As the coronavirus pandemic rips across the world, it's becoming clear that some of the worst-hit places in Europe are care homes.
Research by a team hosted by the London School of Economics, the International Long Term Care Policy Network (LTCPN), paints a grim picture.
The data it collated across five European countries suggests that between 42 and 57 percent of deaths related to COVID-19 have so far occurred in nursing homes.
"We’ve been aware since March that the deaths in care homes were growing very fast in Italy and Spain and we were very keen to track this," said Adelina Comas-Herrara, an assistant professorial research fellow at the LSE.
"We were expecting the number to be big," she told Euronews. "And we were really, really surprised."
Around half of all deaths
In Belgium, 90 percent of care homes have had confirmed cases of COVID-19, and 42 percent of the country's deaths from the disease have come from within them.
The rate is close to 45 percent in France, which was one of the first countries to disclose the number of deaths in its care homes, Comas-Herrara said.
In Italy, her study estimates that more than 9,500 care home residents died as a result of COVID-19, or 53 percent of the country’s total death toll.
In Ireland, care homes accounted for 54 percent of deaths and more than half of the "clusters" of the virus identified nationwide.
There are no official estimates for COVID-19 related mortality in care homes in Spain, but regional data reported by the media suggests that nursing home residents account for 57 percent of deaths – the highest share among the countries studied.
In the UK, "there’s no real reason to expect the percentage to be much different" from the average found across other European countries, Comas-Herrara said.
The UK government has come under criticism for underestimating the actual toll from the virus, as the daily figures it releases only include deaths in hospitals, not nursing homes or other settings.
The team behind the research admits that the data is "imperfect and limited".
"Due to differences in testing availabilities and policies, and to different approaches to recording deaths, international comparisons are difficult," the paper reads.
Many countries simply do not provide official figures on the numbers of people affected by COVID-19 in care homes. In fact, the LTCPN is calling on people to reach out if they can contribute reliable information by email: email@example.com
There are also different ways to count coronavirus deaths, Comas-Herrara explained: there are the cases that have actually tested positive for COVID-19; those that are simply suspected; and "excess deaths" – the extra mortality observed over a period compared to the same time in previous years.
The UK's statistics body, the ONS count COVID-19 deaths in a different way from the DHSC (Department of Health and Social Care). "The DHSC count deaths where a person has been tested positive for coronavirus, and for England this is in hospitals only. The ONS counts deaths where COVID-19 (including suspected cases) was mentioned on the death certificate, regardless of location," the ONS said in a recent report.
Given countries' "lack of consistent testing" for COVID-19, Comas-Herrara's study suggests that this notion of excess mortality might ultimately be the best way to gauge the true toll the disease will have had on care homes – by comparing mortality figures from the period of the pandemic to what it was in previous years at the same season.
Care workers overwhelmed
For now, the impact of the coronavirus pandemic on nursing home residents and staff has become obvious. Many reports detail care homes struggling with too many residents dying at once and too many staff off sick.
In the United States, a care home in New Jersey reportedly found itself overwhelmed by an extraordinary number of COVID-19 deaths over Easter weekend.
Nursing home residents are ideal prey for the virus, as they’re usually aged over 80 and have other health conditions. They live in close quarters and some residents suffering from dementia or Alzheimer’s cannot remember physical distancing rules and stick to them.
Asymptomatic transmission of the disease poses another challenge. In its research, the LTCPN cites epidemiological studies in the United States that found that as many as half of people infected with COVID-19 in care homes did not show any symptoms at the time they were tested.
Care home staff also go from one room to another to look after residents, and many in France have complained of not having enough protective equipment to ensure they’re not unknowingly spreading the disease.