• Linwei Wang, Huiting Ma, Kristy C Y Yiu, Andrew Calzavara, David Landsman, Linh Luong, Adrienne K Chan, Rafal Kustra, Jeffrey C Kwong, Marie-Claude Boily, Stephen Hwang, Sharon Straus, Stefan D Baral, and Sharmistha Mishra.
• MAP Centre for Urban Health Solutions (Wang, Ma, Yiu, Landsman, Luong, Hwang, Mishra), St. Michael's Hospital, University of Toronto; ICES (Calzavara, Kwong); Division of Infectious Diseases, Department of Medicine (Chan, Mishra), University of Toronto; Division of Infectious Diseases (Chan), Sunnybrook Health Sciences Centre, University of Toronto; Dalla Lana School of Public Health (Kustra), University of Toronto; Department of Family and Community Medicine (Kwong), Faculty of Medicine, University of Toronto, Toronto, Ont.; MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology (Boily), Faculty of Medicine, Imperial College, London, UK; Division of General Internal Medicine (Hwang), Department of Medicine, University of Toronto; Department of Medicine (Straus), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Bloomberg School of Public Health (Baral), Johns Hopkins University, Baltimore, Md.
• CMAJ Open. 2020 Oct 1; 8 (4): E627-E636.

BackgroundCongregate settings have been disproportionately affected by coronavirus disease 2019 (COVID-19). Our objective was to compare testing for, diagnosis of and death after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection across 3 settings (residents of long-term care homes, people living in shelters and the rest of the population).MethodsWe conducted a population-based prospective cohort study involving individuals tested for SARS-CoV-2 in the Greater Toronto Area between Jan. 23, 2020, and May 20, 2020. We sourced person-level data from COVID-19 surveillance and reporting systems in Ontario. We calculated cumulatively diagnosed cases per capita, proportion tested, proportion tested positive and case-fatality proportion for each setting. We estimated the age- and sex-adjusted rate ratios associated with setting for test positivity and case fatality using quasi-Poisson regression.ResultsOver the study period, a total of 173 092 individuals were tested for and 16 490 individuals were diagnosed with SARS-CoV-2 infection. We observed a shift in the proportion of cumulative cases from all cases being related to travel to cases in residents of long-term care homes (20.4% [3368/16 490]), shelters (2.3% [372/16 490]), other congregate settings (20.9% [3446/16 490]) and community settings (35.4% [5834/16 490]), with cumulative travel-related cases at 4.1% (674/16490). Cumulatively, compared with the rest of the population, the diagnosed cases per capita was 64-fold and 19-fold higher among long-term care home and shelter residents, respectively. By May 20, 2020, 76.3% (21 617/28 316) of long-term care home residents and 2.2% (150 077/6 808 890) of the rest of the population had been tested. After adjusting for age and sex, residents of long-term care homes were 2.4 (95% confidence interval [CI] 2.2-2.7) times more likely to test positive, and those who received a diagnosis of COVID-19 were 1.4-fold (95% CI 1.1-1.8) more likely to die than the rest of the population.InterpretationLong-term care homes and shelters had disproportionate diagnosed cases per capita, and residents of long-term care homes diagnosed with COVID-19 had higher case fatality than the rest of the population. Heterogeneity across micro-epidemics among specific populations and settings may reflect underlying heterogeneity in transmission risks, necessitating setting-specific COVID-19 prevention and mitigation strategies.Copyright 2020, Joule Inc. or its licensors.

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