Clinical Suspicion of COVID-19 in Nursing Home residents: symptoms and mortality risk factors

ObjectivesTo describe symptomatology, mortality and risk factors for mortality in a large group of Dutch nursing home (NH) residents with clinically-suspected COVID-19 who were tested with a Reverse Transcription Polymerase Chain Reaction (RT-PCR) test. DesignProspective cohort study. Setting and participantsResidents of Dutch NHs with clinically-suspected COVID-19 and who received RT-PCR test. MethodsWe collected data of NH residents with clinically-suspected COVID-19, via electronic health records between March 18th and May 13th, 2020. Registration was performed on diagnostic status (confirmed (COVID-19+)/ruled out (COVID-19-)) and symptomatology (typical and atypical symptoms). Information on mortality and risk factors for mortality were extracted from usual care data. ResultsIn our sample of residents with clinically-suspected COVID-19 (N=4007), COVID-19 was confirmed in 1538 residents (38%). Although, symptomatology overlapped between residents with COVID-19+ and COVID-19-, those with COVID-19+ were three times more likely to die within 30 days (hazard ratio (HR), 3{middle dot}1; 95% CI, 2{middle dot}7 to 3{middle dot}6). Within this group, mortality was higher for men than for women (HR, 1{middle dot}8; 95%, 1{middle dot}5-2{middle dot}2) and we observed a higher mortality for residents with dementia, reduced kidney function, and Parkinsons Disease, even when corrected for age, gender, and comorbidities. Conclusions and implicationsAbout 40% of the residents with clinically-suspected COVID-19 actually had COVID-19, based on the RT-PCR test. Despite an overlap in symptomatology, mortality rate was three times higher for residents with COVID-19+. This emphasizes the importance of using low-threshold testing in NH residents which is an essential prerequisite to using limited personal protective equipment and isolation measures efficiently.

Symptom based and transmission-prevention based testing in long-term care facilities: Symptomatology, clinical course and mortality for residents with COVID-19

ObjectivesInitially, for preventing COVID-19 transmission in long-term care facilities (LTCF) primarily rely on presence of core symptoms (fever, cough, dyspnea), but LTCF residents may also show an atypical course of a SARS-CoV-2 infection. We described the clinical presentation and course of COVID-19 in LTCF residents who were tested either because of presence of core symptoms (S-based) or because of transmission prevention (TP-based) DesignRetrospective cohort study. Setting and participantsAmsta (Amsterdam, The Netherlands), is a 1185-bed LTCF. All LTCF residents who underwent SARS-CoV-2 RT-PCR testing between March 16, 2020 and May 31, 2020 were included (n = 380). MeasuresClinical symptoms, temperature and oxygen saturation were extracted from medical records, 7 days before testing up to 14 days after testing. ResultsSARS-CoV-2 was confirmed in 81 (21%) residents. Of these 81, 36 (44%) residents were tested S-based and 45 (56%) residents were tested TP-based. Yet, CT-values did not differ between the groups. In the 7 days prior to the test the most common symptoms in both groups were: falling (32%), somnolence (25%) and fatigue (21%). Two days before the test, we observed a stronger decrease in oxygen saturation and an increase in temperature for the S-based group compared to the T-based group that remained up to 10 days after testing. Residents with in the S-based group were 2.5 times more likely to decease within 30 days than residents in the TP-based group (HR, 2.56; 95% 1.3 to 5.2). Even though, 73% of the T-based group did eventually developed core symptoms. Conclusion and implicationsMany LTCF residents with a positive PCR did not have core symptoms when tested but had other signs/symptoms in the week before the positive test. Testing policies should therefore be adjusted to prevent transmission. Daily measures of temperature and oxygen saturation can contribute to earlier detection.

A COVID-19 Nursing Home Transmission Study: sequence and metadata from weekly testing in an extensive nursing home outbreak

Background This study aimed to assess the contribution of asymptomatic and presymptomatic residents and staff in SARS-CoV-2 transmission during a large outbreak in a Dutch nursing home. Methods Observational study in a 185-bed nursing home with two consecutive testing strategies: testing of symptomatic cases only, and weekly facility-wide testing of staff and residents regardless of symptoms. Nasopharyngeal and oropharyngeal testing with RT-PCR for SARs-CoV-2 was conducted with a standardized symptom assessment. Positive samples with a cycle threshold (CT) value below 32 were selected for sequencing. Results 185 residents and 244 staff participated. Sequencing identified one cluster. In the symptom-based test strategy period 3/39 residents were presymptomatic versus 38/74 residents in the period of weekly facility-wide testing (p-value<0.001). In total, 51/59 (91.1%) of SARS-CoV-2 positive staff was symptomatic, with no difference between both testing strategies (p-value 0.763). Loss of smell and taste, sore throat, headache or myalga was hardly reported in residents compared to staff (p-value <0.001). Median Ct-value of presymptomatic residents was 21.3, which did not differ from symptomatic (20.8) or asymptomatic (20.5) residents (p-value 0.624). Conclusions The frequency of a/presymptomatic residents compared to staff suggests that a/presymptomatic residents could be unrecognized symptomatic cases. However, symptomatic and presymptomatic/unrecognized symptomatic residents both have the same potential for viral shedding. The high prevalence symptomatic staff found in facility-wide testing suggests that staff has difficulty attributing their symptoms to possible SARS-CoV-2 infection. Weekly testing was an effective strategy for early identification of SARS-Cov-2 cases, resulting in fast isolation and mitigation of this outbreak.

Asymptomatic cases and limited transmission of SARS-CoV-2 in residents and healthcare workers in three Dutch nursing homes

PurposeMany nursing homes worldwide have been hit by outbreaks of the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We aimed to assess the contribution of a- and presymptomatic residents and healthcare workers in transmission of SARS-CoV-2 in three nursing homes. MethodsTwo serial point-prevalence surveys, 1 week apart, among residents and healthcare workers of three Dutch nursing homes with recent SARS-CoV-2 introduction. Nasopharyngeal and oropharyngeal testing for SARS-CoV-2, including reverse-transcriptase polymerase chain reaction (rRT-PCR) was presymptomatic or asymptomatic with standardized symptom assessment. ResultsIn total, 297 residents and 542 healthcare workers participated in the study. At the first point-prevalence survey, 15 residents tested positive of which one was presymptomatic (Ct value>35) and three remained asymptomatic (Ct value of 23, 30 and 32). At the second point-prevalence survey one resident and one healthcare worker tested SARS-CoV-2 positive (Ct value >35 and 24, respectively) and both remained asymptomatic. ConclusionThis study confirms a-and presymptomatic occurrence of Covid-19 among residents and health care workers. Ct values below 25 suggested that these cases have the potential to contribute to viral spread. However, very limited transmission impeded the ability to answer the research question. We describe factors that may contribute to the prevention of transmission and argue that the necessity of large-scale preemptive testing in nursing homes may be dependent of the local situation regarding prevalence of cases in the surrounding community and infection control opportunities. KEY SUMMARY POINTSO_ST_ABSAimC_ST_ABSTo assess the contribution of a- and presymptomatic residents and healthcare workers in transmission of SARS-CoV-2 in three nursing homes by facility wide preemptive testing. FindingsOccurrence of a-and presymptomatic residents and healthcare workers with Ct values below 25 was confirmed. However, evaluation of contribution to transmission of the virus was not possible because of limited positive cases in the follow-up. MessageNecessity of large-scale preemptive testing for a- and presymptomatic SARS-CoV-2 cases in nursing homes may be dependent on prevalence of cases in the surrounding community and infection control opportunities.