Background COVID-19 has affected care home residents internationally, but detailed information on outbreaks is scarce. We aimed to describe the evolution of outbreaks of COVID-19 in all care homes in one large health region in Scotland. MethodsWe did a population analysis of testing, cases, and deaths in care homes in the National Health Service (NHS) Lothian health region of the UK. We obtained data for COVID-19 testing (PCR testing of nasopharyngeal swabs for severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) and deaths (COVID-19-related and non-COVID-19related), and we analysed data by several variables including type of care home, number of beds, and locality. Outcome measures were timing of outbreaks, number of confirmed cases of COVID-19 in care home residents, care home characteristics associated with the presence of an outbreak, and deaths of residents in both care homes and hospitals. We calculated excess deaths (both COVID-19-related and non-COVID-19-related), which we defined as the sum of deaths over and above the historical average in the same period over the past 5 years. FindingsBetween March 10 and Aug 2, 2020, residents at 189 care homes (5843 beds) were tested for COVID-19 when symptomatic. A COVID-19 outbreak was confirmed at 69 (37%) care homes, of which 66 (96%) were care homes for older people. The size of care homes for older people was strongly associated with a COVID-19 outbreak (odds ratio per 20-bed increase 3•35, 95% CI 1•99-5•63). 907 confirmed cases of SARS-CoV-2 infection were recorded during the study period, and 432 COVID-19-related deaths. 229 (25%) COVID-19-related cases and 99 (24%) COVID-related deaths occurred in five (3%) of 189 care homes, and 441 (49%) cases and 207 (50%) deaths were in 13 (7%) care homes. 411 (95%) COVID-19-related deaths occurred in the 69 care homes with a confirmed COVID-19 outbreak, 19 (4%) deaths were in hospital, and two (<1%) were in one of the 120 care homes without a confirmed COVID-19 outbreak. At the 69 care homes with a confirmed COVID-19 outbreak, 74 excess non-COVID-19related deaths were reported, whereas ten non-COVID-19-related excess deaths were observed in the 120 care homes without a confirmed COVID-19 outbreak. 32 fewer non-COVID-19-related deaths than expected were reported among care home residents in hospital.Interpretation The effect of COVID-19 on care homes has been substantial but concentrated in care homes with known outbreaks. A key implication from our findings is that, if community incidence of COVID-19 increases again, many care home residents will be susceptible. Shielding care home residents from potential sources of SARS-CoV-2 infection, and ensuring rapid action to minimise outbreak size if infection is introduced, will be important for any second wave.

Background: COVID-19 has had large impact on care-home residents internationally. This study systematically examines care-home outbreaks of COVID-19 in a large Scottish health board. Methods: Analysis of testing, cases and deaths using linked care-home, testing and mortality data for 189 care-homes with 5843 beds in a large Scottish Health Board up to 15/06/20. Findings: 70 (37.0%) of care-homes experienced a COVID-19 outbreak, 66 of which were in care-homes for older people where care-home size was strongly associated with outbreaks (OR per 20-bed increase 3.50, 95%CI 2.06 to 5.94). There were 852 confirmed cases and 419 COVID-related deaths, 401 (95.7%) of which occurred in care-homes with an outbreak, 16 (3.8%) in hospital, and two in the 119 care-homes without a known outbreak. For non-COVID related deaths, there were 73 excess deaths in care-homes with an outbreak, but no excess deaths in care-homes without an outbreak, and 24 fewer deaths than expected of care-home residents in hospital. A quarter of COVID-19 related cases and deaths occurred in five (2.6%) care-homes, and half in 13 (6.9%) care-homes. Interpretation: The large impact on excess deaths appears to be primarily a direct effect of COVID-19, with cases and deaths are concentrated in a minority of care homes. A key implication is that there is a large pool of susceptible residents if community COVID-19 incidence increases again. Shielding residents from potential sources of infection and rapid action into minimise outbreak size where infection is introduced will be critical in any wave 2. Funding: Not externally funded.

In response to the outbreak of COVID-19, we set up a team to carry out sampling in the community. This enabled individuals to remain in self-isolation in their own homes and to prevent healthcare settings and services from being overwhelmed by admissions for sampling of suspected cases. There is evidence that this is a cost effective, safe and necessary service to complement COVID-19 testing in hospitals.

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