COVID-19 Cases Among Congregate Care Facility Staff by Neighborhood of Residence and Social and Structural Determinants: Observational Study

Abstract

Background: Disproportionate risks of COVID-19 in congregate care facilities including long-term care homes, retirement homes, and shelters both affect and are affected by SARS-CoV-2 infections among facility staff. In cities across Canada, there has been a consistent trend of geographic clustering of COVID-19 cases. However, there is limited information on how COVID-19 among facility staff reflects urban neighborhood disparities, particularly when stratified by the social and structural determinants of community-level transmission.

Objective: This study aimed to compare the concentration of cumulative cases by geography and social and structural determinants across 3 mutually exclusive subgroups in the Greater Toronto Area (population: 7.1 million): community, facility staff, and health care workers (HCWs) in other settings.

Methods: We conducted a retrospective, observational study using surveillance data on laboratory-confirmed COVID-19 cases (January 23 to December 13, 2020; prior to vaccination rollout). We derived neighborhood-level social and structural determinants from census data and generated Lorenz curves, Gini coefficients, and the Hoover index to visualize and quantify inequalities in cases.

Results: The hardest-hit neighborhoods (comprising 20% of the population) accounted for 53.87% (44,937/83,419) of community cases, 48.59% (2356/4849) of facility staff cases, and 42.34% (1669/3942) of other HCW cases. Compared with other HCWs, cases among facility staff reflected the distribution of community cases more closely. Cases among facility staff reflected greater social and structural inequalities (larger Gini coefficients) than those of other HCWs across all determinants. Facility staff cases were also more likely than community cases to be concentrated in lower-income neighborhoods (Gini 0.24, 95% CI 0.15-0.38 vs 0.14, 95% CI 0.08-0.21) with a higher household density (Gini 0.23, 95% CI 0.17-0.29 vs 0.17, 95% CI 0.12-0.22) and with a greater proportion working in other essential services (Gini 0.29, 95% CI 0.21-0.40 vs 0.22, 95% CI 0.17-0.28).

Conclusions: COVID-19 cases among facility staff largely reflect neighborhood-level heterogeneity and disparities, even more so than cases among other HCWs. The findings signal the importance of interventions prioritized and tailored to the home geographies of facility staff in addition to workplace measures, including prioritization and reach of vaccination at home (neighborhood level) and at work.

Keywords: COVID-19; Canada; Toronto; congregate; congregate living; elderly; essential worker; geography; health care worker; long-term care; nurse; nursing home; observational; older adults; retirement; retirement home; risk; shelter; staff; transmission; trend.

Figure 1

Geographic concentration of COVID-19 cases in the community population, among facility staff, and among other health care workers in the Greater Toronto Area (January 23, 2020, to December 13, 2020). The magnitude of concentration is depicted by Lorenz curves (the dashed line represents the line of equality) and the corresponding Gini coefficient for each subgroup. The x-axis represents the cumulative proportion of the population ranked by DAs from the highest to lowest number of cumulative cases per capita. “Community” excludes residents of congregate settings and facility staff (long-term care homes, retirement homes, and shelters), other health care workers, and travel-related cases. “Facility staff” includes staff and volunteers who work in long-term care homes, retirement homes, and shelters and excludes all other health care workers. DA: dissemination area.

Figure 2

A heat map with estimated Gini coefficients showing the magnitude of concentration by social and structural determinants in COVID-19 cases in the community, among facility staff, and among other health care workers in the Greater Toronto Area (January 23, 2020, to December 13, 2020). Gini coefficients above and below the line of equality in the Lorenz curves (Multimedia Appendix 5) are depicted in red and blue, respectively. *Other essential services include trades, transport, and equipment operation; sales and services; manufacturing and utilities; and resources, agriculture, and production [32]. “Community” excludes residents of congregate settings and facility staff (long-term care homes, retirement homes, and shelters), other health care workers, and travel-related cases. “Facility staff” includes staff and volunteers who work in long-term care homes, retirement homes, and shelters and excludes all other health care workers.