tetano
Editor, Senior Moderator
N Engl J Med. 2020 Apr 24.
doi: 10.1056/NEJMoa2008457. Online ahead of print.
Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility
Melissa M Arons[SUP] 1 [/SUP], Kelly M Hatfield[SUP] 1 [/SUP], Sujan C Reddy[SUP] 1 [/SUP], Anne Kimball[SUP] 1 [/SUP], Allison James[SUP] 1 [/SUP], Jesica R Jacobs[SUP] 1 [/SUP], Joanne Taylor[SUP] 1 [/SUP], Kevin Spicer[SUP] 1 [/SUP], Ana C Bardossy[SUP] 1 [/SUP], Lisa P Oakley[SUP] 1 [/SUP], Sukarma Tanwar[SUP] 1 [/SUP], Jonathan W Dyal[SUP] 1 [/SUP], Josh Harney[SUP] 1 [/SUP], Zeshan Chisty[SUP] 1 [/SUP], Jeneita M Bell[SUP] 1 [/SUP], Mark Methner[SUP] 1 [/SUP], Prabasaj Paul[SUP] 1 [/SUP], Christina M Carlson[SUP] 1 [/SUP], Heather P McLaughlin[SUP] 1 [/SUP], Natalie Thornburg[SUP] 1 [/SUP], Suxiang Tong[SUP] 1 [/SUP], Azaibi Tamin[SUP] 1 [/SUP], Ying Tao[SUP] 1 [/SUP], Anna Uehara[SUP] 1 [/SUP], Jennifer Harcourt[SUP] 1 [/SUP], Shauna Clark[SUP] 1 [/SUP], Claire Brostrom-Smith[SUP] 1 [/SUP], Libby C Page[SUP] 1 [/SUP], Meagan Kay[SUP] 1 [/SUP], James Lewis[SUP] 1 [/SUP], Patty Montgomery[SUP] 1 [/SUP], Nimalie D Stone[SUP] 1 [/SUP], Thomas A Clark[SUP] 1 [/SUP], Margaret A Honein[SUP] 1 [/SUP], Jeffrey S Duchin[SUP] 1 [/SUP], John A Jernigan[SUP] 1 [/SUP]
Affiliations
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.
doi: 10.1056/NEJMoa2008457. Online ahead of print.
Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility
Melissa M Arons[SUP] 1 [/SUP], Kelly M Hatfield[SUP] 1 [/SUP], Sujan C Reddy[SUP] 1 [/SUP], Anne Kimball[SUP] 1 [/SUP], Allison James[SUP] 1 [/SUP], Jesica R Jacobs[SUP] 1 [/SUP], Joanne Taylor[SUP] 1 [/SUP], Kevin Spicer[SUP] 1 [/SUP], Ana C Bardossy[SUP] 1 [/SUP], Lisa P Oakley[SUP] 1 [/SUP], Sukarma Tanwar[SUP] 1 [/SUP], Jonathan W Dyal[SUP] 1 [/SUP], Josh Harney[SUP] 1 [/SUP], Zeshan Chisty[SUP] 1 [/SUP], Jeneita M Bell[SUP] 1 [/SUP], Mark Methner[SUP] 1 [/SUP], Prabasaj Paul[SUP] 1 [/SUP], Christina M Carlson[SUP] 1 [/SUP], Heather P McLaughlin[SUP] 1 [/SUP], Natalie Thornburg[SUP] 1 [/SUP], Suxiang Tong[SUP] 1 [/SUP], Azaibi Tamin[SUP] 1 [/SUP], Ying Tao[SUP] 1 [/SUP], Anna Uehara[SUP] 1 [/SUP], Jennifer Harcourt[SUP] 1 [/SUP], Shauna Clark[SUP] 1 [/SUP], Claire Brostrom-Smith[SUP] 1 [/SUP], Libby C Page[SUP] 1 [/SUP], Meagan Kay[SUP] 1 [/SUP], James Lewis[SUP] 1 [/SUP], Patty Montgomery[SUP] 1 [/SUP], Nimalie D Stone[SUP] 1 [/SUP], Thomas A Clark[SUP] 1 [/SUP], Margaret A Honein[SUP] 1 [/SUP], Jeffrey S Duchin[SUP] 1 [/SUP], John A Jernigan[SUP] 1 [/SUP]
Affiliations
- PMID: 32329971
- DOI: 10.1056/NEJMoa2008457
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.