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

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.

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

Published by Residential Forum

The Residential Forum is to promote the achievement of high standards of care and support for children and adults living in residential care and nursing homes, supported housing, residential schools and colleges, hospices and hostels. It contributes to improving the quality of service to the public. Members of the Forum are people of standing and experience drawn from the public, private and voluntary sectors, as well as some who can speak for service users and carers.

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