC deaths
per million population

Australia

31

Israel33

19

Norway44

25

Slovenia

51

5

Hungary

52

3Austria72

13

Germany

99

34

Portugal

130

32

Canada176

142

OECD average

266

112

U.S.

295

91

Ireland329

184

Netherlands

341

50

France

436

208

Italy

543

176

U.K.

547

150

Spain

574

379

Belgium

807

400

Notes
OECD: Organisation for Economic Co-operation and Development.
LTC: Long-term care.
The situation is evolving rapidly and this data represents a snapshot of the pandemic in countries reported by May 25, 2020, at 9 p.m. ET.
Reporting of COVID-19 cases and deaths in the LTC sector is not directly comparable due to different testing and reporting standards
across countries, as well as to different definitions of LTC. In many countries, COVID-19 cases in this sector are under-reported.
Data for Italy is available from only 52% of the nursing homes operating in the country.
Sources
World Health Organization. Coronavirus disease (COVID-2019) situation reports. Accessed May 25, 2020.
World Health Organization Europe. Coronavirus disease (COVID-19) outbreak reports: Country information. Accessed May 25, 2020.
United Nations Department of Economic and Social Affairs, Population Division. World Population Prospects 2019. 2019.
European Centre for Disease Prevention and Control. Accessed May 25, 2020.
National Institute on Ageing. NIA Long-Term Care COVID-19 Tracker. Accessed May 25, 2020.
Daily epidemiological summaries produced by each country, where available, March 1 to May 25, 2020 (e.g., Public Health Agency ofCanada, Robert Koch Institute of Germany).
International Long-term care Policy Network. Accessed May 25, 2020.

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Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?

Figure 2: Percentage of seniors (65+) in LTC byprovince and territory, 2018–2019
Jurisdiction

Percentage 65+ in LTC

Canada

7.0

Newfoundland and Labrador

5.0

Prince Edward Island

6.5

Nova Scotia

5.3

New Brunswick

6.5

Quebec9.5

Ontario

5.8

Manitoba

7.8

Saskatchewan

7.7

Alberta

8.1

British Columbia

5.6

Yukon

3.8

Northwest Territories

3.4

Nunavut

1.8

Notes
LTC: Long-term care.
Data includes nursing homes, retirement homes and homes for residents with disabilities
or mental health needs.
SourceStatistics Canada. Data tables, 2016 Census: Type of collective dwelling (16), age (20)and sex (3) for the population in collective dwellings of Canada, provinces and territories,
2016 Census — 100% data. Accessed May 25, 2020.

8CIHI Snapshot

Pandemic Experience in the Long-Term Care Sector:
How Does Canada Compare With Other Countries?

CIHI Snapshot

Figure 3: Impact of COVID-19 on LTC residents by level of policy response at the time of
1,000 COVID-19 cases
COVID-19 deaths in LTC
as a percentage of all
COVID-19 deaths

COVID-19 deaths in
LTC as a percentage ofCOVID-19 cases

Policy responseCountries

Policy response 1• Stay-at-home order• Economic stimulus• Acute care funding

Canada, France,
Norway, Spain,
U.S., U.K.

52

37

Policy response 2All in response 1 and• LTC visitor restrictions• LTC guidanceIsrael, Belgium, Italy

47

33

Policy response 3
All in response 2 and• Hazard pay• LTC surge staffing• LTC recruitment• PPE funding

Hungary, Portugal​
Ireland, Netherlands

28

26

15

17Austria,​ Australia,​
Policy response 4
All in response 3 andSlovenia• LTC isolation wards• Broad LTC testing• LTC infection control training and audit• LTC rapid response control and prevention teams

Notes
LTC: Long-term care.
PPE: Personal protective equipment.
Countries are grouped according to which policy interventions were announced as mandatory at the time of a country’s first reported 1,000 COVID-19 cases.
Policy implementation can vary substantially within countries as some of these measures may be applied at the local level only. Each COVID-19 policy
response includes the interventions from the previous level.
Specific policies and their implementation differ widely across regions or provinces of a country. For instance, the level of enforcement measures mayvary across regions of a country and may have changed with the evolution of the outbreak in certain regions where more local measures may have been
implemented. Some regions or provinces may have acted earlier than the national announcement in order to better manage their own outbreaks; however,the category of policy response did not change as a whole for the country.
Sources
World Health Organization. COVID-19 Health System Response Monitor. Accessed May 25, 2020.
International Long-term care Policy Network.
Organisation for Economic Co-operation and Development. AI Policy Observatory.
North American Observatory on Health Systems and Policies.

media@cihi.ca

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