COVID-19 in long-term care facilities in Frankfurt am Main, Germany: incidence, case reports, and lessons learned

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Abstract

Abstract: As of August 30, 2020, the World Health Organisation (WHO) reported 24,822,800 COVID-19 infections world wide. Severe disease and deaths occur especially in older people with chronic illnesses. Residents of nursing homes are considered to be the most vulnerable group. In this paper, the experiences with COVID-19 in nursing homes in Frankfurt will be presented and discussed.

Materials and methods: Based on the data of the statutory reporting obligation, the reported COVID-19 cases are presented and incidences are calculated in different age groups and among residents of nursing homes. Outbreaks in various homes are described in detail based on the documentation from the public health department.

Results: By August 28, 2020, 2,665 COVID-19 infections were reported in Frankfurt am Main (incidence 351/100,000 inhabitants), including 116 (4.3%) residents of nursing homes (2,416/100,000 residents). Almost half (39%) of all deaths in Frankfurt (n=69; incidence 9.1/100,000) were among nursing home residents (n=27; incidence 558/100,000 nursing home residents), with 22 of them in just one long-term care facility (LTCF). Compared to previous years, the mortality rate in nursing homes did not increase in the first half of 2020. In one home, 75% of residents tested positive for SARS-CoV-2 and 25% died; in two other homes, 6.7% and 14.1% of the residents became infected, and the mortality rate was 0.5% and 1%, resp. In the other 42 homes in the city (3,906 beds), the infection rate remained below 1% and the death rate was 0.1%.

Discussion: In many countries, 30–70% of all deaths occur among nursing home residents, including Frankfurt (39%). An increase in overall mortality compared to previous years was not observed in Frankfurt as a whole or in the nursing homes in the city specifically. Due to the measures taken (monitoring of residents and staff, nursing care in protective clothing, prohibition or restriction of visits, physical distancing, isolation of infected people and quarantining of contact persons), only individual cases of COVID-19 illnesses occurred in nursing home residents in most homes and the outbreaks in the three homes could be stopped. We do not recommend regular nontargeted testing in nursing homes, but rather vigilance and the implementation of good hygiene as well as immediate targeted testing if COVID-19 is suspected in residents or staff. In order to mitigate the considerable negative effects of these measures on the residents, a good balance should be sought between infection prevention and the goal of ensuring self-determination and the residents’ quality of life.

Zusammenfassung

Abstract: Bis zum 30.08.2020 meldete die Weltgesundheitsorganisation (WHO) weltweit 24.822.800 COVID-19 Infektionen. Schwere Krankheitsverläufe und Todesfälle treten besonders bei Älteren mit Vorerkrankungen auf. Bewohner von Altenpflegeheimen gelten als die vulnerabelste Gruppe. In der Arbeit sollen die Erfahrungen in den Altenpflegeheimen in Frankfurt diskutiert werden.

Material und Methode: Basierend auf den Daten der gesetzlichen Meldepflicht werden die gemeldeten Fälle dargestellt und Inzidenzen in verschiedenen Altersgruppen und bei Bewohnern von Altenpflegeheimen errechnet. Anhand der Dokumentation des Gesundheitsamtes werden Ausbrüche in verschiedenen Heimen detailliert beschrieben.

Ergebnisse: Bis zum 28.08.2020 wurden in Frankfurt am Main 2.665 COVID-19 Infektionen gemeldet (Inzidenz 351/100.000 Einwohner), darunter 116 (4,3%) bei Bewohnern von Altenpflegeheimen (Inzidenz 2.416/100.000 Altenpflegeheimbewohner). Nahezu die Hälfte (39%) aller Todesfälle in Frankfurt (n=69; Inzidenz 9,1/100.000) betraf Bewohner von Altenpflegeheimen (n=27; Inzidenz 558/100,000 Altenpflegeheimbewohner); davon 22 Bewohner in einem Heim. Im Vergleich mit den Vorjahren war die Sterblichkeit in den Pflegeheimen im ersten Halbjahr 2020 nicht erhöht. In einem Heim wurden 75% der Bewohner positiv getestet, 25% verstarben; in zwei weiteren Heimen traten bei 6,7% bzw. 14,1% der Bewohner Infektionen auf; die Sterblichkeit betrug 0,5% bzw. 1%. In den anderen 42 Heimen in der Stadt (3.906 Betten) blieb die Infektionsrate unter 1% und die Sterberate betrug 0,1%.

Diskussion: In vielen Ländern treten 30–70 % aller Todesfälle bei Altenpflegeheimbewohnern auf, auch in Frankfurt am Main (39%). Eine Erhöhung der Gesamtsterblichkeit im Vergleich zu den Vorjahren war in Frankfurt und in den Altenpflegeheimen in der Stadt nicht zu beobachten. Durch die ergriffenen Maßnahmen (Monitoring von Bewohnern und Personal, Pflege in Schutzkleidung, Verbot bzw. Einschränkung von Besuchen, Social Distancing, Isolierung von Infizierten und Quarantänisierung von Kontaktpersonen) traten in den meisten Heimen keine oder allenfalls Einzelfälle an COVID-19 Erkrankungen bei Altenpflegeheimbewohnern auf und die Ausbrüche in den drei Heimen konnten gut beendet werden. Statt ungezielter Testreihen empfehlen wir hohe Wachsamkeit, gute Hygiene und sofortiges gezieltes Testen beim Auftreten eines Verdachts auf COVID-19 als bessere Strategie. Um die erheblichen negativen Auswirkungen dieser Maßnahmen auf die Bewohner zu mildern, sollte im weiteren dringend eine ausgewogene Balance zwischen der Infektionsprävention und dem Ziel der Selbstbestimmung und Lebensqualität der Bewohner angestrebt werden.

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Most cited references 63

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Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility

Melissa M. Arons, Kelly Hatfield, Sujan Reddy … (2020)

Abstract Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can spread rapidly within skilled nursing facilities. After identification of a case of Covid-19 in a skilled nursing facility, we assessed transmission and evaluated the adequacy of symptom-based screening to identify infections in residents. Methods We conducted two serial point-prevalence surveys, 1 week apart, in which assenting residents of the facility underwent nasopharyngeal and oropharyngeal testing for SARS-CoV-2, including real-time reverse-transcriptase polymerase chain reaction (rRT-PCR), viral culture, and sequencing. Symptoms that had been present during the preceding 14 days were recorded. Asymptomatic residents who tested positive were reassessed 7 days later. Residents with SARS-CoV-2 infection were categorized as symptomatic with typical symptoms (fever, cough, or shortness of breath), symptomatic with only atypical symptoms, presymptomatic, or asymptomatic. Results Twenty-three days after the first positive test result in a resident at this skilled nursing facility, 57 of 89 residents (64%) tested positive for SARS-CoV-2. Among 76 residents who participated in point-prevalence surveys, 48 (63%) tested positive. Of these 48 residents, 27 (56%) were asymptomatic at the time of testing; 24 subsequently developed symptoms (median time to onset, 4 days). Samples from these 24 presymptomatic residents had a median rRT-PCR cycle threshold value of 23.1, and viable virus was recovered from 17 residents. As of April 3, of the 57 residents with SARS-CoV-2 infection, 11 had been hospitalized (3 in the intensive care unit) and 15 had died (mortality, 26%). Of the 34 residents whose specimens were sequenced, 27 (79%) had sequences that fit into two clusters with a difference of one nucleotide. Conclusions Rapid and widespread transmission of SARS-CoV-2 was demonstrated in this skilled nursing facility. More than half of residents with positive test results were asymptomatic at the time of testing and most likely contributed to transmission. Infection-control strategies focused solely on symptomatic residents were not sufficient to prevent transmission after SARS-CoV-2 introduction into this facility.

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Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington

Temet M. McMichael, Dustin W Currie, Shauna Clark … (2020)

Abstract Background Long-term care facilities are high-risk settings for severe outcomes from outbreaks of Covid-19, owing to both the advanced age and frequent chronic underlying health conditions of the residents and the movement of health care personnel among facilities in a region. Methods After identification on February 28, 2020, of a confirmed case of Covid-19 in a skilled nursing facility in King County, Washington, Public Health–Seattle and King County, aided by the Centers for Disease Control and Prevention, launched a case investigation, contact tracing, quarantine of exposed persons, isolation of confirmed and suspected cases, and on-site enhancement of infection prevention and control. Results As of March 18, a total of 167 confirmed cases of Covid-19 affecting 101 residents, 50 health care personnel, and 16 visitors were found to be epidemiologically linked to the facility. Most cases among residents included respiratory illness consistent with Covid-19; however, in 7 residents no symptoms were documented. Hospitalization rates for facility residents, visitors, and staff were 54.5%, 50.0%, and 6.0%, respectively. The case fatality rate for residents was 33.7% (34 of 101). As of March 18, a total of 30 long-term care facilities with at least one confirmed case of Covid-19 had been identified in King County. Conclusions In the context of rapidly escalating Covid-19 outbreaks, proactive steps by long-term care facilities to identify and exclude potentially infected staff and visitors, actively monitor for potentially infected patients, and implement appropriate infection prevention and control measures are needed to prevent the introduction of Covid-19.

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Asymptomatic Transmission, the Achilles’ Heel of Current Strategies to Control Covid-19

Monica Gandhi, Deborah S. Yokoe, Diane Havlir (2020)

Traditional infection-control and public health strategies rely heavily on early detection of disease to contain spread. When Covid-19 burst onto the global scene, public health officials initially deployed interventions that were used to control severe acute respiratory syndrome (SARS) in 2003, including symptom-based case detection and subsequent testing to guide isolation and quarantine. This initial approach was justified by the many similarities between SARS-CoV-1 and SARS-CoV-2, including high genetic relatedness, transmission primarily through respiratory droplets, and the frequency of lower respiratory symptoms (fever, cough, and shortness of breath) with both infections developing a median of 5 days after exposure. However, despite the deployment of similar control interventions, the trajectories of the two epidemics have veered in dramatically different directions. Within 8 months, SARS was controlled after SARS-CoV-1 had infected approximately 8100 persons in limited geographic areas. Within 5 months, SARS-CoV-2 has infected more than 2.6 million people and continues to spread rapidly around the world. What explains these differences in transmission and spread? A key factor in the transmissibility of Covid-19 is the high level of SARS-CoV-2 shedding in the upper respiratory tract, 1 even among presymptomatic patients, which distinguishes it from SARS-CoV-1, where replication occurs mainly in the lower respiratory tract. 2 Viral loads with SARS-CoV-1, which are associated with symptom onset, peak a median of 5 days later than viral loads with SARS-CoV-2, which makes symptom-based detection of infection more effective in the case of SARS CoV-1. 3 With influenza, persons with asymptomatic disease generally have lower quantitative viral loads in secretions from the upper respiratory tract than from the lower respiratory tract and a shorter duration of viral shedding than persons with symptoms, 4 which decreases the risk of transmission from paucisymptomatic persons (i.e., those with few symptoms). Arons et al. now report in the Journal an outbreak of Covid-19 in a skilled nursing facility in Washington State where a health care provider who was working while symptomatic tested positive for infection with SARS-CoV-2 on March 1, 2020. 5 Residents of the facility were then offered two facility-wide point-prevalence screenings for SARS-CoV-2 by real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) of nasopharyngeal swabs on March 13 and March 19–20, along with collection of information on symptoms the residents recalled having had over the preceding 14 days. Symptoms were classified into typical (fever, cough, and shortness of breath), atypical, and none. Among 76 residents in the point-prevalence surveys, 48 (63%) had positive rRT-PCR results, with 27 (56%) essentially asymptomatic, although symptoms subsequently developed in 24 of these residents (within a median of 4 days) and they were reclassified as presymptomatic. Quantitative SARS-CoV-2 viral loads were similarly high in the four symptom groups (residents with typical symptoms, those with atypical symptoms, those who were presymptomatic, and those who remained asymptomatic). It is notable that 17 of 24 specimens (71%) from presymptomatic persons had viable virus by culture 1 to 6 days before the development of symptoms. Finally, the mortality from Covid-19 in this facility was high; of 57 residents who tested positive, 15 (26%) died. An important finding of this report is that more than half the residents of this skilled nursing facility (27 of 48) who had positive tests were asymptomatic at testing. Moreover, live coronavirus clearly sheds at high concentrations from the nasal cavity even before symptom development. Although the investigators were not able to retrospectively elucidate specific person-to-person transmission events and although symptom ascertainment may be unreliable in a group in which more than half the residents had cognitive impairment, these results indicate that asymptomatic persons are playing a major role in the transmission of SARS-CoV-2. Symptom-based screening alone failed to detect a high proportion of infectious cases and was not enough to control transmission in this setting. The high mortality (>25%) argues that we need to change our current approach for skilled nursing facilities in order to protect vulnerable, enclosed populations until other preventive measures, such as a vaccine or chemoprophylaxis, are available. A new approach that expands Covid-19 testing to include asymptomatic persons residing or working in skilled nursing facilities needs to be implemented now. Despite “lockdowns” in these facilities, coronavirus outbreaks continue to spread, with 1 in 10 nursing homes in the United States (>1300 skilled nursing facilities) now reporting cases, with the likelihood of thousands of deaths. 6 Mass testing of the residents in skilled nursing facilities will allow appropriate isolation of infected residents so that they can be cared for and quarantine of exposed residents to minimize the risk of spread. Mass testing in these facilities could also allow cohorting 7 and some resumption of group activities in a nonoutbreak setting. Routine rRT-PCR testing in addition to symptomatic screening of new residents before entry, conservative guidelines for discontinuation of isolation, 7 and periodic retesting of long-term residents, as well as both periodic rRT-PCR screening and surgical masking of all staff, are important concomitant measures. There are approximately 1.3 million Americans currently residing in nursing homes. 8 Although this recommendation for mass testing in skilled nursing facilities could be initially rolled out in geographic areas with high rates of community Covid-19 transmission, an argument can be made to extend this recommendation to all U.S.-based skilled nursing facilities now because case ascertainment is uneven and incomplete and because of the devastating consequences of outbreaks. Immediately enforceable alternatives to mass testing in skilled nursing facilities are few. The public health director of Los Angeles has recommended that families remove their loved ones from nursing homes, 9 a measure that is not feasible for many families. Asymptomatic transmission of SARS-CoV-2 is the Achilles’ heel of Covid-19 pandemic control through the public health strategies we have currently deployed. Symptom-based screening has utility, but epidemiologic evaluations of Covid-19 outbreaks within skilled nursing facilities such as the one described by Arons et al. strongly demonstrate that our current approaches are inadequate. This recommendation for SARS-CoV-2 testing of asymptomatic persons in skilled nursing facilities should most likely be expanded to other congregate living situations, such as prisons and jails (where outbreaks in the United States, whose incarceration rate is much higher than rates in other countries, are increasing), enclosed mental health facilities, and homeless shelters, and to hospitalized inpatients. Current U.S. testing capability must increase immediately for this strategy to be implemented. Ultimately, the rapid spread of Covid-19 across the United States and the globe, the clear evidence of SARS-CoV-2 transmission from asymptomatic persons, 5 and the eventual need to relax current social distancing practices argue for broadened SARS-CoV-2 testing to include asymptomatic persons in prioritized settings. These factors also support the case for the general public to use face masks 10 when in crowded outdoor or indoor spaces. This unprecedented pandemic calls for unprecedented measures to achieve its ultimate defeat.

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Author and article information

Journal

Journal ID (nlm-ta): GMS Hyg Infect Control

Journal ID (iso-abbrev): GMS Hyg Infect Control

Journal ID (publisher-id): GMS Hyg Infect Control

Title: GMS Hygiene and Infection Control

Publisher: German Medical Science GMS Publishing House

ISSN (Electronic): 2196-5226

Publication date (Electronic): 05 November 2020

Publication date Collection: 2020

Volume: 15

Electronic Location Identifier: Doc26

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[1 ]Public Health Department of the City of Frankfurt am Main, Germany

Author notes

*To whom correspondence should be addressed: Ursel Heudorf, MDRO Network Rhine-Main, Breite Gasse 28, 60313 Frankfurt am Main, Germany, Phone: 0049 6921248884, E-mail: mre-rhein-main@ 123456stadt-frankfurt.de

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Publisher ID: dgkh000361 Publisher ID: Doc26 Other ID: urn:nbn:de:0183-dgkh0003611

DOI: 10.3205/dgkh000361

PMC ID: 7656980

PubMed ID: 33214991

SO-VID: bd5af1df-d2d9-4cfe-b8ec-a095dd48ff52

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.

COVID-19 in long-term care facilities in Frankfurt am Main, Germany: incidence, case reports, and lessons learned Translated title: COVID-19 in Altenpflegeheimen in Frankfurt am Main, Deutschland: Inzidenz, Fallbeispiele und „lessons learned“

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Novel Coronavirus Disease COVID-19

Most cited references 63

Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility

Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington

Asymptomatic Transmission, the Achilles’ Heel of Current Strategies to Control Covid-19

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