{"paper_id":"0e9c7dfc-0e8d-4fad-b5dc-29a65dd004d9","body_text":"Assessing COVID-19 Vaccine Effectiveness in Frail Long-Term Care Facilities Residents in a Middle-Income Country | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing COVID-19 Vaccine Effectiveness in Frail Long-Term Care Facilities Residents in a Middle-Income Country Joice Coutinho de Alvarenga, Flávia Lanna de Moraes, Jáder Freitas Maciel Garcia de Carvalho, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4001109/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: During the COVID-19 pandemic, individuals residing in long-term care facilities (LTCF) are particularly vulnerable to adverse outcomes due to their higher rates of frailty, disabilities, cognitive impairment, dementia, and chronic illnesses. In low and middle-income nations, research on immunizing frail populations is lacking, while most studies on COVID-19 in LTCF come from wealthier nations and may not fully capture the situation in emerging countries. Methods: We aimed to evaluate the effectiveness of first, second and third COVID-19 vaccine doses, against infections, hospitalizations, and deaths, and their association with frailty, age, sex and chronic disease, among older adults, in a social vulnerability context. This retrospective cohort study, comprises a total of 712 older adults, in a social vulnerability context, of 29 LTCF, in Brazil. Continuous variables were described by medians and interquartile ranges and categorical variables were represented by absolute and relative frequencies. The Mann-Whitney test was used. For evaluating the relation between categorical variables, Pearson's chi-square test was used. When comparing proportions, the Z test of proportion was applied. A significance level of 5% was considered. Results: Median age was 81.37 years, 72.8% were female, 94.61% were frail, 79.97% had a cognitive impairment, 69.54% had a mobility impairment, 78.37% have, at least, one chronic disease and 72.73% use five or more medications per day. Before the vaccine, mobility impairment was associated with great contamination rates (p=.03); frailty (p=.02) and previous pulmonary disease (p=.03) with symptoms of gravity; frailty (p=.02), pulmonary disease (p=.04) and male sex (p=.02) with emergency care or hospital admission. After the third vaccine dose, only frailty remains associated with admissions (p=.03). The number of positive cases (p=.001), symptomatic patients (p<.001), admissions (p=.001) and deaths (p<.001) were substantially reduced after the three vaccine doses. Conclusions and Implications: Even in a frail population, the vaccine was effective, in the reduction of positive cases, the number of symptomatic patients, admission to emergency or hospital care and deaths. Before the vaccine, frailty, previous pulmonary disease and male sex were associated with worse outcomes. After the vaccine, frailty remains associated with a major number of admissions. COVID-19 SARS-CoV-2 frailty long-term facilities Figures Figure 1 Figure 2 Figure 3 Background In the COVID-19 pandemic, long-term care facilities (LTCF) residents represent those at greatest risk of poor outcomes, including high mortality rates and prolongate hospitalization. 1,2 Older adults who live in LTCF have an elevated prevalence of frailty, disabilities, cognitive impairment, dementia and a heightened burden of chronic infirmities, in comparison to their community-residing counterparts. 3,4 In the general population, discernible risk factors for mortality and hospital admission encompass the male gender, advancing age, chronic diseases (diabetes, hypertension, kidney disease, cardiovascular disease, obesity, pulmonary disorders, malignancies) and frailty. 5-7 In the LTCF residents, increased age, frailty, male gender, impaired cognitive function and impaired physical function have all evinced association with mortality. 8-10 In the context of low and middle-income nations, studies evaluating immunization in frail populations remain scarce, since they are routinely excluded from trials. The majority of the studies evaluating COVID-19 in LTCF have been conducted in developed countries, which may not reflect the realities of emerging countries. Inequality was shown as a determinant agent of disparate outcomes in the COVID-19 pandemic. 11-13 The suboptimal healthcare provisioning, prevalent in low and middle-income countries, invariably contribute to a heightened prevalence of frail older adults, with a high number and gravity of chronic ailments. 14,15 In this study, we aimed to evaluate the effectiveness of COVID-19 vaccines among frail and socially vulnerable LTCF residents, in a middle-income country. After a meticulous survey of existing literature, we could not identify prior studies that have evaluated the vaccine efficacy within a comparable demographic profile. Therefore, we sought to evaluate the response of first, second and third COVID-19 vaccine doses, against infections, hospitalizations, and deaths, and the association of frailty, age, sex, cognitive impairment, mobility impairment, chronic diseases and polypharmacy with those outcomes. This study encompasses the periods of alpha, gamma, delta, and omicron variants, which provides a better understanding of vaccine effectiveness, against different lineages. Methods Study Design This is a retrospective cohort study, conducted across 29 LTCF located in a prominent city in southeastern Brazil. The study took place during the period from January 2021 to September 2022. Study participants The enrolled LTCF were characterized as philanthropic institutions, being financially supported by religious organizations as well as the local public social assistance department. All residents within these institutions were invited to participate in the study. Exclusion criteria were limited to patients who declined research participation. Data collection Within the designated LTCF, a universal SARS-CoV-2 testing approach was adopted: when any resident or staff member exhibited symptoms, the entire population of residents and workers underwent testing, using PCR-based assays of nasopharyngeal swab. The research team conducted a daily monitoring of newly confirmed positive cases and the clinical progression of participants who tested positive. Information concerning emergency care or hospital admissions and deaths was updated routinely. Reported mortality cases were subsequently cross-referenced with the national death registry. Vaccination details encompassing dates, vaccine types, and the dosing regimen, were extracted from the national vaccination registry card, of each participant. The vaccination of LTCF residents was initiated in January 2021, with the administration of the CoronaVac vaccine (Sinovac Biotech). In February 2021, the ChAdOx1-S vaccine (Oxford–AstraZeneca) became additionally available for administration. For recipients of the CoronaVac vaccine, the second dose was administered within three to four weeks following the initial dose. Meanwhile, for the ChAdOx1-S vaccine, an interval of eight to twelve weeks was stipulated for the second dose administration. The third dose was deployed in LTCF in November 2021. During this period, the Comirnaty vaccine (Pfizer–BioNTech) and the Janssen Ad26.COV2.S vaccine (Johnson & Johnson) was also incorporated into the LTCF vaccination regimen. Participant' characteristics, including sex, age, birth date, presence of chronic medical conditions and number of current medications in use were obtained from long-term facilities records. All participants underwent a comprehensive clinical and functional evaluation conducted by a team of geriatric medical specialists. Frailty was assessed using two different scales. The first one was the Clinical-Functional Vulnerability Index-20 (IVCF-20), a screening tool, validated in Brazil to be used even for non-medical professionals. 16 In the IVCF-20, frailty is stratified from 1 to 40, with scores 1-6 denoting low clinical functional vulnerability; 7-14 indicating moderate vulnerability and 15-40 signifying high vulnerability. This score is detailed in Supplementary Figure 1. The second scale employed was the Clinical-Functional Classification (CCF) of older adults 17 a standard scale in Brazil, based on Instrumental Activities of Daily Living (IADL), Basics Activities of Daily Living (BADL) and the presence of chronic health conditions. The CCF is an ordinal hierarchical scale ranging from 1 to 10: stratum 1-3 means a robust (fit) older adult, independent for all activities of daily living; stratum 4-5 denotes an older adult at risk of frail (vulnerable older adult); and 6 to 10 indicates frail older adult (stratum 6 are independent for BADL but dependent for some IADL; stratum 7 are independent for BADL but dependent for all IADL; stratum 8 are dependent for some BADL; stratum 9 are dependent for almost all BADL, but can eat independently; and 10, dependent for all BADL). Details of this scale are contemplated in Supplementary Figure 2. As the defining criteria for typical symptoms of COVID-19, we relied upon the Centers for Disease Control and Prevention (CDC) study, 18 which outlines the most prevalent manifestations of the disease: cough, fever, myalgia, headaches, dyspnea, odynophagia, rhinorrhea, anosmia, and ageusia. Study Variables The selected categorical variables encompassed: sex, race, frailty accessed by CCF, RT-PCR for SARS-CoV-2 (classified into three categories: positive, negative, indeterminate) and vaccine type. The dichotomous variables were: the presence of hypertension, diabetes, prior pulmonary disease, presence of cognitive impairment, mobility impairment, presence of typical symptoms associated with COVID-19, admission to emergency care, hospitalization and death. Age, number of medications in use and the IVCF-20 score were evaluated both as quantitative and categorical variables. Age was stratified into four distinct categories: participants below 70 years, those between 70 and 79, individuals aged 80 to 89, and those aged 90 or above. For the number of medications in use, were created two categories: with polypharmacy (use of five or more medications per day), or without polypharmacy. For the IVCF-20 score, the instrument's reference values were used to create three categories: scores 1-6 denoting low clinical functional vulnerability; 7-14 indicating moderate vulnerability and 15-40 signifying high vulnerability. Statistical analysis In the descriptive analysis, categorical variables were described using absolute frequency and proportion, while continuous variables were summarized with measures of central tendency (mean and standard deviation, median and quartiles). To compare continuous variables, the Mann-Whitney test was used due to non-normal data distribution, assessed using the Shapiro-Wilk test. In the evaluation of categorical variables, Pearson's chi-square test was employed, and for proportion comparisons, the Z test of proportion was utilized. All analyses were performed using Stata software version 16 (StataCorp LLC, College Station, TX), with a significance level of 5%. The primary outcome was overall vaccine effectiveness, irrespective of vaccine type, against infections, admissions to emergency care, hospitalizations, and deaths. Additionally, we evaluated the factors associated with a great risk of contamination, symptoms, admissions to emergency service, or hospital admissions. Ethics approval Brazilian Commission for Research Ethics (COEP-UFMG) approved the study protocol (CAAE: 40666720.0.0000.5149). Results A total of 712 LTCF residents were included. The characteristics of the participants are summarized in Table 1. The median age was 81.3 years (IQR 74-89), with 518 individuals (72.8%) being female. The prevalence of frailty was 94.6% (27.7% CCF 6-7, 24.8% CCF 8 and 42.05% CCF 9-10). Cognitive impairment was observed in 79.9% of participants, while 69.5% exhibited mobility impairment, 78.3% presented with at least one chronic disease, and 72.7% reported the use of five or more medications per day, ranging from a minimum of 1 to a maximum of 17 drugs daily. Table 1 : Descriptive Statistics of Overall Study Population Characteristic n % Age <70 86 12,1 70-79 222 31,22 80-89 244 34,32 90+ 159 22,36 Sex Female 518 72,86 Male 193 27,14 Race White 238 37,01 Black 149 23,17 Pardo 256 39,81 CCF Robust (1-3) 7 0,99 Risk of frail (4-5) 31 4,4 Frail 6-7 195 27,7 Frail 8 175 24,86 Frail 9-10 296 42,05 IVCF-20 Low Vulnerability (0-6) 58 8,43 Moderate Vulnerability (7-14) 112 16,28 High Vulnerability (15-40) 518 75,29 Polypharmacy < 4 different drugs/day 153 27,27 ≥ 5 different drugs/day 408 72,73 Comorbidities Diabetes 148 24,07 Hypertension 415 67,48 Pulmonary disease 89 14,45 Cognitive impairment 491 79,97 Mobility impairment 443 69,54 The vaccination adherence was 99.5% of the cohort, all of whom received the complete three-dose regimen. In the first and second doses, 91.7% of the cohort received the ChAdOx1-S vaccine. In the third dose, 98.6% of the participants received the Comirnaty vaccine. Details regarding vaccine types are elaborated upon Supplementary Table 1. The vaccination had a significant impact on the reduction in positive cases (p=.001), in admissions to emergency care (p<.001), hospitalization (p=.002) and deaths (p<.001). Prior to the vaccination, a total of 191 positive cases were documented, corresponding to 26.8% of the entire cohort. Among these contaminated individuals, 43.5% exhibited typical respiratory symptoms, 29.3% required emergency care or hospitalization, and 27 COVID-19 related deaths occurred, corresponding to a case fatality rate of 14.1%. After the first dose, 25 positive cases had occurred and after the second dose, 28 positive cases. Only six participants (24% of positive participants) were admitted to emergency care or hospital, after the first dose and six participants after the second dose. Two deaths were observed after both the first and second doses. The period subsequent to the administration of the third dose coincided with the prevalence of the Omicron variant. During this period, the number of positive cases had arisen, with 136 positive cases, representing 19.2% of the cohort. Although, 85.3% were asymptomatic. Among the contaminated participants, 15 (11.1%) necessitated admission to emergency care or hospitalization. Five deaths have occurred, culminating in a post-vaccination case fatality rate of 3.8%, during the dominance of the Omicron variant. Details about vaccine effects are shown in Figure 1. Figure 1. The number of positive cases, symptomatic participants, admission to emergency service, hospitalization and deaths, among LTCF residents, before the vaccine, and after the first, second and third vaccine doses. The red line corresponds to the proportion of positive cases in the general population. When risk factors were analyzed (Figure 2), frailty, advanced age, presence of chronic diseases, cognitive impairment and polypharmacy were not associated with a higher rate of contamination by SARS-CoV-2. Mobility impairment, however, exhibited a significant correlation with a higher number of positive cases (p=.03) but not with typical symptoms and admission to emergency or hospital care. Before the vaccination, individuals with a history of pulmonary disease (p=.03) and those dependent for BADL (p=.02) exhibited a higher prevalence of typical symptoms compared to other study participants. Furthermore, a significant association between dependence for BADL (p=.005), male sex (p=.02) and pulmonary disease (p=.008) was observed with a heightened number of admissions to emergency services and hospitalization (Figure 2). In the non-vaccinated frail subgroup (CCF 8-10), 63 participants, which represents 48.4% of the positive cases exhibited typical symptoms and 45 participants (34.6%) necessitated emergency care or hospital admission. After the administration of three vaccine doses, the number of symptomatic patients in this group decreased to 16 (16.8%) and 12 participants (12.6%) needed admission, as depicted in Figure 2. Prior to the vaccination, within the pulmonary disease group, 61.5% of the positive participants displayed typical respiratory symptoms and 50% required emergency care or hospital medical support. After the three doses, the number of symptomatic patients dwindled to 14.2%, with the same percentage necessitating medical intervention in this subgroup. Male participants exhibited a higher frequency of hospitalization than females (p=.02). Pre-vaccination, 42% of male participants had been admitted to emergency care or hospital (Figure 2), compared to 24.8% of females. Following vaccination, admissions among males became comparable to those observed among females, with a comparable proportion of 13.5% of the positive cases in males and 15.1% in females, and no statistically significant difference between the two groups. Age, hypertension, diabetes, cognitive impairment and polypharmacy did not exhibit significant associations with increased contamination rates, symptoms, admissions to emergency care and hospitalization. Figure 2: The risk factors associated with a higher proportion of positive cases, symptomatic patients, and hospitalizations. Table 2 compares the number of positive cases, symptomatic participants and participants requiring emergency or hospital care, before and after the three vaccine doses, across different risk factor subgroups. After the three vaccine doses, there was a significant reduction in the proportion of symptomatic patients and admissions, in almost all risk factor subgroups, with the exception of participants with diabetes, in which a reduction in the number of admissions occurred, although, was not statistically significant. Table 2: Comparison between the number of positive cases, symptomatic participants and participants who need emergency or hospital care, before and after the three vaccine doses, in different subgroups of risk factors. Characteristics Positive cases Symptoms Admission Before After Before After Before After N % N % p N % N % p N % N % p Age ≥ 80 119 31 74 27 0.3 51 43 14 18 <0.001 34 28 10 13 0.01 CCF 8-10 130 31 94 29 0.6 63 48 16 16 <0.001 45 34 12 12 <0.001 IVCF-20 ≥ 15 139 30 99 28 0.6 61 44 15 15 <0.001 41 29 13 13 0.002 Male 49 30 37 25 0.3 25 50 5 13 <0.001 21 42 4 10 0.001 Cognitive impairment 142 30 93 27 0.2 64 45 12 12 <0.001 43 30 9 9 <0.001 Mobility impairment 116 27 89 30 0.4 53 45 13 14 <0.001 38 32 11 12 <0.001 Diabetes 42 31 26 26 0.4 17 40 3 11 0.008 12 28 3 11 0.8 Hypertension 112 28 73 25 0.4 47 42 13 17 <0.001 32 28 9 12 0.007 Pulmonary disease 25 29 14 24 0.5 16 61 2 14 0.004 13 50 2 14 0.02 Polypharmacy 125 32 63 23 0.01 55 44 11 17 <0.001 40 32 9 14 0.007 When the number of positive cases was evaluated in association with LTC characteristics (Figure 3), we observed a trend indicating higher proportions of positive cases in LTCFs with larger resident populations. The number of cases was significantly lower in LTC with a smaller number of residents, in contrast to LTCF with more than 20 residents (p=.002). Figure 3. Correlation between the number of residents in each LTCF and the proportion of positive cases. Discussion Our cohort comprised over 700 profoundly frail residents within a LTCF setting, in a context marked by social vulnerability. Among these individuals, over 50% were aged above 80 years, with more than 90% displaying signs of frailty and over 60% exhibiting a state of extreme frailty, with BADL dependence. Nearly 80% of the participants had cognitive impairment, while close to 70% with mobility limitations. Additionally, over 70% had at least one chronic medical condition, and more than 70% necessitated the administration of five or more medications on a daily basis. Even within this cohort marked by a high degree of frailty, disabilities, and clinical severity conditions, we consistently observed the effectiveness of vaccines. To our knowledge, subsequent to an extensive literature review, this is the first Brazilian study that evaluated the vaccine effectiveness in this population profile. Another distinguishing aspect of this study is that all participants underwent a specialized geriatric assessment, enhancing the reliability of the disclosed information. Our study is in concordance with several previous studies, which attest to the vaccine's effectiveness in preventing infections, hospitalizations and deaths. 19,20 A clear benefit was already observed after the first dose in our study population. Following the administration of first and second vaccine doses, the number of positive cases, symptomatic patients, admission to emergency service, admission to hospital and deaths diminish significantly, even during periods marked by heightened caseloads in the general populace. In the period corresponding to Omicron variant predominance, the number of infected participants arises, even after three vaccine doses. Within our cohort, even with an increase in the number of positive cases, the proportion of symptomatic patients, patients who needed admission to emergency service or hospitalization and deaths, remains low, when compared to the period before the first dose. Regarding the Omicron variant, the vaccine effectiveness remained high for preventing death and serious cases but reduced for infection. Before the vaccine, we found an association between contamination and mobility impairment. This finding is in concordance with previous studies, that evidence the role of staff contact in the contamination of LTCF residents. 22-25 Residents who have mobility impairment inherently necessitate increased support for ambulation, personal hygiene, and dressing, heightening the proximity to caregiving assistants. Furthermore, we found an association between the number of LTCF residents and heightened contamination rates. A LTCF characterized by a larger resident population necessitates a correspondingly increased staffing capacity. It is plausible that a substantial circulation of staff members might significantly contribute to the transmission of viral infections among the residents. 26 Previous studies have shown male sex as a risk factor for worse outcomes. 27-29 In our cohort, before the vaccination, male sex was associated with a great proportion of emergency and hospital admissions. However, subsequent to vaccination, the risk profile among males became comparable to that observed among females. Hypertension 10 and diabetes 10,27,30 were considered risk factors for hospital admission and death, due to COVID-19. In our cohort, these chronic diseases were not associated with contamination, symptoms or admissions. It is conceivable that within this highly frail population profile, the overarching influence of frailty supersedes the individual impact of these chronic conditions. Notably, frailty manifests as a condition of heightened severity compared to standalone chronic diseases. Corroborating this idea, similarly to previous studies 31-36 , frailty was associated with more typical symptoms and more admissions to emergency or hospital care. The vaccine was capable of mitigating this effect, by reducing the number of symptomatic patients and admissions. Some previous studies have shown age as a risk factor for worse outcomes in COVID-19 8,37 and other studies refute this association. 9 In our cohort, age was not associated with greater contamination, symptoms or admissions. In accordance with prior research findings, it has been found that pulmonary disease exhibits a correlation with the severity of symptoms and the need for emergency and hospital care. 38 After the three vaccine doses, a significant reduction in symptomatic patients and admissions was noticed in this subgroup, showing the potential of the vaccine to protect the most susceptible groups. When we compare the period before and after the vaccination, we observe a reduction in symptomatic patients and those who need admission, in all subgroups of risk factors. Frail individuals are particularly susceptible to the deterioration of their health status due to acute illnesses. 40 Mitigating the severity of such acute insults holds paramount significance in the reduction of the propensity toward aggravated disabilities and frailty. Moreover, admission to emergency care or hospitalization among frail older adults, is accompanied by deleterious complications including delirium, agitation, aggressiveness, disorientation; 41 falls; 42 iatrogenic treatments, sarcopenia and pressure injuries. 43 These complications are associated with major mortality rates. 44 Consequently, the implementation of preventive measures with the potential to reduce hospitalizations is crucial in this population. Conclusion and implications Our study provides important insights into vaccine effectiveness, even in an extremely frail and socially vulnerable population. The vaccine was effective in the reduction of severe cases and admissions, even in the Omicron variant wave and in all subgroups of risk factors. Aging is a risk factor for several infectious diseases, including COVID-19 and although immune senescence may compromise vaccine effectiveness, it was not observed in our study. Limitations Our study was unable to undertake a comprehensive evaluation of distinctions among various vaccine types, as the number of recipients for both CoronaVac and Ad26.COV2.S was reduced. Given that a substantial proportion of participants exhibited cognitive impairment, hindering their ability to provide self-reported health statuses and medication regimens, we relied on indirect information sourced from LTCF medical records, which could have caused some information bias. However, the LTCF assumed responsibility for overseeing all aspects of participants' healthcare, thus potentially enhancing the reliability of our data. Within our cohort, a small number of individuals with antecedent pulmonary conditions and diabetes was observed, potentially restricting our subgroup analyses. List Of Abbreviations BADL Basics Activities of Daily Living CCF Clinical-Functional Classification CDC Centers for Disease Control and Prevention IADL Instrumental Activities of Daily Living IVCF-20 Clinical-Functional Vulnerability Index-20 LTCF Long-term care facilities RT-PCR Reverse transcription polymerase chain reaction SARS-CoV-2 S evere acute respiratory syndrome coronavirus 2 Declarations Ethics approval and consent to participate : Brazilian Commission for Research Ethics (COEP-UFMG) approved the study protocol (CAAE: 40666720.0.0000.5149). Informed consent was obtained from all enrolled institutions. Consent for publication : not applicable. Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests : The authors declare that they have no competing interests. Funding : The authors declared no potential conflicts. Authors' contributions: All authors meet the criteria for authorship stated in the editorial policies. and authors' specific areas of contributions are listed below: Study concept and design: JA, UT, EM. Acquisition of data: JA, FM, JC, RS. Analysis and interpretation of data: JA, FM, UT. Drafting of the manuscript: JA Critical revision of the manuscript: JA, FM, JC, RS, UT, EM. All authors have approved the final version of the manuscript and agree to be accountable for all aspects of this work. Acknowledgements: Not applicable. Conflicts of Interest: The authors declare no conflicts of interest. Declaration of generative AI and AI-assisted technologies in the writing process: During the preparation of this work, the authors used Grammarly (Grammarly Inc) to verification of grammatical correctness and the detection of plagiarism. After using this tool/service, the authors reviewed and edited the content as needed and takes full responsibility for the content of the publication. 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Journal of the American Medical Directors Association . 2022 Sep 2022;23(9)doi:10.1016/j.jamda.2022.06.028 Panagiotou OA, Kosar CM, White EM, et al. Risk Factors Associated With All-Cause 30-Day Mortality in Nursing Home Residents With COVID-19. JAMA Intern Med . Apr 01 2021;181(4):439-448. doi:10.1001/jamainternmed.2020.7968 Burgaña Agoües A, Serra Gallego M, Hernández Resa R, et al. Risk Factors for COVID-19 Morbidity and Mortality in Institutionalised Elderly People. Int J Environ Res Public Health . Sep 28 2021;18(19)doi:10.3390/ijerph181910221 De Vito A, Fiore V, Princic E, et al. Predictors of infection, symptoms development, and mortality in people with SARS-CoV-2 living in retirement nursing homes. PLoS One . 2021;16(3):e0248009. doi:10.1371/journal.pone.0248009 Ballin M, Bergman J, Kivipelto M, et al. Excess Mortality After COVID-19 in Swedish Long-Term Care Facilities. J Am Med Dir Assoc . Aug 2021;22(8):1574-1580.e8. doi:10.1016/j.jamda.2021.06.010 Pranata R, Henrina J, Lim MA, et al. Clinical frailty scale and mortality in COVID-19: A systematic review and dose-response meta-analysis. Arch Gerontol Geriatr . 2021;93:104324. doi:10.1016/j.archger.2020.104324 Maltese G, Corsonello A, Di Rosa M, et al. Frailty and COVID-19: A Systematic Scoping Review. J Clin Med . Jul 04 2020;9(7)doi:10.3390/jcm9072106 Cangiano B, Fatti LM, Danesi L, et al. Mortality in an Italian nursing home during COVID-19 pandemic: correlation with gender, age, ADL, vitamin D supplementation, and limitations of the diagnostic tests. Aging (Albany NY) . Dec 22 2020;12(24):24522-24534. doi:10.18632/aging.202307 A BA, M SG, R HR, et al. Risk Factors for COVID-19 Morbidity and Mortality in Institutionalised Elderly People. International journal of environmental research and public health . 09/28/2021 2021;18(19)doi:10.3390/ijerph181910221 Zou Y, Han M, Wang J, et al. Predictive value of frailty in the mortality of hospitalized patients with COVID-19: a systematic review and meta-analysis. Ann Transl Med . Feb 2022;10(4):166. doi:10.21037/atm-22-274 Zhang XM, Jiao J, Cao J, et al. Frailty as a predictor of mortality among patients with COVID-19: a systematic review and meta-analysis. BMC Geriatr . Mar 17 2021;21(1):186. doi:10.1186/s12877-021-02138-5 Hägg S, Jylhävä J, Wang Y, et al. Age, Frailty, and Comorbidity as Prognostic Factors for Short-Term Outcomes in Patients With Coronavirus Disease 2019 in Geriatric Care. J Am Med Dir Assoc . Nov 2020;21(11):1555-1559.e2. doi:10.1016/j.jamda.2020.08.014 Dessie ZG, Zewotir T. Mortality-related risk factors of COVID-19: a systematic review and meta-analysis of 42 studies and 423,117 patients. OriginalPaper. BMC Infectious Diseases . 2021-08-21 2021;21(1):1-28. doi:doi:10.1186/s12879-021-06536-3 Araf Y, Akter F, Tang YD, et al. Omicron variant of SARS-CoV-2: Genomics, transmissibility, and responses to current COVID-19 vaccines. J Med Virol . May 2022;94(5):1825-1832. doi:10.1002/jmv.27588 Hussien H, Nastasa A, Apetrii M, et al. Different aspects of frailty and COVID-19: points to consider in the current pandemic and future ones. BMC Geriatr . Jun 27 2021;21(1):389. doi:10.1186/s12877-021-02316-5 Zhang XM, Jiao J, Xie XH, Wu XJ. The Association Between Frailty and Delirium Among Hospitalized Patients: An Updated Meta-Analysis. J Am Med Dir Assoc . Mar 2021;22(3):527-534. doi:10.1016/j.jamda.2021.01.065 Brand CA, Sundararajan V. A 10-year cohort study of the burden and risk of in-hospital falls and fractures using routinely collected hospital data. Qual Saf Health Care . Dec 2010;19(6):e51. doi:10.1136/qshc.2009.038273 Mart MF, Pun BT, Pandharipande P, et al. ICU Survivorship-The Relationship of Delirium, Sedation, Dementia, and Acquired Weakness. Crit Care Med . Aug 01 2021;49(8):1227-1240. doi:10.1097/CCM.0000000000005125 Flaatten H, De Lange DW, Morandi A, et al. The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (≥ 80 years). Intensive Care Med . Dec 2017;43(12):1820-1828. doi:10.1007/s00134-017-4940-8 Additional Declarations No competing interests reported. Supplementary Files SupplementaryFiles.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-4001109\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":276227929,\"identity\":\"cb3d43b2-11c1-4bbc-b964-1321815f9e6b\",\"order_by\":0,\"name\":\"Joice Coutinho de Alvarenga\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYBACxgbGBhAtAxOQMwBTBhYEtfDABIwNGJhBWiQI2gbXkrgBrIUBtxbm9ubGDx8Y7HgMjp99+Ljgl136dvb+oxt+FEgw8Ld3J2B1WM/BZskZDMk8BmfSjY1n9iXn7uw5zHazB+gwiTNnN2DVMiOxjZn3HzOPZEMamzRvD3PuhhvJbDd4gFoMJHJxa/nDUM8j2f+M/TdvT326AVDLzT+EtDAwHObhl0hjY+b5cTgBpOU2XltAfulhOA7U8oxZmrfhuOGGM4fNbssYSPDg8othe/vDDz8YquXY+NMYP/P8qZY3ON747OabPzZy/O292LU0oNjZhmDzMOAA8qjcP7jUjYJRMApGwUgGAIatXIepvhuCAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Universidade Federal de Minas Gerais\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Joice\",\"middleName\":\"Coutinho\",\"lastName\":\"de Alvarenga\",\"suffix\":\"\"},{\"id\":276227930,\"identity\":\"836085ad-52fd-432d-aae9-2d2f02672b1a\",\"order_by\":1,\"name\":\"Flávia Lanna de Moraes\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Universidade Federal de Minas Gerais\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Flávia\",\"middleName\":\"Lanna\",\"lastName\":\"de Moraes\",\"suffix\":\"\"},{\"id\":276227931,\"identity\":\"fd30a483-272e-4d8e-9d80-793633119fe3\",\"order_by\":2,\"name\":\"Jáder Freitas Maciel Garcia de Carvalho\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Universidade Federal de Minas Gerais\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jáder\",\"middleName\":\"Freitas Maciel Garcia\",\"lastName\":\"de Carvalho\",\"suffix\":\"\"},{\"id\":276227932,\"identity\":\"9fe07ffc-a26e-4234-8e8e-a462623fe7e4\",\"order_by\":3,\"name\":\"Rodrigo Ribeiro dos Santos\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Universidade Federal de Minas Gerais\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Rodrigo\",\"middleName\":\"Ribeiro dos\",\"lastName\":\"Santos\",\"suffix\":\"\"},{\"id\":276227933,\"identity\":\"1d7d1961-1595-439d-bc92-747f067329a4\",\"order_by\":4,\"name\":\"Unaí Tupinambás\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Universidade Federal de Minas Gerais\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Unaí\",\"middleName\":\"\",\"lastName\":\"Tupinambás\",\"suffix\":\"\"},{\"id\":276227934,\"identity\":\"1a8dde5f-bd5e-444f-90d3-791fb7665b54\",\"order_by\":5,\"name\":\"Edgar Nunes de Moraes\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Universidade Federal de Minas Gerais\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Edgar\",\"middleName\":\"Nunes\",\"lastName\":\"de Moraes\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-02-29 20:31:34\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-4001109/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-4001109/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":52039610,\"identity\":\"e629ddab-c111-4d39-8ddf-7e9b3805456b\",\"added_by\":\"auto\",\"created_at\":\"2024-03-05 17:41:40\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":56257,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe number of positive cases, symptomatic participants, admission to emergency service, hospitalization and deaths, among LTCF residents, before the vaccine, and after the first, second and third vaccine doses. The red line corresponds to the proportion of positive cases in the general population.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4001109/v1/82d81d24a29045ad6f832aa5.png\"},{\"id\":52039608,\"identity\":\"8816e5a7-cccf-4da9-97e8-bbd5bf54a809\",\"added_by\":\"auto\",\"created_at\":\"2024-03-05 17:41:40\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":64680,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe risk factors associated with a higher proportion of positive cases, symptomatic patients, and hospitalizations.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4001109/v1/553c54f9d7d304ce992a96a6.png\"},{\"id\":52039609,\"identity\":\"92c394be-3296-484b-82d0-eb449fbe1701\",\"added_by\":\"auto\",\"created_at\":\"2024-03-05 17:41:40\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":25983,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eCorrelation between the number of residents in each LTCF and the proportion of positive cases.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4001109/v1/012913493d19c8f662445f15.png\"},{\"id\":80797927,\"identity\":\"3e413de8-e0a5-494b-aa8a-acdd654faf59\",\"added_by\":\"auto\",\"created_at\":\"2025-04-17 07:54:07\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":880166,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4001109/v1/bfdff3aa-e944-4c97-ad79-41831d37f8ea.pdf\"},{\"id\":52039611,\"identity\":\"e9468c9e-a947-4303-adfc-9c70969d89fb\",\"added_by\":\"auto\",\"created_at\":\"2024-03-05 17:41:40\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":299970,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryFiles.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4001109/v1/ecc4021ed28d7f63b98e118b.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Assessing COVID-19 Vaccine Effectiveness in Frail Long-Term Care Facilities Residents in a Middle-Income Country\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eIn the COVID-19 pandemic, long-term care facilities (LTCF) residents represent those at greatest risk of poor outcomes, including high mortality rates and prolongate hospitalization.\\u003csup\\u003e1,2\\u003c/sup\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOlder adults who live in LTCF have an elevated prevalence of frailty, disabilities, cognitive impairment, dementia and a heightened burden of chronic infirmities, in comparison to their community-residing counterparts.\\u003csup\\u003e3,4\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn the general population, discernible risk factors for mortality and hospital admission encompass the male gender, advancing age, chronic diseases (diabetes, hypertension, kidney disease, cardiovascular disease, obesity, pulmonary disorders, malignancies) and frailty.\\u003csup\\u003e5-7\\u003c/sup\\u003e In the LTCF residents, increased age, frailty, male gender, impaired cognitive function and impaired physical function have all evinced association with mortality.\\u003csup\\u003e8-10\\u003c/sup\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn the context of low and middle-income nations, studies evaluating immunization in frail populations remain scarce, since they are routinely excluded from trials. The majority of the studies evaluating COVID-19 in LTCF have been conducted in developed countries, which may not reflect the realities of emerging countries. Inequality was shown as a determinant agent of disparate outcomes in the COVID-19 pandemic.\\u003csup\\u003e11-13\\u003c/sup\\u003e The suboptimal healthcare provisioning, prevalent in low and middle-income countries, invariably contribute to a heightened prevalence of frail older adults, with a high number and gravity of chronic ailments.\\u003csup\\u003e14,15\\u003c/sup\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn this study, we aimed to evaluate the effectiveness of COVID-19 vaccines among frail and socially vulnerable LTCF residents, in a middle-income country. After a meticulous survey of existing literature, we could not identify prior studies that have evaluated the vaccine efficacy within a comparable demographic profile. Therefore, we sought to evaluate the response of first, second and third COVID-19 vaccine doses, against infections, hospitalizations, and deaths, and the association of frailty, age, sex, cognitive impairment, mobility impairment, chronic diseases and polypharmacy with those outcomes. This study encompasses the periods of alpha, gamma, delta, and omicron variants, which provides a better understanding of vaccine effectiveness, against different lineages.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cem\\u003eStudy Design\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis is a retrospective cohort study, conducted across 29 LTCF located in a prominent city in southeastern Brazil. The study took place during the period from January 2021 to September 2022.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eStudy participants\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe enrolled LTCF were characterized as philanthropic institutions, being financially supported by religious organizations as well as the local public social assistance department.\\u003c/p\\u003e\\n\\u003cp\\u003eAll residents within these institutions were invited to participate in the study. Exclusion criteria were limited to patients who declined research participation.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eData collection\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWithin the designated LTCF, a universal SARS-CoV-2 testing approach was adopted: when any resident or staff member exhibited symptoms, the entire population of residents and workers underwent testing, using PCR-based assays of nasopharyngeal swab.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe research team conducted a daily monitoring of newly confirmed positive cases and the clinical progression of participants who tested positive. Information concerning emergency care or hospital admissions and deaths was updated routinely. Reported mortality cases were subsequently cross-referenced with the national death registry.\\u003c/p\\u003e\\n\\u003cp\\u003eVaccination details encompassing dates, vaccine types, and the dosing regimen, were extracted from the national vaccination registry card, of each participant. The vaccination of LTCF residents was initiated in January 2021, with the administration of the CoronaVac vaccine (Sinovac Biotech). In February 2021, the ChAdOx1-S vaccine (Oxford\\u0026ndash;AstraZeneca) became additionally available for administration. For recipients of the CoronaVac vaccine, the second dose was administered within three to four weeks following the initial dose. Meanwhile, for the ChAdOx1-S vaccine, an interval of eight to twelve weeks was stipulated for the second dose administration. The third dose was deployed in LTCF in November 2021. During this period, the Comirnaty vaccine (Pfizer\\u0026ndash;BioNTech) and the Janssen Ad26.COV2.S vaccine (Johnson \\u0026amp; Johnson) was also incorporated into the LTCF vaccination regimen.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eParticipant\\u0026apos; characteristics, including sex, age, birth date, presence of chronic medical conditions and number of current medications in use were obtained from long-term facilities records. All participants underwent a comprehensive clinical and functional evaluation conducted by a team of geriatric medical specialists. Frailty was assessed using two different scales. The first one was the Clinical-Functional Vulnerability Index-20 (IVCF-20), a screening tool, validated in Brazil to be used even for non-medical professionals.\\u003csup\\u003e16\\u003c/sup\\u003e In the IVCF-20, frailty is stratified from 1 to 40, with scores 1-6 denoting low clinical functional vulnerability; 7-14 indicating moderate vulnerability and 15-40 signifying high vulnerability. This score is detailed in Supplementary Figure 1.\\u003c/p\\u003e\\n\\u003cp\\u003eThe second scale employed was the Clinical-Functional Classification (CCF) of older adults\\u003csup\\u003e17\\u003c/sup\\u003e a standard scale in Brazil, based on Instrumental Activities of Daily Living (IADL), Basics Activities of Daily Living (BADL) and the presence of chronic health conditions. The CCF is an ordinal hierarchical scale ranging from 1 to 10: stratum 1-3 means a robust (fit) older adult, independent for all activities of daily living; stratum 4-5 denotes an older adult at risk of frail (vulnerable older adult); and 6 to 10 indicates frail older adult (stratum 6 are independent for BADL but dependent for some IADL; stratum 7 are independent for BADL but dependent for all IADL; stratum 8 are dependent for some BADL; stratum 9 are dependent for almost all BADL, but can eat independently; and 10, dependent for all BADL). Details of this scale are contemplated in Supplementary Figure 2. \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAs the defining criteria for typical symptoms of COVID-19, we relied upon the Centers for Disease Control and Prevention (CDC) study,\\u003csup\\u003e18\\u003c/sup\\u003e which outlines the most prevalent manifestations of the disease: cough, fever, myalgia, headaches, dyspnea, odynophagia, rhinorrhea, anosmia, and ageusia.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eStudy Variables\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe selected categorical variables encompassed: sex, race, frailty accessed by CCF, RT-PCR for SARS-CoV-2 (classified into three categories: positive, negative, indeterminate) and vaccine type.\\u003c/p\\u003e\\n\\u003cp\\u003eThe dichotomous variables were: the presence of hypertension, diabetes, prior pulmonary disease, presence of cognitive impairment, mobility impairment, presence of typical symptoms associated with COVID-19, admission to emergency care, hospitalization and death. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAge, number of medications in use and the IVCF-20 score were evaluated both as quantitative and categorical variables. Age was stratified into four distinct categories: \\u0026nbsp;participants below 70 years, those between 70 and 79, individuals aged 80 to 89, and those aged 90 or above. For the number of medications in use, were created two categories: with polypharmacy (use of five or more medications per day), or without polypharmacy. For the IVCF-20 score, the instrument\\u0026apos;s reference values were used to create three categories: scores 1-6 denoting low clinical functional vulnerability; 7-14 indicating moderate vulnerability and 15-40 signifying high vulnerability.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eStatistical analysis\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn the descriptive analysis, categorical variables were described using absolute frequency and proportion, while continuous variables were summarized with measures of central tendency (mean and standard deviation, median and quartiles). To compare continuous variables, the Mann-Whitney test was used due to non-normal data distribution, assessed using the Shapiro-Wilk test. In the evaluation of categorical variables, Pearson\\u0026apos;s chi-square test was employed, and for proportion comparisons, the Z test of proportion was utilized. All analyses were performed using Stata software version 16 (StataCorp LLC, College Station, TX), with a significance level of 5%.\\u003c/p\\u003e\\n\\u003cp\\u003eThe primary outcome was overall vaccine effectiveness, irrespective of vaccine type, against infections, admissions to emergency care, hospitalizations, and deaths. Additionally, we evaluated the factors associated with a great risk of contamination, symptoms, admissions to emergency service, or hospital admissions.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eEthics approval\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eBrazilian Commission for Research Ethics (COEP-UFMG) approved the study protocol (CAAE: 40666720.0.0000.5149).\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eA total of 712 LTCF residents were included. The characteristics of the participants are summarized in Table 1. The median age was 81.3 years (IQR 74-89), with 518 individuals (72.8%) being female. The prevalence of frailty was 94.6% (27.7% CCF 6-7, 24.8% CCF 8 and 42.05% CCF 9-10). Cognitive impairment was observed in 79.9% of participants, while 69.5% exhibited mobility impairment, 78.3% presented with at least one chronic disease, and 72.7% reported the use of five or more medications per day, ranging from a minimum of 1 to a maximum of 17 drugs daily.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1\\u003c/strong\\u003e: Descriptive Statistics of Overall Study Population\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"315\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eCharacteristic\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003en\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eAge\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;70\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e86\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e12,1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e70-79\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e222\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e31,22\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e80-89\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e244\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e34,32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e90+\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e159\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e22,36\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eSex\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e518\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e72,86\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e193\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e27,14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eRace\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eWhite\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e238\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e37,01\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eBlack\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e149\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e23,17\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ePardo\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e256\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e39,81\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eCCF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Robust (1-3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0,99\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eRisk of frail (4-5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e4,4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eFrail 6-7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e195\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e27,7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eFrail 8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e175\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e24,86\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eFrail 9-10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e296\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e42,05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eIVCF-20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eLow Vulnerability (0-6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e58\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e8,43\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eModerate Vulnerability (7-14)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e112\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e16,28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eHigh Vulnerability (15-40)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e518\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e75,29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003ePolypharmacy\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt; 4 different drugs/day\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e153\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e27,27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026ge; 5 different drugs/day\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e408\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e72,73\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eComorbidities\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Diabetes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e148\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e24,07\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Hypertension\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e415\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e67,48\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Pulmonary disease\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e89\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e14,45\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Cognitive impairment\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e491\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e79,97\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"64.44444444444444%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Mobility impairment\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"18.095238095238095%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e443\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.46031746031746%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e69,54\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe vaccination adherence was 99.5% of the cohort, all of whom received the complete three-dose regimen. In the first and second doses, 91.7% of the cohort received the ChAdOx1-S vaccine. In the third dose, 98.6% of the participants received the Comirnaty vaccine. Details regarding vaccine types are elaborated upon Supplementary Table 1.\\u003c/p\\u003e\\n\\u003cp\\u003eThe vaccination had a significant impact on the reduction in positive cases (p=.001), in admissions to emergency care (p\\u0026lt;.001), hospitalization (p=.002) and deaths (p\\u0026lt;.001). Prior to the vaccination, a total of 191 positive cases were documented, corresponding to 26.8% of the entire cohort. Among these contaminated individuals, 43.5% exhibited typical respiratory symptoms, 29.3% required emergency care or hospitalization, and 27 COVID-19 related deaths occurred, corresponding to a case fatality rate of 14.1%. After the first dose, 25 positive cases had occurred and after the second dose, 28 positive cases. Only six participants (24% of positive participants) were admitted to emergency care or hospital, after the first dose and six participants after the second dose. Two deaths were observed after both the first and second doses.\\u003c/p\\u003e\\n\\u003cp\\u003eThe period subsequent to the administration of the third dose coincided with the prevalence of the Omicron variant. During this period, the number of positive cases had arisen, with 136 positive cases, representing 19.2% of the cohort. Although, 85.3% were asymptomatic. Among the contaminated participants, 15 (11.1%) necessitated admission to emergency care or hospitalization. Five deaths have occurred, culminating in a post-vaccination case fatality rate of 3.8%, during the dominance of the Omicron variant. Details about vaccine effects are shown in Figure 1.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFigure 1.\\u0026nbsp;\\u003c/strong\\u003eThe number of positive cases, symptomatic participants, admission to emergency service, hospitalization and deaths, among LTCF residents, before the vaccine, and after the first, second and third vaccine doses. The red line corresponds to the proportion of positive cases in the general population.\\u003c/p\\u003e\\n\\u003cp\\u003eWhen risk factors were analyzed (Figure 2), frailty, advanced age, presence of chronic diseases, cognitive impairment and polypharmacy were not associated with a higher rate of contamination by SARS-CoV-2. Mobility impairment, however, exhibited a significant correlation with a higher number of positive cases (p=.03) but not with typical symptoms and admission to emergency or hospital care.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eBefore the vaccination, individuals with a history of pulmonary disease (p=.03) and those dependent for BADL (p=.02) exhibited a higher prevalence of typical symptoms compared to other study participants. Furthermore, a significant association between dependence for BADL (p=.005), male sex (p=.02) and pulmonary disease (p=.008) was observed with a heightened number of admissions to emergency services and hospitalization (Figure 2).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn the non-vaccinated frail subgroup (CCF 8-10), 63 participants, which represents 48.4% of the positive cases exhibited typical symptoms and 45 participants (34.6%) necessitated emergency care or hospital admission. After the administration of three vaccine doses, the number of symptomatic patients in this group decreased to 16 (16.8%) and 12 participants (12.6%) needed admission, as depicted in Figure 2.\\u003c/p\\u003e\\n\\u003cp\\u003ePrior to the vaccination, within the pulmonary disease group, 61.5% of the positive participants displayed typical respiratory symptoms and 50% required emergency care or hospital medical support. After the three doses, the number of symptomatic patients dwindled to 14.2%, with the same percentage necessitating medical intervention in this subgroup.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eMale participants exhibited a higher frequency of hospitalization than females (p=.02). Pre-vaccination, 42% of male participants had been admitted to emergency care or hospital (Figure 2), compared to 24.8% of females. Following vaccination, admissions among males became comparable to those observed among females, with a comparable proportion of 13.5% of the positive cases in males and 15.1% in females, and no statistically significant difference between the two groups.\\u003c/p\\u003e\\n\\u003cp\\u003eAge, hypertension, diabetes, cognitive impairment and polypharmacy did not exhibit significant associations with increased contamination rates, symptoms, admissions to emergency care and hospitalization.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFigure 2:\\u003c/strong\\u003e The risk factors associated with a higher proportion of positive cases, symptomatic patients, and hospitalizations.\\u003c/p\\u003e\\n\\u003cp\\u003eTable 2 compares the number of positive cases, symptomatic participants and participants requiring emergency or hospital care, before and after the three vaccine doses, across different risk factor subgroups. After the three vaccine doses, there was a significant reduction in the proportion of symptomatic patients and admissions, in almost all risk factor subgroups, with the exception of participants with diabetes, in which a reduction in the number of admissions occurred, although, was not statistically significant.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"537\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"100%\\\" colspan=\\\"16\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTable 2:\\u0026nbsp;\\u003c/strong\\u003eComparison between the number of positive cases, symptomatic participants and participants who need emergency or hospital care, before and after the three vaccine doses, in different subgroups of risk factors.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.588454376163874%\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCharacteristics\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.85661080074488%\\\" colspan=\\\"5\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePositive cases\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"23.277467411545622%\\\" colspan=\\\"5\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSymptoms\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"23.277467411545622%\\\" colspan=\\\"5\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAdmission\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.588454376163874%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.193668528864059%\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003eBefore\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"6.890130353817504%\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003eAfter\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.772811918063315%\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.007448789571695%\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003eBefore\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"6.890130353817504%\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003eAfter\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.379888268156424%\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.007448789571695%\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003eBefore\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"6.890130353817504%\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003eAfter\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.379888268156424%\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\"\\u003e\\n \\u003cp\\u003eN\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\"\\u003e\\n \\u003cp\\u003e%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\"\\u003e\\n \\u003cp\\u003eN\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\"\\u003e\\n \\u003cp\\u003e%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\"\\u003e\\n \\u003cp\\u003ep\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\"\\u003e\\n \\u003cp\\u003eN\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\"\\u003e\\n \\u003cp\\u003e%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\"\\u003e\\n \\u003cp\\u003eN\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\"\\u003e\\n \\u003cp\\u003e%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\"\\u003e\\n \\u003cp\\u003ep\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\"\\u003e\\n \\u003cp\\u003eN\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\"\\u003e\\n \\u003cp\\u003e%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\"\\u003e\\n \\u003cp\\u003eN\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\"\\u003e\\n \\u003cp\\u003e%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\"\\u003e\\n \\u003cp\\u003ep\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eAge \\u0026ge; 80\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e119\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e74\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e51\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e43\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e18\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e34\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.01\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eCCF 8-10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e130\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e94\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e63\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e48\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e45\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e34\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eIVCF-20 \\u0026ge; 15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e139\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e99\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e61\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e44\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e41\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.002\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e49\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e37\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e50\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e21\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e42\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eCognitive impairment\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e142\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e93\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e64\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e45\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e43\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eMobility impairment\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e116\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e89\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e30\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e53\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e45\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e38\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eDiabetes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e42\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e26\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e26\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e17\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.008\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003eHypertension\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e112\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e73\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e47\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e42\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e17\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.007\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003ePulmonary disease\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e24\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e0.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e61\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.004\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e50\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.02\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"32.407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003ePolypharmacy\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.62962962962963%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e125\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e63\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e23\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"5.7407407407407405%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.01\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e55\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e44\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e17\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"4.444444444444445%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"3.5185185185185186%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"8.333333333333334%\\\" valign=\\\"bottom\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.007\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWhen the number of positive cases was evaluated in association with LTC characteristics (Figure 3), we observed a trend indicating higher proportions of positive cases in LTCFs with larger resident populations. The number of cases was significantly lower in LTC with a smaller number of residents, in contrast to LTCF with more than 20 residents (p=.002).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFigure 3.\\u0026nbsp;\\u003c/strong\\u003eCorrelation between the number of residents in each LTCF and the proportion of positive cases.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eOur cohort comprised over 700 profoundly frail residents within a LTCF setting, in a context marked by social vulnerability. Among these individuals, over 50% were aged above 80 years, with more than 90% displaying signs of frailty and over 60% exhibiting a state of extreme frailty, with BADL dependence. Nearly 80% of the participants had cognitive impairment, while close to 70% with mobility limitations. Additionally, over 70% had at least one chronic medical condition, and more than 70% necessitated the administration of five or more medications on a daily basis. Even within this cohort marked by a high degree of frailty, disabilities, and clinical severity conditions, we consistently observed the effectiveness of vaccines. To our knowledge, subsequent to an extensive literature review, this is the first Brazilian study that evaluated the vaccine effectiveness in this population profile. Another distinguishing aspect of this study is that all participants underwent a specialized geriatric assessment, enhancing the reliability of the disclosed information.\\u003c/p\\u003e\\n\\u003cp\\u003eOur study is in concordance with several previous studies, which attest to the vaccine\\u0026apos;s effectiveness in preventing infections, hospitalizations and deaths.\\u003csup\\u003e19,20\\u003c/sup\\u003e A clear benefit was already observed after the first dose in our study population. Following the administration of first and second vaccine doses, the number of positive cases, symptomatic patients, admission to emergency service, admission to hospital and deaths diminish significantly, even during periods marked by heightened caseloads in the general populace.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn the period corresponding to Omicron variant predominance, the number of infected participants arises, even after three vaccine doses. Within our cohort, even with an increase in the number of positive cases, the proportion of symptomatic patients, patients who needed admission to emergency service or hospitalization and deaths, remains low, when compared to the period before the first dose. Regarding the Omicron variant, the vaccine effectiveness remained high for preventing death and serious cases but reduced for infection.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Before the vaccine, we found an association between contamination and mobility impairment. This finding is in concordance with previous studies, that evidence the role of staff contact in the contamination of LTCF residents.\\u003csup\\u003e22-25\\u003c/sup\\u003e Residents who have mobility impairment inherently necessitate increased support for ambulation, personal hygiene, and dressing, heightening the proximity to caregiving assistants. Furthermore, we found an association between the number of LTCF residents and heightened contamination rates. A LTCF characterized by a larger resident population necessitates a correspondingly increased staffing capacity. It is plausible that a substantial circulation of staff members might significantly contribute to the transmission of viral infections among the residents.\\u003csup\\u003e26\\u003c/sup\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003ePrevious studies have shown male sex as a risk factor for worse outcomes.\\u003csup\\u003e27-29\\u003c/sup\\u003e In our cohort, before the vaccination, male sex was associated with a great proportion of emergency and hospital admissions. However, subsequent to vaccination, the risk profile among males became comparable to that observed among females.\\u003c/p\\u003e\\n\\u003cp\\u003eHypertension\\u003csup\\u003e10\\u003c/sup\\u003e and diabetes\\u003csup\\u003e10,27,30\\u003c/sup\\u003e were considered risk factors for hospital admission and death, due to COVID-19. In our cohort, these chronic diseases were not associated with contamination, symptoms or admissions. It is conceivable that within this highly frail population profile, the overarching influence of frailty supersedes the individual impact of these chronic conditions. Notably, frailty manifests as a condition of heightened severity compared to standalone chronic diseases.\\u003c/p\\u003e\\n\\u003cp\\u003eCorroborating this idea, similarly to previous studies\\u003csup\\u003e31-36\\u003c/sup\\u003e, frailty was associated with more typical symptoms and more admissions to emergency or hospital care. The vaccine was capable of mitigating this effect, by reducing the number of symptomatic patients and admissions.\\u003c/p\\u003e\\n\\u003cp\\u003eSome previous studies have shown age as a risk factor for worse outcomes in COVID-19\\u003csup\\u003e8,37\\u003c/sup\\u003e and other studies refute this association.\\u003csup\\u003e9\\u003c/sup\\u003e In our cohort, age was not associated with greater contamination, symptoms or admissions.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn accordance with prior research findings, it has been found that pulmonary disease exhibits a correlation with the severity of symptoms and the need for emergency and hospital care.\\u003csup\\u003e38\\u003c/sup\\u003e After the three vaccine doses, a significant reduction in symptomatic patients and admissions was noticed in this subgroup, showing the potential of the vaccine to protect the most susceptible groups.\\u003c/p\\u003e\\n\\u003cp\\u003eWhen we compare the period before and after the vaccination, we observe a reduction in symptomatic patients and those who need admission, in all subgroups of risk factors. Frail individuals are particularly susceptible to the deterioration of their health status due to acute illnesses.\\u003csup\\u003e40\\u003c/sup\\u003e Mitigating the severity of such acute insults holds paramount significance in the reduction of the propensity toward aggravated disabilities and frailty.\\u003c/p\\u003e\\n\\u003cp\\u003eMoreover, admission to emergency care or hospitalization among frail older adults, is accompanied by deleterious complications including delirium, agitation, aggressiveness, disorientation;\\u003csup\\u003e41\\u003c/sup\\u003e falls;\\u003csup\\u003e42\\u003c/sup\\u003e iatrogenic treatments, sarcopenia and pressure injuries.\\u003csup\\u003e43\\u003c/sup\\u003e These complications are associated with major mortality rates.\\u003csup\\u003e44\\u003c/sup\\u003e Consequently, the implementation of preventive measures with the potential to reduce hospitalizations is crucial in this population.\\u003c/p\\u003e\"},{\"header\":\"Conclusion and implications\",\"content\":\"\\u003cp\\u003eOur study provides important insights into vaccine effectiveness, even in an extremely frail and socially vulnerable population. The vaccine was effective in the reduction of severe cases and admissions, even in the Omicron variant wave and in all subgroups of risk factors. Aging is a risk factor for several infectious diseases, including COVID-19 and although immune senescence may compromise vaccine effectiveness, it was not observed in our study.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Limitations\",\"content\":\"\\u003cp\\u003eOur study was unable to undertake a comprehensive evaluation of distinctions among various vaccine types, as the number of recipients for both CoronaVac and Ad26.COV2.S was reduced.\\u003c/p\\u003e\\n\\u003cp\\u003eGiven that a substantial proportion of participants exhibited cognitive impairment, hindering their ability to provide self-reported health statuses and medication regimens, we relied on indirect information sourced from LTCF medical records, which could have caused some information bias. However, the LTCF assumed responsibility for overseeing all aspects of participants\\u0026apos; healthcare, thus potentially enhancing the reliability of our data.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eWithin our cohort, a small number of individuals with antecedent pulmonary conditions and diabetes was observed, potentially restricting our subgroup analyses.\\u003c/p\\u003e\"},{\"header\":\"List Of Abbreviations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eBADL\\u0026nbsp;\\u003c/strong\\u003e Basics Activities of Daily Living\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCCF\\u0026nbsp;\\u0026nbsp;\\u003c/strong\\u003eClinical-Functional Classification\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCDC\\u0026nbsp;\\u003c/strong\\u003e\\u0026nbsp;Centers for Disease Control and Prevention\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eIADL\\u0026nbsp;\\u003c/strong\\u003e\\u0026nbsp;Instrumental Activities of Daily Living\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eIVCF-20\\u0026nbsp;\\u0026nbsp;\\u003c/strong\\u003eClinical-Functional Vulnerability Index-20\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLTCF\\u0026nbsp;\\u0026nbsp;\\u003c/strong\\u003eLong-term care facilities\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eRT-PCR \\u0026nbsp;\\u003c/strong\\u003eReverse transcription polymerase chain reaction\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSARS-CoV-2\\u0026nbsp;\\u003c/strong\\u003e S\\u003cem\\u003eevere acute respiratory syndrome coronavirus 2\\u003c/em\\u003e\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cem\\u003eEthics approval and consent to participate\\u003c/em\\u003e: Brazilian Commission for Research Ethics (COEP-UFMG) approved the study protocol (CAAE: 40666720.0.0000.5149). Informed consent was obtained from all enrolled institutions.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eConsent for publication\\u003c/em\\u003e: not applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eAvailability of data and materials\\u003c/em\\u003e: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eCompeting interests\\u003c/em\\u003e: The authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eFunding\\u003c/em\\u003e: The authors declared no potential conflicts.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eAuthors\\u0026apos; contributions:\\u0026nbsp;\\u003c/em\\u003eAll authors meet the criteria for authorship stated in the editorial policies.\\u0026nbsp;and authors\\u0026apos; specific areas of contributions are listed below:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eStudy concept and design: JA, UT, EM.\\u003c/li\\u003e\\n \\u003cli\\u003eAcquisition of data: JA, FM, JC, RS.\\u003c/li\\u003e\\n \\u003cli\\u003eAnalysis and interpretation of data: JA, FM, UT. \\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eDrafting of the manuscript: JA\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eCritical revision of the manuscript: JA, FM, JC, RS, UT, EM.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eAll authors have approved the final version of the manuscript and agree to be accountable for all aspects of this work.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eAcknowledgements:\\u003c/em\\u003e Not applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflicts of Interest:\\u0026nbsp;\\u003c/strong\\u003eThe authors declare no conflicts of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eDeclaration of generative AI and AI-assisted technologies in the writing process:\\u0026nbsp;\\u003c/strong\\u003eDuring the preparation of this work, the authors used Grammarly (Grammarly Inc) to verification of grammatical correctness and the detection of plagiarism. After using this tool/service, the authors reviewed and edited the content as needed and takes full responsibility for the content of the publication.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eComas-Herrera A MJ, Byrd W, Lorenz-Dant K, et al. Mortality associated with COVID-19 outbreaks in care homes: international evidence. 2020-04-12 2020;doi:https://doi.org/10.21953/lse.mlre15e0u6s6\\u003c/li\\u003e\\n\\u003cli\\u003eLee D CC, Tang A, Brister S, Ezike N. \\u003cem\\u003eNotes from the Field:\\u003c/em\\u003e COVID-19\\u0026ndash;Associated Mortality Risk Among Long-Term Care Facility Residents and Community-Dwelling Adults Aged \\u0026ge;65 Years. \\u003cem\\u003eMMWR Morb Mortal Wkly\\u003c/em\\u003e. 2022-06-15T06:27:48Z 2022;(Rep 2022;71:803\\u0026ndash;805)doi:DOI: http://dx.doi.org/10.15585/mmwr.mm7124a4\\u003c/li\\u003e\\n\\u003cli\\u003eBriggs R CT, Collins R, O\\u0026apos;Neill D, Kennelly SP. 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Different aspects of frailty and COVID-19: points to consider in the current pandemic and future ones. \\u003cem\\u003eBMC Geriatr\\u003c/em\\u003e. Jun 27 2021;21(1):389. doi:10.1186/s12877-021-02316-5\\u003c/li\\u003e\\n\\u003cli\\u003eZhang XM, Jiao J, Xie XH, Wu XJ. The Association Between Frailty and Delirium Among Hospitalized Patients: An Updated Meta-Analysis. \\u003cem\\u003eJ Am Med Dir Assoc\\u003c/em\\u003e. Mar 2021;22(3):527-534. doi:10.1016/j.jamda.2021.01.065\\u003c/li\\u003e\\n\\u003cli\\u003eBrand CA, Sundararajan V. A 10-year cohort study of the burden and risk of in-hospital falls and fractures using routinely collected hospital data. \\u003cem\\u003eQual Saf Health Care\\u003c/em\\u003e. Dec 2010;19(6):e51. doi:10.1136/qshc.2009.038273\\u003c/li\\u003e\\n\\u003cli\\u003eMart MF, Pun BT, Pandharipande P, et al. ICU Survivorship-The Relationship of Delirium, Sedation, Dementia, and Acquired Weakness. \\u003cem\\u003eCrit Care Med\\u003c/em\\u003e. Aug 01 2021;49(8):1227-1240. doi:10.1097/CCM.0000000000005125\\u003c/li\\u003e\\n\\u003cli\\u003eFlaatten H, De Lange DW, Morandi A, et al. The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (\\u0026ge; 80 years). \\u003cem\\u003eIntensive Care Med\\u003c/em\\u003e. Dec 2017;43(12):1820-1828. doi:10.1007/s00134-017-4940-8\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"COVID-19, SARS-CoV-2, frailty, long-term facilities\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-4001109/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-4001109/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground: \\u003c/strong\\u003eDuring the COVID-19 pandemic, individuals residing in long-term care facilities (LTCF) are particularly vulnerable to adverse outcomes due to their higher rates of frailty, disabilities, cognitive impairment, dementia, and chronic illnesses. In low and middle-income nations, research on immunizing frail populations is lacking, while most studies on COVID-19 in LTCF come from wealthier nations and may not fully capture the situation in emerging countries.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods: \\u003c/strong\\u003eWe aimed to evaluate the effectiveness of first, second and third COVID-19 vaccine doses, against infections, hospitalizations, and deaths, and their association with frailty, age, sex and chronic disease, among older adults, in a social vulnerability context. This retrospective cohort study, comprises a total of 712 older adults, in a social vulnerability context, of 29 LTCF, in Brazil.\\u003cstrong\\u003e \\u003c/strong\\u003eContinuous variables were described by medians and interquartile ranges and categorical variables were represented by absolute and relative frequencies. The Mann-Whitney test was used. For evaluating the relation between categorical variables, Pearson's chi-square test was used. When comparing proportions, the Z test of proportion was applied. A significance level of 5% was considered.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults: \\u003c/strong\\u003eMedian age was 81.37 years, 72.8% were female, 94.61% were frail, 79.97% had a cognitive impairment, 69.54% had a mobility impairment, 78.37% have, at least, one chronic disease and 72.73% use five or more medications per day. Before the vaccine, mobility impairment was associated with great contamination rates (p=.03); frailty (p=.02) and previous pulmonary disease (p=.03) with symptoms of gravity; frailty (p=.02), pulmonary disease (p=.04) and male sex (p=.02) with emergency care or hospital admission. After the third vaccine dose, only frailty remains associated with admissions (p=.03). The number of positive cases (p=.001), symptomatic patients (p\\u0026lt;.001), admissions (p=.001) and deaths (p\\u0026lt;.001) were substantially reduced after the three vaccine doses.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions and Implications: \\u003c/strong\\u003eEven in a frail population, the vaccine was effective, in the reduction of positive cases, the number of symptomatic patients, admission to emergency or hospital care and deaths. Before the vaccine, frailty, previous pulmonary disease and male sex were associated with worse outcomes. After the vaccine, frailty remains associated with a major number of admissions.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Assessing COVID-19 Vaccine Effectiveness in Frail Long-Term Care Facilities Residents in a Middle-Income Country\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-03-05 17:41:35\",\"doi\":\"10.21203/rs.3.rs-4001109/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"03580835-b797-4d37-ab96-d1e6ab771251\",\"owner\":[],\"postedDate\":\"March 5th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-04-17T07:53:52+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-03-05 17:41:35\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-4001109\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-4001109\",\"identity\":\"rs-4001109\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}