Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility
Melissa M Arons, Kelly M Hatfield, Sujan C Reddy, Anne Kimball, Allison James, Jesica R Jacobs, Joanne Taylor, Kevin Spicer, Ana C Bardossy, Lisa P Oakley, Sukarma Tanwar, Jonathan W Dyal, Josh Harney, Zeshan Chisty, Jeneita M Bell, Mark Methner, Prabasaj Paul, Christina M Carlson, Heather P McLaughlin, Natalie Thornburg, Suxiang Tong, Azaibi Tamin, Ying Tao, Anna Uehara, Jennifer Harcourt, Shauna Clark, Claire Brostrom-Smith, Libby C Page, Meagan Kay, James Lewis, Patty Montgomery, Nimalie D Stone, Thomas A Clark, Margaret A Honein, Jeffrey S Duchin, John A Jernigan, Public Health–Seattle and King County and CDC COVID-19 Investigation Team, Atar Baer, Leslie M Barnard, Eileen Benoliel, Meaghan S Fagalde, Jessica Ferro, Hal Garcia-Smith, Elysia Gonzales, Noel Hatley, Grace Hatt, Michaela Hope, Melinda Huntington-Frazier, Vance Kawakami, Jennifer L Lenahan, Margaret D Lukoff, Emily B Maier, Shelly McKeirnan, Jennifer L Morgan, Laura A Mummert, Sargis Pogosjans, Leilani Schwarcz, Daniel Smith, Steven Stearns, Kaitlyn J Sykes, Holly Whitney, Michelle Banks, Arun Balajee, Eric J Chow, Barbara Cooper, Dustin W Currie, Jessica Healy, Michael Hughes, Temet M McMichael, Leisha Nolen, Christine Olson, Agam K Rao, Kristine Schmit, Noah G Schwartz, Farrell Tobolowsky, Rachael Zacks, Suzanne Zane, Jing Zhang, Krista Queen, Clinton R Paden, Brett Whitaker, Steve Lindstrom, Denny Russell, Brian Hiatt, Jessica Gant, Melissa M Arons, Kelly M Hatfield, Sujan C Reddy, Anne Kimball, Allison James, Jesica R Jacobs, Joanne Taylor, Kevin Spicer, Ana C Bardossy, Lisa P Oakley, Sukarma Tanwar, Jonathan W Dyal, Josh Harney, Zeshan Chisty, Jeneita M Bell, Mark Methner, Prabasaj Paul, Christina M Carlson, Heather P McLaughlin, Natalie Thornburg, Suxiang Tong, Azaibi Tamin, Ying Tao, Anna Uehara, Jennifer Harcourt, Shauna Clark, Claire Brostrom-Smith, Libby C Page, Meagan Kay, James Lewis, Patty Montgomery, Nimalie D Stone, Thomas A Clark, Margaret A Honein, Jeffrey S Duchin, John A Jernigan, Public Health–Seattle and King County and CDC COVID-19 Investigation Team, Atar Baer, Leslie M Barnard, Eileen Benoliel, Meaghan S Fagalde, Jessica Ferro, Hal Garcia-Smith, Elysia Gonzales, Noel Hatley, Grace Hatt, Michaela Hope, Melinda Huntington-Frazier, Vance Kawakami, Jennifer L Lenahan, Margaret D Lukoff, Emily B Maier, Shelly McKeirnan, Jennifer L Morgan, Laura A Mummert, Sargis Pogosjans, Leilani Schwarcz, Daniel Smith, Steven Stearns, Kaitlyn J Sykes, Holly Whitney, Michelle Banks, Arun Balajee, Eric J Chow, Barbara Cooper, Dustin W Currie, Jessica Healy, Michael Hughes, Temet M McMichael, Leisha Nolen, Christine Olson, Agam K Rao, Kristine Schmit, Noah G Schwartz, Farrell Tobolowsky, Rachael Zacks, Suzanne Zane, Jing Zhang, Krista Queen, Clinton R Paden, Brett Whitaker, Steve Lindstrom, Denny Russell, Brian Hiatt, Jessica Gant
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.
Copyright © 2020 Massachusetts Medical Society.
Figures
References
- Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med 2020;382:929-936.
- McMichael TM, Currie DW, Clark S, et al. Epidemiology of Covid-19 in a long-term care facility in King County, Washington. N Engl J Med. DOI: 10.1056/NEJMoa2005412.
- McMichael TM, Clark S, Pogosjans S, et al. COVID-19 in a long-term care facility — King County, Washington, February 27–March 9, 2020. MMWR Morb Mortal Wkly Rep 2020;69:339-342.
- Kimball A, Hatfield KM, Arons M, et al. Asymptomatic and presymptomatic SARS-CoV-2 infections in residents of a long-term care skilled nursing facility — King County, Washington, March 2020. MMWR Morb Mortal Wkly Rep 2020;69:377-381.
- Centers for Disease Control and Prevention. Preparing for COVID-19: long-term care facilities, nursing homes. 2020. ().
- Centers for Disease Control and Prevention. Interim guidelines for collecting, handling, and testing clinical specimens from persons for coronavirus disease 2019 (COVID-19). 2020. ().
- Centers for Disease Control and Prevention. Symptoms. Coronavirus 2019 (COVID-19). 2020. ().
- Centers for Disease Control and Prevention. Real-time RT-PCR panel for detection 2019-novel coronavirus. 2020. ().
- Centers for Disease Control and Prevention. 2019-Novel coronavirus (2019-nCoV) real-time rRT-PCR panel primers and probes. 2020. ().
- Kumar S, Stecher G, Li M, Knyaz C, Tamura K. MEGA X: molecular evolutionary genetics analysis across computing platforms. Mol Biol Evol 2018;35:1547-1549.
- Public Health — Seattle and King County. COVID-19 data dashboard: King County COVID-19 outbreak summary ().
- Wei WE, Li Z, Chiew CJ, Yong SE, Toh MP, Lee VJ. Presymptomatic transmission of SARS-CoV-2 — Singapore, January 23–March 16, 2020. MMWR Morb Mortal Wkly Rep 2020;69:411-415.
- Tong Z-D, Tang A, Li K-F, et al. Potential presymptomatic transmission of SARS-CoV-2, Zhejiang Province, China, 2020. Emerg Infect Dis 2020;26:1052-1054.
- Qian G, Yang N, Ma AHY, et al. A COVID-19 transmission within a family cluster by presymptomatic infectors in China. Clin Infect Dis 2020. March 23 (Epub ahead of print).
- Chow EJ, Schwartz NG, Tobolowsky FA, et al. Symptom screening at illness onset of health care personnel with SARS-CoV-2 infection in King County, Washington. JAMA 2020. April 17 (Epub ahead of print).
- Aw D, Silva AB, Palmer DB. Immunosenescence: emerging challenges for an ageing population. Immunology 2007;120:435-446.
- Lam P-P, Coleman BL, Green K, et al. Predictors of influenza among older adults in the emergency department. BMC Infect Dis 2016;16:615-615.
- Sayers G, Igoe D, Carr M, et al. High morbidity and mortality associated with an outbreak of influenza A(H3N2) in a psycho-geriatric facility. Epidemiol Infect 2013;141:357-365.
- Zou L, Ruan F, Huang M, et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med 2020;382:1177-1179.
- To KK-W, Tsang OT-Y, Leung W-S, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis 2020. March 23 (Epub ahead of print).
- Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. JAMA 2020. March 03 (Epub ahead of print).
- Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings (interim guidance). 2020. ().
Source: PubMed