Incidence, Mortality, and Risk Factors of COVID-19 in Nursing Homes

Round 1

Reviewer 1 Report

Dear authors, the article does not add many information for international readers, but it is very interesting since it overtly describe the past situation in Spain. Hence, it could be helpful for you country.

Overall, the article is well written.

I have few minor points:

Please thoroughly check for typos /there are several merged words throughout the manuscript)

 

Page 1 Line 43: NH’s residentshave an elevated risk of COVID19 considering the high age, the deficient immune response, and the prevalence of chronic disease

No, you have correctly described the reasons why NHs residents had (and have) an elevated risk of COVID-19 in page 1 lines 45-46.  Page 1 line 43 should be restated as "NH's residents have an elevated risk of moderate to severe COVID19 etc.

Page 3 Line 108: However, CIR and MR in some NHs could have an increase 108 due to maintaining the initial populations.

That is a limitation as the choice of using CIR could have overestimated the actual incidence and the related secondary outcomes. It is important that you have underlined it.

Page 3, line 124: Following etc.

Please change it to “According to”

Page 9, lines 248-249: In our study, CIR in the municipalities where the NH 248 was located was not found COVID-19 risk factor in contrast with other studies.

Please restate. It is messy.

Page 9, line 264 “This is concordant..”

Please, change concordant with “consistent”

Methods: can you describe the index of disability that you have chosen?

Discussion: can you briefly discuss how the "age of the facility" could have been associated to MR?

Conclusions: please, briefly discuss how to prevent some of the highlighted risk factors.

References: I think there are too many references. Your study is not a review. If feasible, please select only the most important ones and discard the others.

Author Response

1. First reviewer: 

Dear authors, the article does not add many information for international readers, but it is very interesting since it overtly describes the past situation in Spain. Hence, it could be helpful for your country.

Overall, the article is well written.

-Thank you very much for your revision and useful comments.

I have a few minor points:

Please thoroughly check for typos /there are several merged words throughout the manuscript)

 - We review typos and merged words.

Page 1 Line 43: NH’s residents have an elevated risk of COVID19 considering the high age, the deficient immune response, and the prevalence of chronic disease

No, you have correctly described the reasons why NHs residents had (and have) an elevated risk of COVID-19 in page 1 lines 45-46.  Page 1 line 43 should be restated as "NH's residents have an elevated risk of moderate to severe COVID19 etc.

-We change this phase.

Page 3 Line 108: However, CIR and MR in some NHs could have an increase 108 due to maintaining the initial populations.

That is a limitation as the choice of using CIR could have overestimated the actual incidence and the related secondary outcomes. It is important that you have underlined it

-We appreciate this indication and we add a more complete explanation in the discussion. By the way, during the study period, the resident population of nursing homes was stable and few new residents were incorporated.   

Page 3, line 124: Following etc. Please change it to “According to”

-We change this phase.

Page 9, lines 248-249: In our study, CIR in the municipalities where the NH 248 was located was not found COVID-19 risk factor in contrast with other studies.

Please restate. It is messy.

-We modify the phrase.

Page 9, line 264 “This is concordant..” Please, change concordant with “consistent”

-We replace the phrase.

Methods: can you describe the index of disability that you have chosen?

-A description of the index of disability is made, considering four degree:  0 no disability, 1 milt / minor disability, 2 moderate disability, and 3 severe/profound disabilities. 

Discussion: can you briefly discuss how the "age of the facility" could have been associated with MR?

-We explain that “age of the facility” could be a proxy of the NHS physical environment and equipment, and the older could have more deficiencies than the new.  

Conclusions: please, briefly discuss how to prevent some of the highlighted risk factors.

- In the conclusions, we mention how to prevent the highlighted risk factors.

References: I think there are too many references. Your study is not a review. If feasible, please select only the most important ones and discard the others.

-We valued your comment. However, we think that all the references have been useful for us and they could help to understand our study. 

Reviewer 2 Report

The paper is quite interesting and globally the research is well designed and conducted. My main concerns regard the English language and style (need an extensive editing, above all in the first part of the manuscript) and the poor conclusions (need an important extension). 

Author Response

2. Second Reviewer.

Comments and Suggestions for Authors

The paper is quite interesting and globally the research is well designed and conducted. My main concerns regard the English language and style (need an extensive editing, above all in the first part of the manuscript) and the poor conclusions (need an important extension). 

-Thank you very much for your revision and comments.

-An English expert has reviewed the manuscript, and we have augmented the discussion.

Reviewer 3 Report

The article is interesting and the subject deserves to be published.
Specify how many % were confirmed by PCR test "Most cases and deaths were confirmed by confirmed by arnian detection of SARS-CoV-2 by 78 the real-time reverse transcriptase-polymerase chain reaction transcriptase-reverse polymerase (RT-PCR) test." I have not seen all the tables, some of them are incomplete, you can't see the variables like table n°3.
I think that the use of too many abbreviations spoils the reading. It is absolutely necessary to be more explicit in the presentation of the results, you describe associations without giving the meaning of this association. For example In Table 4, the RIC of residents was significantly associated with the RIC of staff occupancy rate (ARR = 2.09 95% CI 1.69-2.58), resident to staff ratio (ARR = 1.41 95% CI 1.09-1.82), resident-to-nurse ratio (ARR = 1.38 95% CI 1.24-1.54), bed-to-nurse aide ratio (ARR = 1.11 95% 1.01-1.22) and overcrowding index (RTa = 2.29 95% CI 1.69-3.10). The CIR of ratio, bathroom-to-resident ratio, and bed-to-staff ratio were not associated with the CIR of residents

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Author Response

3. Third Reviewer.

Comments and Suggestions for Authors

The article is interesting and the subject deserves to be published.

 

-We are grateful for your revision and comments.

Specify how many % were confirmed by PCR test "Most cases and deaths were confirmed by confirmed by arnian detection of SARS-CoV-2 by 78 the real-time reverse transcriptase-polymerase chain reaction transcriptase-reverse polymerase (RT-PCR) test."

 

-After revision, we can indicate that 100% COVID-19 cases and deaths were laboratory-confirmed with RT-PCR during the study period. 

I have not seen all the tables, some of them are incomplete, you can't see the variables like table n°3

 

-Table 3 has changed to a better vision.

I think that the use of too many abbreviations spoils the reading.

 

-Thank you very much for your suggestion. We have removed a lot of abbreviations from the manuscript.

 

It is absolutely necessary to be more explicit in the presentation of the results, you describe associations without giving the meaning of this association. For example In Table 4, the RIC of residents was significantly associated with the RIC of staff occupancy rate (ARR = 2.09 95% CI 1.69-2.58), resident to staff ratio (ARR = 1.41 95% CI 1.09-1.82), resident-to-nurse ratio (ARR = 1.38 95% CI 1.24-1.54), bed-to-nurse aide ratio (ARR = 1.11 95% 1.01-1.22) and overcrowding index (RTa = 2.29 95% CI 1.69-3.10). The CIR of ratio, bathroom-to-resident ratio, and bed-to-staff ratio were not associated with the CIR of residents

 

-We appreciate your comment and put more detail describing the associations. In the statistical methods, relative risk and 95% confidence interval are indicated.

 

Round 2

Reviewer 2 Report

The authors have definitely improved the manuscript, following all the indications proposed.