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Nursing homes: the titanic of cruise ships – will residential aged care facilities survive the coronavirus disease 2019 pandemic?
editorial
Publication date (Electronic):
10 August 2020
Journal:
Internal Medicine Journal
Publisher:
John Wiley & Sons Australia, Ltd
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Abstract
Australians living in residential aged care facilities (RACF) are extremely vulnerable to coronavirus disease 2019 (COVID‐19). Residents are both more at risk of contracting the virus and more at risk of dying because of it. Internationally RACF have been the epicentre of the pandemic. Some estimates suggest more than half of all COVID‐19 deaths have been residents of aged care facilities. RACF outbreaks overseas have contributed significantly to community transmission. There is much we can learn from overseas experiences about how to prevent and manage COVID‐19 outbreaks in Australian RACF. International approaches have prioritised protecting acute health services while preventing and preparing for outbreaks within RACF has received less attention. We suggest this is now not the right approach, as without significant support, an outbreak in an RACF is likely to lead to widespread transmission and death both in RACF and the community.
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Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020
Anne Kimball, Kelly Hatfield, Melissa Arons … (2020)
Older adults are susceptible to severe coronavirus disease 2019 (COVID-19) outcomes as a consequence of their age and, in some cases, underlying health conditions ( 1 ). A COVID-19 outbreak in a long-term care skilled nursing facility (SNF) in King County, Washington that was first identified on February 28, 2020, highlighted the potential for rapid spread among residents of these types of facilities ( 2 ). On March 1, a health care provider at a second long-term care skilled nursing facility (facility A) in King County, Washington, had a positive test result for SARS-CoV-2, the novel coronavirus that causes COVID-19, after working while symptomatic on February 26 and 28. By March 6, seven residents of this second facility were symptomatic and had positive test results for SARS-CoV-2. On March 13, CDC performed symptom assessments and SARS-CoV-2 testing for 76 (93%) of the 82 facility A residents to evaluate the utility of symptom screening for identification of COVID-19 in SNF residents. Residents were categorized as asymptomatic or symptomatic at the time of testing, based on the absence or presence of fever, cough, shortness of breath, or other symptoms on the day of testing or during the preceding 14 days. Among 23 (30%) residents with positive test results, 10 (43%) had symptoms on the date of testing, and 13 (57%) were asymptomatic. Seven days after testing, 10 of these 13 previously asymptomatic residents had developed symptoms and were recategorized as presymptomatic at the time of testing. The reverse transcription–polymerase chain reaction (RT-PCR) testing cycle threshold (Ct) values indicated large quantities of viral RNA in asymptomatic, presymptomatic, and symptomatic residents, suggesting the potential for transmission regardless of symptoms. Symptom-based screening in SNFs could fail to identify approximately half of residents with COVID-19. Long-term care facilities should take proactive steps to prevent introduction of SARS-CoV-2 ( 3 ). Once a confirmed case is identified in an SNF, all residents should be placed on isolation precautions if possible ( 3 ), with considerations for extended use or reuse of personal protective equipment (PPE) as needed ( 4 ). Immediately upon identification of the index case in facility A on March 1, nursing and administrative leadership instituted visitor restrictions, twice-daily assessments of COVID-19 signs and symptoms among residents, and fever screening of all health care personnel at the start of each shift. On March 6, Public Health – Seattle and King County, in collaboration with CDC, recommended infection prevention and control measures, including isolation of all symptomatic residents and use of gowns, gloves, eye protection, facemasks, and hand hygiene for health care personnel entering symptomatic residents’ rooms. A data collection tool was developed to ascertain symptom status and underlying medical conditions for all residents. On March 13, the symptom assessment tool was completed by facility A’s nursing staff members by reviewing screening records of residents for the preceding 14 days and by clinician interview of residents at the time of specimen collection. For residents with significant cognitive impairment, symptoms were obtained solely from screening records. A follow-up symptom assessment was completed 7 days later by nursing staff members. Nasopharyngeal swabs were obtained from all 76 residents who agreed to testing and were present in the facility at the time; oropharyngeal swabs were also collected from most residents, depending upon their cooperation. The Washington State Public Health Laboratory performed one-step real-time RT-PCR assay on all specimens using the SARS-CoV-2 CDC assay protocol, which determines the presence of the virus through identification of two genetic markers, the N1 and N2 nucleocapsid protein gene regions ( 5 ). The Ct, the cycle number during RT-PCR testing when detection of viral amplicons occurs, is inversely correlated with the amount of RNA present; a Ct value <40 cycles denotes a positive result for SARS-CoV-2, with a lower value indicating a larger amount of viral RNA. Residents were assessed for stable chronic symptoms (e.g., chronic, unchanged cough) as well as typical and atypical signs and symptoms of COVID-19. Typical COVID-19 signs and symptoms include fever, cough, and shortness of breath ( 3 ); potential atypical symptoms assessed included sore throat, chills, increased confusion, rhinorrhea or nasal congestion, myalgia, dizziness, malaise, headache, nausea, and diarrhea. Residents were categorized as asymptomatic (no symptoms or only stable chronic symptoms) or symptomatic (at least one new or worsened typical or atypical symptom of COVID-19) on the day of testing or during the preceding 14 days. Residents with positive test results and were asymptomatic at time of testing were reevaluated 1 week later to ascertain whether any symptoms had developed in the interim. Those who developed new symptoms were recategorized as presymptomatic. Ct values were compared for the recategorized symptom groups using one-way analysis of variance (ANOVA) for all residents with positive test results for SARS-CoV-2. Analyses were conducted using SAS statistical software (version 9.4; SAS Institute). On March 13, among the 82 residents in facility A; 76 (92.7%) underwent symptom assessment and testing; three (3.7%) refused testing, two (2.4%) who had COVID-19 symptoms were transferred to a hospital before testing, and one (1.2%) was unavailable. Among the 76 tested residents, 23 (30.3%) had positive test results. Demographic characteristics were similar among the 53 (69.7%) residents with negative test results and the 23 (30.3%) with positive test results (Table 1). Among the 23 residents with positive test results, 10 (43.5%) were symptomatic, and 13 (56.5%) were asymptomatic. Eight symptomatic residents had typical COVID-19 symptoms, and two had only atypical symptoms; the most common atypical symptoms reported were malaise (four residents) and nausea (three). Thirteen (24.5%) residents who had negative test results also reported typical and atypical COVID-19 symptoms during the 14 days preceding testing. TABLE 1 Demographics and reported symptoms for residents of a long-term care skilled nursing facility at time of testing* (N = 76), by SARS-CoV-2 test results — facility A, King County, Washington, March 2020 Characteristic Initial SARS-CoV-2 test results Negative, no. (%) Positive, no. (%) Overall 53 (100) 23 (100) Women 32 (60.4) 16 (69.6) Age, mean (SD) 75.1 (10.9) 80.7 (8.4) Current smoker† 7 (13.2) 1 (4.4) Long-term admission type to facility A 35 (66.0) 15 (65.2) Length of stay in facility A before test date, days, median (IQR) 94 (40–455) 70 (21–504) Symptoms in last 14 days Symptomatic 13 (24.5) 10 (43.5) At least one typical COVID-19 symptom§ 9 (17.0) 8 (34.8) Only atypical COVID-19 symptoms¶ 4 (7.5) 2 (8.7) Asymptomatic 40 (75.5) 13 (56.5) No symptoms 32 (60.4) 8 (34.8) Only stable, chronic symptoms 8 (15.1) 5 (21.7) Specific signs and symptoms reported as new or worse in last 14 days Typical symptoms Fever 3 (5.7) 1 (4.3) Cough 6 (11.3) 7 (30.4) Shortness of breath 0 (0) 1 (4.4) Atypical symptoms Malaise 1 (1.9) 4 (17.4) Nausea 0 (0) 3 (13.0) Sore throat 2 (3.8) 2 (8.7) Confusion 2 (3.8) 1 (4.4) Dizziness 1 (1.9) 1 (4.4) Diarrhea 3 (5.7) 1 (4.4) Rhinorrhea/Congestion 1 (1.9) 0 (0) Myalgia 0 (0) 0 (0) Headache 0 (0) 0 (0) Chills 0 (0) 0 (0) Any preexisting medical condition listed 53 (100) 22 (95.7) Specific conditions** Chronic lung disease 16 (30.2) 10 (43.5) Diabetes 20 (37.7) 9 (39.1) Cardiovascular disease 36 (67.9) 20 (87.0) Cerebrovascular accident 19 (35.9) 8 (34.8) Renal disease 18 (34.0) 9 (39.1) Received hemodialysis 2 (3.8) 2 (8.7) Cognitive Impairment 28 (52.8) 13 (56.5) Obesity 11 (20.8) 6 (26.1) Abbreviations: COVID-19 = coronavirus disease 2019; IQR = interquartile range, SD = standard deviation. * Testing performed on March 13, 2020. † Unknown for one resident with negative test results. § Typical symptoms include fever, cough, and shortness of breath. ¶ Atypical symptoms include chills, malaise, sore throat, increased confusion, rhinorrhea or nasal congestion, myalgia, dizziness, headache, nausea, and diarrhea. ** Residents might have multiple conditions. One week after testing, the 13 residents who had positive test results and were asymptomatic on the date of testing were reassessed; 10 had developed symptoms and were recategorized as presymptomatic at the time of testing (Table 2). The most common signs and symptoms that developed were fever (eight residents), malaise (six), and cough (five). The mean interval from testing to symptom onset in the presymptomatic residents was 3 days. Three residents with positive test results remained asymptomatic. TABLE 2 Follow-up symptom assessment 1 week after testing for SARS-CoV-2 among 13 residents of a long-term care skilled nursing facility who were asymptomatic on March 13, 2020 (date of testing) and had positive test results — facility A, King County, Washington, March 2020 Symptom status 1 week after testing No. (%) Asymptomatic 3 (23.1) Developed new symptoms 10 (76.7) Fever 8 (61.5) Malaise 6 (46.1) Cough 5 (38.4) Confusion 4 (30.8) Rhinorrhea/Congestion 4 (30.8) Shortness of breath 3 (23.1) Diarrhea 3 (23.1) Sore throat 1 (7.7) Nausea 1 (7.7) Dizziness 1 (7.7) Real-time RT-PCR Ct values for both genetic markers among residents with positive test results for SARS-CoV-2 ranged from 18.6 to 29.2 (symptomatic [typical symptoms]), 24.3 to 26.3 (symptomatic [atypical symptoms only]), 15.3 to 37.9 (presymptomatic), and 21.9 to 31.0 (asymptomatic) (Figure). There were no significant differences between the mean Ct values in the four symptom status groups (p = 0.3). FIGURE Cycle threshold (Ct) values* for residents of a long-term care skilled nursing facility with positive test results for SARS-CoV-2 by real-time reverse transcription–polymerase chain reaction on March 13, 2020 (n = 23), by symptom status†,§ at time of test — facility A, King County, Washington * Ct values are the number of cycles needed for detection of each genetic marker identified by real-time reverse transcription–polymerase chain reaction testing. A lower Ct value indicates a higher amount of viral RNA. Paired values for each resident are depicted using a different shape. Each resident has two Ct values for the two genetic markers (N1 and N2 nucleocapsid protein gene regions). † Typical symptoms include fever, cough, and shortness of breath. § Atypical symptoms include chills, malaise, sore throat, increased confusion, rhinorrhea or nasal congestion, myalgia, dizziness, headache, nausea, and diarrhea. The figure is a scatter plot showing the cycle threshold values for residents of a long-term care skilled nursing facility with positive test results for SARS-CoV-2 by real-time reverse transcription–polymerase chain reaction on March 13, 2020 (n = 23), by symptom status at time of test, in facility A, King County, Washington. Discussion Sixteen days after introduction of SARS-CoV-2 into facility A, facility-wide testing identified a 30.3% prevalence of infection among residents, indicating very rapid spread, despite early adoption of infection prevention and control measures. Approximately half of all residents with positive test results did not have any symptoms at the time of testing, suggesting that transmission from asymptomatic and presymptomatic residents, who were not recognized as having SARS-CoV-2 infection and therefore not isolated, might have contributed to further spread. Similarly, studies have shown that influenza in the elderly, including those living in SNFs, often manifests as few or atypical symptoms, delaying diagnosis and contributing to transmission ( 6 – 8 ). These findings have important implications for infection control. Current interventions for preventing SARS-CoV-2 transmission primarily rely on presence of signs and symptoms to identify and isolate residents or patients who might have COVID-19. If asymptomatic or presymptomatic residents play an important role in transmission in this population at high risk, additional prevention measures merit consideration, including using testing to guide cohorting strategies or using transmission-based precautions for all residents of a facility after introduction of SARS-CoV-2. Limitations in availability of tests might necessitate taking the latter approach at this time. Although these findings do not quantify the relative contributions of asymptomatic or presymptomatic residents to SARS-CoV-2 transmission in facility A, they suggest that these residents have the potential for substantial viral shedding. Low Ct values, which indicate large quantities of viral RNA, were identified for most of these residents, and there was no statistically significant difference in distribution of Ct values among the symptom status groups. Similar Ct values were reported in asymptomatic adults in China who were known to transmit SARS-CoV-2 ( 9 ). Studies to determine the presence of viable virus from these specimens are currently under way. SNFs have additional infection prevention and control challenges compared with those of assisted living or independent living long-term care facilities. For example, SNF residents might be in shared rooms rather than individual apartments, and there is often prolonged and close contact between residents and health care providers related to the residents’ medical conditions and cognitive function. The index patient in this outbreak was a health care provider, which might have contributed to rapid spread in the facility. In addition, health care personnel in all types of long-term care facilities might have limited experience with proper use of PPE. Symptom ascertainment and room isolation can be exceptionally challenging in elderly residents with neurologic conditions, including dementia. In addition, symptoms of COVID-19 are common and might have multiple etiologies in this population; 24.5% of facility A residents with negative test results for SARS-CoV-2 reported typical or atypical symptoms. The findings in this report are subject to at least two limitations. First, accurate symptom ascertainment in persons with cognitive impairment and other disabilities is challenging; however, this limitation is estimated to be representative of symptom data collected in most SNFs, and thus, these findings might be generalizable. Second, because this analysis was conducted among residents of an SNF, it is not known whether findings apply to the general population, including younger persons, those without underlying medical conditions, or similarly aged populations in the general community. This analysis suggests that symptom screening could initially fail to identify approximately one half of SNF residents with SARS-CoV-2 infection. Unrecognized asymptomatic and presymptomatic infections might contribute to transmission in these settings. During the current COVID-19 pandemic, SNFs and all long-term care facilities should take proactive steps to prevent introduction of SARS-CoV-2, including restricting visitors except in compassionate care situations, restricting nonessential personnel from entering the building, asking staff members to monitor themselves for fever and other symptoms, screening all staff members at the beginning of their shift for fever and other symptoms, and supporting staff member sick leave, including for those with mild symptoms ( 3 ). Once a facility has a case of COVID-19, broad strategies should be implemented to prevent transmission, including restriction of resident-to-resident interactions, universal use of facemasks for all health care personnel while in the facility, and if possible, use of CDC-recommended PPE for the care of all residents (i.e., gown, gloves, eye protection, N95 respirator, or, if not available, a face mask) ( 3 ). In settings where PPE supplies are limited, strategies for extended PPE use and limited reuse should be employed ( 4 ). As testing availability improves, consideration might be given to test-based strategies for identifying residents with SARS-CoV-2 infection for the purpose of cohorting, either in designated units within a facility or in a separate facility designated for residents with COVID-19. During the COVID-19 pandemic, collaborative efforts are crucial to protecting the most vulnerable populations. Summary What is already known about this topic? Once SARS-CoV-2 is introduced in a long-term care skilled nursing facility (SNF), rapid transmission can occur. What is added by this report? Following identification of a case of coronavirus disease 2019 (COVID-19) in a health care worker, 76 of 82 residents of an SNF were tested for SARS-CoV-2; 23 (30.3%) had positive test results, approximately half of whom were asymptomatic or presymptomatic on the day of testing. What are the implications for public health practice? Symptom-based screening of SNF residents might fail to identify all SARS-CoV-2 infections. Asymptomatic and presymptomatic SNF residents might contribute to SARS-CoV-2 transmission. Once a facility has confirmed a COVID-19 case, all residents should be cared for using CDC-recommended personal protective equipment (PPE), with considerations for extended use or reuse of PPE as needed.
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Nursing Homes Are Ground Zero for COVID-19 Pandemic
Michael L Barnett, David Grabowski (2020)
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Universal and Serial Laboratory Testing for SARS-CoV-2 at a Long-Term Care Skilled Nursing Facility for Veterans — Los Angeles, California, 2020
Amy Dora, Alexander Winnett, Lauren P. Jatt … (2020)
On March 28, 2020, two residents of a long-term care skilled nursing facility (SNF) at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) had positive test results for SARS-CoV-2, the cause of coronavirus disease 2019 (COVID-19), by reverse transcription–polymerase chain reaction (RT-PCR) testing of nasopharyngeal specimens collected on March 26 and March 27. During March 29–April 23, all SNF residents, regardless of symptoms, underwent serial (approximately weekly) nasopharyngeal SARS-CoV-2 RT-PCR testing, and positive results were communicated to the county health department. All SNF clinical and nonclinical staff members were also screened for SARS-CoV-2 by RT-PCR during March 29–April 10. Nineteen of 99 (19%) residents and eight of 136 (6%) staff members had positive test results for SARS-CoV-2 during March 28–April 10; no further resident cases were identified on subsequent testing on April 13, April 22, and April 23. Fourteen of the 19 residents with COVID-19 were asymptomatic at the time of testing. Among these residents, eight developed symptoms 1–5 days after specimen collection and were later classified as presymptomatic; one of these patients died. This report describes an outbreak of COVID-19 in an SNF, with case identification accomplished by implementing several rounds of RT-PCR testing, permitting rapid isolation of both symptomatic and asymptomatic residents with COVID-19. The outbreak was successfully contained following implementation of this strategy. VAGLAHS includes 150 long-term care beds in three SNF patient care areas, or wards; SNF wards A and B are in building 1, and ward C is in building 2. Buildings 1 and 2 do not share common areas, but residents might have indirect contact with outside persons while receiving medical services such as dialysis. These wards admit residents who require intravenous antibiotics, complex wound care, other rehabilitation needs, routine dialysis, chemotherapy, or radiation therapy; underlying conditions, including chronic obstructive pulmonary disease, hypertension, cardiovascular disease, and chronic kidney disease, are common. At the time of the outbreak, 99 (66%) beds were occupied; >95% of residents were men aged 50–100 years. All data were abstracted from the VAGLAHS electronic health record system on which all records are maintained on inpatients, SNF residents, and outpatients. To reduce the risk for introduction of SARS-CoV-2, on March 6, all VAGLAHS staff members and visitors were screened for symptoms of COVID-19 (i.e., fever, cough, or shortness of breath), travel to countries that had CDC travel warnings for COVID-19, and any close contact with persons with known COVID-19; those with relevant symptoms or exposures were not allowed entry to any area of the facility. On March 11, all SNF admissions were suspended, and daily temperature and symptom screening began for all residents. Residents with fever or lower respiratory tract signs or symptoms were placed on droplet and contact precautions in single-person rooms. On March 17, visitors were prohibited from entering any SNF building. On March 26, the index patient (patient A0.1 † ) in ward A developed fever. A second ward A patient (patient A0.2) developed fever and cough on March 27. Nasopharyngeal swabs collected the day of fever onset were reported as positive for SARS-CoV-2 for both patients A0.1 and A0.2 on March 28. In response, during March 29–31, VAGLAHS staff members screened all building 1 (wards A and B) residents, regardless of symptoms, by SARS-CoV-2 RT-PCR testing of nasopharyngeal swabs. On March 29, a resident from ward C (C0.1) in building 2 became symptomatic; SARS-CoV-2 RT-PCR nasopharyngeal testing was positive on March 30, prompting testing of all building 2 residents on March 31. All three residents with a diagnosis of COVID-19 (patients A0.1, A0.2, and C0.1) were transferred to the affiliated acute care hospital for isolation and clinical management. Implementation of infection control procedures (i.e., hand hygiene, droplet and contact precautions for persons with fever or lower respiratory tract signs or symptoms), and strategies for case identification and containment were reviewed with SNF staff members. Although staff members could previously be assigned to daily shifts on different wards, beginning on March 28, each staff member was assigned to a single ward. During the outbreak, an infection control nurse regularly reviewed and monitored the use of recommended personal protective equipment (PPE) with all SNF staff members. Protocols for use of PPE, based on CDC guidance, § did not change during the outbreak. All staff members were screened by RT-PCR at least once during March 29–April 10. RT-PCR Testing of Residents RT-PCR testing of all residents, conducted during March 29–March 31 in wards A, B, and C, identified SARS-CoV-2 in four (13%) of 30 residents on ward A, none of 30 residents on ward B, and 10 (28%) of 36 residents on ward C. All infected residents were transferred to the affiliated hospital for isolation and clinical management, and the wards were closed to new admissions. Following the initial testing, some residents moved between the SNF and the affiliated hospital for treatment of medical conditions unrelated to COVID-19. Considering the number of cases identified through initial testing, the Infection Control team, in coordination with the SNF nursing staff members, implemented serial (approximately weekly) RT-PCR testing among residents of wards A and C until no additional residents received a positive test result. On April 3, all 22 remaining ward A residents received negative test results and were subsequently transferred to wards B and C. Ward A was converted into a COVID-19 recovery unit to cohort patients without acute hospital needs with continued RT-PCR–positive test results during convalescence. On April 6, the 28 residents on ward C were retested; two had positive test results and were transferred to the COVID-19 recovery unit (Box). A third round of testing was performed on ward C on April 13; all 27 residents had negative test results. During April 22–23, a final round of testing conducted on wards B and C identified no positive test results among the remaining 83 residents. BOX Discharge criteria for Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) facility patients with positive test results for SARS-CoV-2 and criteria for transfer back to acute care hospital — Los Angeles, California, 2020 Required criteria for discharge from acute care to COVID-19 recovery unit * Confirmed COVID-19 diagnosis During the preceding 2 days Temperature 93% or no change from established baseline for residents with chronic oxygen requirement for 24 hours before transfer D-dimer 99.9°F (>37.7°C) Respiratory rate ≥24 per minute Abbreviations: COVID-19 = coronavirus disease 2019; FEU = fibrinogen equivalent units; SNF = long-term care skilled nursing facility; VA = Veterans Affairs. * Laboratory tests are not required for asymptomatic comfort care residents who are otherwise candidates for transfer to the COVID-19 recovery unit. † A test-based strategy is preferred for discontinuation of transmission-based precautions for residents who are being transferred to a long-term care or assisted living facility. All testing must be complete before transfer. In total, three residents were identified with COVID-19 based on testing conducted because of symptoms, and 16 additional residents were identified with COVID-19 because of RT-PCR testing, two of whom reported or were identified with symptoms at the time of RT-PCR testing (Table). Fourteen of the 19 (74%) residents with COVID-19 reported no symptoms at the time of testing; among these residents, eight were presymptomatic, developing symptoms 1–5 days after the date of specimen collection. One of the three initially identified patients, C0.1, a man aged >90 years, died. TABLE Characteristics of long-term care skilled nursing facility residents with positive test results for SARS-CoV-2 (N = 19) — Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, 2020 Characteristic No. (%) Asymptomatic* (n = 6) Presymptomatic* (n = 8) Symptomatic* (n = 5) All (N = 19) Demographic Age, yrs, median (IQR) 75 (72–75) 67 (66–84.5) 84 (70–85) 75 (66–85) Male sex 6 (100) 8 (100) 5 (100) 19 (100) Race/Ethnicity† Asian — — — — Black or African American 2 (33) 4 (50) 2 (40) 8 (42) Native Hawaiian or Pacific Islander — 1 (13) — 1 (5) White 3 (50) 3 (38) 2 (40) 8 (42) Unknown 1 (17) — 1 (20) 2 (11) Hispanic — — — — Underlying medical condition§ Hypertension 5 (83) 5 (63) 3 (60) 13 (68) Cardiovascular disease 3 (50) 4 (50) 5 (100) 12 (63) Diabetes 4 (67) 5 (63) 2 (40) 11 (58) Body mass index >30 kg/m2 3 (50) 2 (25) 2 (40) 7 (37) Chronic kidney disease (stage 4 or above) — 2 (25) 1 (20) 3 (16) Chronic obstructive pulmonary disease 1 (17) 1 (13) 2 (40) 4 (21) Symptoms at time of or after testing¶ Constitutional symptom — 6 (75) 5 (100) 11 (58) Fever — 6 (75) 5 (100) 11 (58) Myalgia — — 1 (20) 1 (5) Headache — 1 (13) 1 (20) 2 (11) Respiratory symptom — 4 (38) 5 (100) 9 (47) Cough — 2 (25) 5 (100) 7 (37) Dyspnea — 2 (25) 1 (20) 3 (16) Gastrointestinal symptom — 5 (63) 1 (20) 6 (32) Nausea — 1 (13) — 1 (5) Emesis — 1 (13) — 1 (5) Diarrhea — 2 (25) — 2 (11) Poor appetite — 3 (38) 1 (20) 4 (21) Laboratory findings on admission,**,†† median (IQR) [No.] WBC (x 1,000/μL) 4.32 (3.67–5.91) [5] 4.35 (3.93–6.10) [8] 6.24 (6.09–7.08) [5] 5.32 (3.94–6.20) [18] Lymphocytes (%) 31.5 (26.4–32.7) [5] 22.0 (17.5–25.9) [8] 16.7 (11.4–16.9) [5] 22.0 (17.0–30.3) [18] Lymphocytes (x 1,000/μL) 1,200 (1,140–1,200) [5] 960 (775–1,105) [8] 880 (770–1,200) [5] 1,025 (835–1,200) [18] Creatinine (mg/dL) 1.00 (0.89–1.05) [4] 1.01 (0.82–1.07) [8] 2.84 (1.99–3.23) [5] 1.04 (0.88–1.41) [17] AST (U/L) 19 (17–21) [3] 24 (20–29) [5] 31 (NA) [1] 22 (19–29) [9] ALT (U/L) 16 (13–21) [4] 17 (14–44) [6] 28 (21–28) [3] 16 (14–28) [13] D–Dimer (μg/mL FEU) 0.54 (0.42–0.83) [4] 0.66 (0.55–1.42) [7] 0.94 (0.59–1.17) [3] 0.63 (0.50–1.29) [14] Ferritin (ng/mL) 60.8 (51.2–99.7) [5] 343.0 (162.5–540.6) [8] 184.6 (NA) [2] 179.1 (59.0–354.2) [15] CRP (mg/dL) 0.605 (0.420–1.190) [4] 1.070 (0.900–2.565) [7] 6.765 (NA) [2] 1.03 (0.71–2.63) [13] Outcomes Supplemental oxygen required — 4 (50) 4 (80) 8 (42) Death — — 1 (20) 1 (5) Length of hospital stay, days, median (IQR) 6 (1–6) 9 (7–10) 10 (5–13) 6 (5–10) Abbreviations: ALT = alanine aminotransferase; AST = aspartate aminotransferase; CRP = C-reactive protein; FEU = fibrinogen equivalent units; IQR = interquartile range (1st–3rd); NA = not applicable; WBC = white blood cell. * Patients were classified as symptomatic if they had at least one listed symptom at the time of first positive specimen collection, presymptomatic if they did not exhibit symptoms at the time of specimen collection but later developed at least one listed symptom, and asymptomatic if they did not exhibit symptoms at any time between specimen collection and the last date of data collection. † Asian, black, Native Hawaiian or Pacific Islander, and white residents in this cohort were non-Hispanic; Hispanic persons could be of any race. § Comorbidities were determined based on documented SNOMED CT and International Classification of Diseases, Ninth Revision codes and review of patient’s vital signs, laboratory values, imaging findings, and provider notes. Chronic kidney disease stage was calculated using the Cockcroft-Gault equation to determine creatinine clearance; patients with estimated glomerular filtration rates 100.4°F (>38°C) or fever reported by provider. ** These values include the first available laboratory results within 48 hours of admission for each patient. †† Reference values are as follows: WBC = 4.5–11.0 x 1,000 per μL; lymphocytes = 600–4,800 x 1,000 per μL; % lymphocytes = 20%–40%; creatinine = 0.66–1.28 mg per dL; AST = 13–35 U per liter; ALT = 7–45 U per liter; d-Dimer = 0.00–0.42 μg per mL FEU; ferritin = 22–322 ng per mL; CRP = 0–0.744 mg per dL. RT-PCR Testing of Staff Members During March 29–April 10, universal RT-PCR testing of all 136 staff members identified eight (6%) infections: three in registered nurses and five in licensed vocational nurses, all of whom worked in wards A or C. Four of the eight infected staff members were symptomatic and were tested within 2 days after symptom onset; one developed fever at work and was immediately tested and sent home. None of the others worked during or after symptom onset. Although serial RT-PCR testing of staff members was not feasible because of limited testing supplies, testing remained available for symptomatic staff members. No cases among staff members were identified after the initial round of testing. Discussion During March 26–April 23, a total of 19 cases of COVID-19 were diagnosed among 99 SNF residents (19.2%). At the time of diagnosis, 14 of 19 residents were asymptomatic, eight of whom were presymptomatic; one patient died. One half of the eight staff members with a diagnosis of COVID-19 were initially asymptomatic. This report demonstrates the high prevalence of asymptomatic SARS-CoV-2 infection that can occur in SNFs, highlighting the potential for widespread transmission among residents and staff members before illness is recognized and demonstrating the utility of universal RT-PCR testing for COVID-19 after case identification in this setting. SNFs and other long-term care facilities where residents have high rates of underlying medical conditions are particularly susceptible to COVID-19 outbreaks ( 1 – 3 ). Limited testing and delayed recognition of symptomatic cases in congregate living settings can result in large and protracted outbreaks ( 3 ). In a recently described outbreak within homeless shelters, RT-PCR testing of all residents, coupled with rapid isolation and cohorting procedures, limited transmission ( 4 ). Multiple studies have demonstrated efficient transmission of SARS-CoV-2 from infected persons who are not yet symptomatic ( 1 , 5 , 6 ). One study in Italy showed through community surveillance testing that 43% of persons with confirmed SARS-CoV-2 infection were asymptomatic and that transmission from asymptomatic and presymptomatic persons also occurred within households. ¶ In this cohort, transmission from asymptomatic persons was likely, because a large proportion of residents and staff members did not have symptoms at the time of diagnosis. RT-PCR testing among SNF residents was repeated approximately weekly until all residents had negative test results. Serial testing aided the identification of subsequent cases. Testing of staff members might be especially important because they can acquire SARS-CoV-2 in the community and reintroduce it into the SNF. Although serial laboratory testing of staff members was considered after the initial round of testing, insufficient supplies limited the ability to fully carry this out. Swift isolation and cohorting of residents with COVID-19 reduced further transmission within the SNF; residents who had positive test results were quickly transferred out of the SNF, either to the acute care hospital or directly to a separate COVID-19 recovery unit. The conversion of ward A into a COVID-19 recovery unit allowed cohorting of clinically stable residents within the SNF without requiring transfer to the affiliated hospital. This measure decreased burden on the hospital and allowed residents to remain in a familiar setting. Restricting staff movement between SNF wards reduced potential for transmission between wards. With these measures, the outbreak in ward A was suppressed within 1 week, the outbreak in ward C was suppressed within 2 weeks, and no cases occurred in ward B. The Centers for Medicare & Medicaid Services currently recommends symptom screening of all SNF patients and cohorting of staffing teams for infected and uninfected patients ( 7 ). Medicare has expanded coverage for SARS-CoV-2 tests ( 7 ), and, as of April 30, Los Angeles County Department of Public Health had endorsed mass testing if a COVID-19 case is identified in a long-term care facility ( 8 ). At the time of the VAGLAHS SNF outbreak, the Los Angeles County Department of Public Health criteria for testing did not include RT-PCR testing of asymptomatic persons ( 9 ). The findings in this report are subject to at least three limitations. First, because residents’ recall might be limited by cognitive disorders or recall bias, over- or underreporting of symptoms was possible and could have affected classification of patients as symptomatic or asymptomatic. Second, symptom data obtained from medical records might have been incomplete, because the daily symptom screening only included fever and respiratory symptoms and did not include symptoms more recently recognized as being associated with COVID-19, such as loss of sense of smell or taste,** which could have led to an overestimation of the asymptomatic population. Finally, because the all-male cohort of patients with laboratory-confirmed COVID-19 might have comorbidity profiles that differ from other groups, these findings might not be generalizable to other SNFs. This investigation demonstrates the benefit of RT-PCR testing of SNF residents and staff members for SARS-CoV-2 after an initial case of COVID-19 is diagnosed. Identification of asymptomatic COVID-19 cases after initial RT-PCR testing supports implementation of serial laboratory testing in SNFs where COVID-19 cases have been identified. Identification of asymptomatic and presymptomatic residents with positive laboratory results for SARS-CoV-2 facilitated rapid transfer of these residents out of the SNF until a dedicated ward to cohort those with COVID-19 was created within the SNF, thereby reducing transmission. In congregate living settings that include persons with conditions that might place them at high risk for severe COVID-19, universal and serial laboratory-based testing for SARS-CoV-2 is an effective strategy that can be implemented for rapid identification of infection to minimize transmission. Summary What is already known about this topic? Long-term care skilled nursing facilities (SNFs) are at high risk for COVID-19 outbreaks. Many SNF residents and staff members identified with COVID-19 are asymptomatic and presymptomatic. What is added by this report? After identification of two cases of COVID-19 in an SNF in Los Angeles, universal, serial reverse transcription–polymerase chain reaction (RT-PCR) testing of residents and staff members aided in rapid identification of additional cases and isolation and cohorting of these residents and interruption of transmission in the facility. What are the implications for public health practice? Universal and serial RT-PCR testing in SNFs can identify cases during an outbreak, and rapid isolation and cohorting can help interrupt transmission.
Author and article information
Contributors
Frances Crotty:
ORCID: https://orcid.org/0000-0002-2339-5530
frances.crotty@mh.org.au
Journal
Journal ID (nlm-ta): Intern Med J
Journal ID (iso-abbrev): Intern Med J
Journal ID (doi): 10.1111/(ISSN)1445-5994
Journal ID (publisher-id): IMJ
Title:
Internal Medicine Journal
Publisher:
John Wiley & Sons Australia, Ltd
(Melbourne
)
ISSN
(Print):
1444-0903
ISSN
(Electronic):
1445-5994
Publication date
(Electronic):
10
August
2020
Electronic Location Identifier: 10.1111/imj.14966
Affiliations
Author notes
[*]
[*
]
Correspondence
Frances Crotty, Department of Medicine and Aged Care, The Royal Melbourne Hospital, 300 Grattan Street, Parkville, Vic. 3050, Australia.
Email: frances.crotty@ 123456mh.org.au
Frances Crotty, Department of Medicine and Aged Care, The Royal Melbourne Hospital, 300 Grattan Street, Parkville, Vic. 3050, Australia.
Email: frances.crotty@ 123456mh.org.au
Author information
Frances Crotty
https://orcid.org/0000-0002-2339-5530
Article
Publisher ID: IMJ14966DOI: 10.1111/imj.14966
PMC ID: 7436225
PubMed ID: 32776671
SO-VID: 407f23c5-4a68-4d5e-a3d7-234a62fa66e3
Copyright © © 2020 Royal Australasian College of Physicians
License:
This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.
History
Date
received
: 23
April
2020
Date
revision received
: 20
June
2020
Date
accepted
: 20
June
2020
Page count
Figures: 0,
Tables: 0,
Pages: 4,
Words: 2919
Categories
Subject:
Editorial
Subject:
Editorial
Custom metadata
source-schema-version-number 2.0
edited-state corrected-proof
details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.7 mode:remove_FC converted:19.08.2020
Data availability: