COVID-19 in French Nursing Homes during the Second Pandemic Wave: A Mixed-Methods Cross-Sectional Study

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French nursing homes were deeply affected by the first wave of the COVID-19 pandemic, with 38% of all residents infected and 5% dying. Yet, little was done to prepare these facilities for the second pandemic wave, and subsequent outbreak response strategies largely duplicated what had been done in the spring of 2020, regardless of the unique needs of the care home environment.


A cross-sectional, mixed-methods study using retrospective, quantitative data from residents of 14 nursing homes between November 2020 and mid-January 2021. Four facilities were purposively selected as qualitative study sites for additional in-person, in-depth interviews in January and February 2021.


The average attack rate in the 14 participating nursing facilities was 39% among staff and 61% among residents. One-fifth (20) of infected residents ultimately died from COVID-19 and its complications. Failure-to-Thrive-Syndrome (FTTS) was diagnosed in 23% of COVID-positive residents. Those at highest risk of death were men (HR=1.78; IC95: 1.18 – 2.70; p=0.006) with FTTS (HR=4.04; IC95: 1.93 – 8.48; p<0.001) in facilities with delayed implementation of universal FFP2 masking policies (HR=1.05; IC95: 1.02 – 1.07; p<0.001). The lowest mortality was found in residents of facilities with a partial (HR=0.30; IC95: 0.18 – 0.51; p<0.001) or full-time physician on staff (HR=0.20; IC95: 0.08 – 0.53; p=0.001). Significant themes emerging from qualitative analysis centered on (i) the structural, chronic neglect of nursing homes, (ii) the negative effects of the top-down, bureaucratic nature of COVID-19 crisis response, and (iii) the counterproductive effects of lockdowns on both residents and staff.


Despite high resident mortality during the first pandemic wave, French nursing homes were ill-prepared for the second, with risk factors (especially staffing, lack of medical support, isolation/quarantine policy etc) that affected case fatality and residents’ and caregivers’ overall well-being and mental health.


What is already known?

  • Though much was learned about COVID-19 in nursing homes during the first pandemic wave (Spring 2020), descriptions of the second wave in these facilities is nearly absent from the scientific literature.

  • Prior COVID-19 research in nursing homes has rarely been qualitative and has almost never interviewed care home residents themselves.

  • First-wave research indicated that much stronger outbreak and infection prevention was urgently needed to bolster nursing facilities’ preparedness. Higher staff-to-resident ratios, less staff turnover, more masks, better organization, more medical support, and more epidemiological tools were found to reduce COVID-19’s impact.

What are the new findings?

  • Our results document a lack of preparedness for the second wave, with attack rates among staff (39% overall) and residents (61% overall) similar to levels seen during the first wave peak.

  • Despite authorities’ claims to have reinforced these structures’ readiness, and despite much research into the needs in these environments, preventive measures (like strict lockdowns) remained largely unchanged and had a direct impact on residents, with 23% of COVID-positives also diagnosed with Failure-to-Thrive Syndrome.

  • Qualitative results detailed how ill-suited and inflexible some preventive measures were for residents and staff alike. Participants described precarious and understaffed living and working conditions as substantial and long-standing difficulties that became critical risks during the COVID-19 outbreak, and compromised the response.

What do the new findings imply?

  • These results suggest that knowledge gained during the first pandemic wave was not consistently applied to care home policy or practice in France, and that these nursing homes were not always safe environments that considered residents’ mental health and well-being alongside infection prevention.

  • Despite the high mortality of the first pandemic wave, French nursing homes were ill-prepared for the second. As a 5 th wave descends on France (albeit with much higher COVID-19 vaccination rates), applying the lessons from previous periods (especially with regard to staffing, isolation of the elderly, medical supplies, standard of care procedures) must be prioritized.

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  1. SciScore for 10.1101/2021.12.12.21267681: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsConsent: Participants had to be able to give informed consent, capably interact, and have no major cognitive disorders.
    IRB: Ethics: This study received approval from the MSF Ethical Review Board (ERB) and the Commission Nationale de l’Informatique et des Libertés (CNIL) in France.
    Sex as a biological variableAll interviewed residents were women, as were the majority of study participants overall (82.9%).
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    Interview data were written, analyzed and coded in Excel spreadsheets.
    suggested: None

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Limitations: Our study is limited by the fact that study site selection was not random but was instead steered by discussions with MSF. Moreover, since MSF targeted mostly struggling nursing homes, the study included only a small number that did not have major outbreaks (or contained their outbreaks early). As a result, comparing these facilities to others in Provence and Occitania (or France) should be made with care. Participant selection was biased by the fact that only residents who were fully capable of interacting with investigators and were able to give informed consent could be interviewed, thus excluding anyone with major cognitive disorders (a relatively frequent condition in nursing homes). Quantitative data were neither exhaustive nor always electronically recorded. Associations between COVID-19 deaths and FTTS were complicated by the co-morbidities that many residents also lived with, though adjusted analysis attempted to control for potential confounding.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

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