Point Prevalence Testing of Residents for SARS-CoV-2 in a Subset of Connecticut Nursing Homes | Geriatrics | JAMA | JAMA Network
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Figure.  Map of Coronavirus Disease 2019 Case Rates per 100 000 People in Towns or County Subdivisions in Connecticut Scaled by Color as of May 26, 2020
Map of Coronavirus Disease 2019 Case Rates per 100 000 People in Towns or County Subdivisions in Connecticut Scaled by Color as of May 26, 2020

Point prevalence surveys were conducted in 33 of 215 nursing homes across Connecticut. Nursing homes included in this analysis are represented by black dots placed in the midpoint of their respective town, with the size of the dot corresponding to the number of nursing homes included in each town. Nursing homes not included in this analysis are represented by open dots. Data on state case counts were obtained from https://portal.ct.gov/Coronavirus.

Table.  Summary of Point Prevalence Results From Molecular Testing of Nasopharyngeal Swabs for SARS-CoV-2 in Nursing Homes in Connecticut (N = 33), May 2 to May 19, 2020
Summary of Point Prevalence Results From Molecular Testing of Nasopharyngeal Swabs for SARS-CoV-2 in Nursing Homes in Connecticut (N = 33), May 2 to May 19, 2020
1.
Connecticut Department of Public Health. COVID-19 daily DPH reports library. Updated July 31, 2020. Accessed June 10, 2020. https://data.ct.gov/Health-and-Human-Services/COVID-19-Daily-DPH-Reports-Library/bqve-e8um
2.
Bigelow  BF, Tang  O, Barshick  B,  et al.  Outcomes of universal COVID-19 testing following detection of incident cases in 11 long-term care facilities.   JAMA Intern Med. Published online July 14, 2020. doi:10.1001/jamainternmed.2020.3738PubMedGoogle Scholar
3.
Feaster  M, Goh  YY.  High proportion of asymptomatic SARS-CoV-2 infections in 9 long-term care facilities, Pasadena, California, USA, April 2020.   Emerg Infect Dis. 2020;26(10). doi:10.3201/eid2610.202694 PubMedGoogle Scholar
4.
Sanchez  GV, Biedron  C, Fink  LR,  et al.  Initial and repeated point prevalence surveys to inform SARS-CoV-2 infection prevention in 26 skilled nursing facilities: Detroit, Michigan, March-May 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(27):882-886. doi:10.15585/mmwr.mm6927e1PubMedGoogle ScholarCrossref
5.
Richardson  S, Hirsch  JS, Narasimhan  M,  et al; Northwell COVID-19 Research Consortium.  Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.   JAMA. 2020;323(20):2052-2059. doi:10.1001/jama.2020.6775PubMedGoogle ScholarCrossref
6.
Centers for Disease Control and Prevention. Testing guidelines for nursing homes: interim SARS-CoV-2 testing guidelines for nursing home residents and healthcare personnel. Updated July 21, 2020. Accessed July 15, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html
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    1 Comment for this article
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    Imbalance in the Reporting of Symptomatic Disease between Nursing Homes
    Hristos Dagres, MD, MPH | Free-lancer
    I read with great interest the article of Parikh et al on the number of residents from 33 Nursing Homes (NH) in Connecticut that were found positive in SARS-CoV-2. The high percentage of residents that remained asymptomatic (78%) is remarkable, as they are mainly elderly with several comorbidities. However, there are some points that - probably due to the limited space of the article - have not been discussed and may need further clarifications:

    Were there significant differences in demographics (e.g. age, sex, race or ethnicity, etc.) and in medical history (e.g. number and type of comorbidities) between
    the three groups that tested positive (asymptomatic, pre-symptomatic, symptomatic when NPS was performed)?

    In NH # 4 there are 4 residents noted as pre-symptomatic; according to the footnote these 4 residents died between NPS and follow-up. Did they develop symptoms compatible with COVID-19 or, simply, were they considered pre-symptomatic because they died after a positive SARS-CoV-2 test? Is there any explanation for this cluster, since they make up 25% of the positive cases in this NH and nothing similar has been noted in other centers?

    There seems to be great heterogeneity between the NHs in terms of symptom reporting. In some NHs, although they had > 20 residents positive for SARS-CoV-2, none developed any symptoms (eg NH # 14, 28, 29, 11, 17, etc.) while in other centers almost all patients were symptomatic a the time of NPS or developed symptoms between NPS and follow up. The possibility of under-reporting of symptoms was discussed in the article and does explain this heterogeneity in part. However I would like to underline the opposite possibility: the over-reporting of COVID-19-related symptoms. Some NHs, in their attempt to show due diligence, may report mild, non-specific symptoms, which are not associated with SARS-CoV-2 but with comorbidities and/or side effects of concomitant medication. Since the term "symptom" is rather vague and may range from mild events to death, it would be helpful if the authors could also present the number of clinically significant events (eg hospitalizations, admissions to ICU or death events) that were associated with the symptoms, if these data is available
    CONFLICT OF INTEREST: I was employed on behalf of a Swiss Pharmaceutical Company, in Drug Development/ Oncology
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    Research Letter
    August 10, 2020

    Point Prevalence Testing of Residents for SARS-CoV-2 in a Subset of Connecticut Nursing Homes

    Author Affiliations
    • 1Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
    • 2Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
    • 3Connecticut Department of Public Health, Hartford
    JAMA. 2020;324(11):1101-1103. doi:10.1001/jama.2020.14984

    The first case of coronavirus disease 2019 (COVID-19) in Connecticut was reported in a nursing home (NH) on March 15, 2020. Within the next 2 months, 80.0% of Connecticut’s 215 NHs reported at least 1 case of COVID-19, accounting for 61.6% of COVID-19 deaths in the state.1 Residents were initially tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) only if symptomatic, as per recommendations from the Centers for Disease Control and Prevention. In early May, NHs were prioritized and selected for point prevalence surveys to provide a baseline for residents not previously identified as infected. We describe the results of these surveys in a targeted subset of Connecticut NHs between May 2 and 19, 2020.

    Methods

    We prioritized NHs in which establishment of baseline resident SARS-CoV-2 status would improve control measures, such as cohorting of individuals, based on a low proportion of previously infected residents (but at least 1 case), a high number of residents with unknown SARS-CoV-2 status, and evidence of at least 1 newly identified case in the previous 7 days. NHs with data verified by authors and completing surveys by May 19 were included. Several lower-priority NHs that had executed testing independently or expressed interest in surveys were also included.

    Nasopharyngeal swabs were tested via polymerase chain reaction–based methods for detection of SARS-CoV-2 using 6 platforms in 8 laboratories (eMethods in the Supplement). Verbal consent and specimen collection were obtained by NH staff for residents without a prior confirmed SARS-CoV-2–positive test result. Symptoms were assessed by NH staff on the day of the survey, including atypical presentations in elderly individuals, and for 14 days after testing, following guidelines from the Centers for Disease Control and Prevention.

    NH quality rating and number of licensed beds were obtained from the Nursing Home Compare database and case rates and location from the state.

    The surveys were conducted as part of the state’s public health response for outbreak control and, therefore, were exempt from the need for institutional review board approval.

    Results

    Point prevalence surveys were conducted in 33 NHs across Connecticut, representing 15.3% of NHs statewide (n = 215). The geographic distribution of included and remaining NHs is shown in the Figure. Included NHs had a quality rating of 3.58 stars (vs 3.93 stars in the remaining NHs; P = .24) and 135 beds (vs 127 beds; P = .23), and the case rate in the towns in which they were located was 617 cases/100 000 individuals (vs 1263/100 000; P < .001).

    Overall, 2117 residents were tested (median per NH, 51; range, 14-242) and 601 (28.3%) were positive. Of the 601 positive residents, 530 (88.2%) were asymptomatic when sampled; 11.7% (62/530) developed symptoms within 14 days (presymptomatic). All SARS-CoV-2–positive residents were asymptomatic or presymptomatic at the time of testing in 45.5% of NHs (Table). The median time from the first case to the survey was 37 days (range, 6-54). Nineteen facilities had at least 50% of residents testing positive (range, 50%-94%), with testing occurring a median of 37 days (range, 7-54) from detection of the first facility case.

    Discussion

    In a sample of NHs in Connecticut with at least 1 COVID-19 case in the week preceding point prevalence surveys, 28% of residents tested positive, of which 78% remained asymptomatic and 10% were presymptomatic. The proportion of asymptomatic residents is higher than in previous smaller survey studies of long-term care facilities, which found percentages of 50% to 55%.2-4

    The study limitations include sampling of selected NHs in 1 state and no staff testing. The high proportion of asymptomatic patients may be overestimated due to challenges in ascertaining symptoms in elderly individuals with atypical or mild presentations, exclusion of symptomatic patients who previously tested positive, or the possibility of symptom resolution before testing. In addition, COVID-19 rates in surrounding communities were not factored into NH prioritization and repeat testing was not performed.

    NHs house particularly vulnerable populations because of their age, rates of comorbidities, and clustering.5 Point prevalence surveys may be necessary to limit spread in NHs, with a prioritized rollout in situations with limited control and testing capacity. Repeated testing in NHs may also be useful.4,6

    Section Editor: Jody W. Zylke, MD, Deputy Editor.
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    Article Information

    Corresponding Author: Sunil Parikh, MD, MPH, Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College St, New Haven, CT 06520 (sunil.parikh@yale.edu).

    Accepted for Publication: July 24, 2020.

    Published Online: August 10, 2020. doi:10.1001/jama.2020.14984

    Author Contributions: Drs Parikh and Leung had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Parikh and O’Laughlin contributed equally to this work.

    Concept and design: Parikh, O’Laughlin, Ehrlich, Leung.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Parikh, O’Laughlin, Ehrlich, Harizaj.

    Critical revision of the manuscript for important intellectual content: Parikh, O’Laughlin, Ehrlich, Campbell, Durante, Leung.

    Statistical analysis: Parikh, Ehrlich.

    Administrative, technical, or material support: O’Laughlin, Ehrlich, Campbell, Harizaj, Durante, Leung.

    Supervision: Parikh, Leung.

    Conflict of Interest Disclosures: None reported.

    Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

    Additional Contributions: We thank the Connecticut Department of Public Health team including Barbara Cass, RN; Anu Paranandi, DO, MPH; Erin Grogan, RN, MS; Naissa Piverger, MPH; Meghan Maloney, MPH; Ellen Neuhaus, MD; Surjit Sethuraman; Kim Hriceniak, RNC, BSN; Kristin Soto, MPH; and Terry Rabatsky-Ehr, MS, MPH, for building and maintaining a nursing home surveillance system for coronavirus disease 2019. We thank Ben Gagne and members of the Connecticut National Guard for assisting in the deployment of point prevalence survey test kits. We thank Linda Niccolai, PhD, and team from the Yale School of Public Health for assistance with developing and executing the nursing home surveillance system. No individuals listed received compensation for their contributions to this work.

    References
    1.
    Connecticut Department of Public Health. COVID-19 daily DPH reports library. Updated July 31, 2020. Accessed June 10, 2020. https://data.ct.gov/Health-and-Human-Services/COVID-19-Daily-DPH-Reports-Library/bqve-e8um
    2.
    Bigelow  BF, Tang  O, Barshick  B,  et al.  Outcomes of universal COVID-19 testing following detection of incident cases in 11 long-term care facilities.   JAMA Intern Med. Published online July 14, 2020. doi:10.1001/jamainternmed.2020.3738PubMedGoogle Scholar
    3.
    Feaster  M, Goh  YY.  High proportion of asymptomatic SARS-CoV-2 infections in 9 long-term care facilities, Pasadena, California, USA, April 2020.   Emerg Infect Dis. 2020;26(10). doi:10.3201/eid2610.202694 PubMedGoogle Scholar
    4.
    Sanchez  GV, Biedron  C, Fink  LR,  et al.  Initial and repeated point prevalence surveys to inform SARS-CoV-2 infection prevention in 26 skilled nursing facilities: Detroit, Michigan, March-May 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(27):882-886. doi:10.15585/mmwr.mm6927e1PubMedGoogle ScholarCrossref
    5.
    Richardson  S, Hirsch  JS, Narasimhan  M,  et al; Northwell COVID-19 Research Consortium.  Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.   JAMA. 2020;323(20):2052-2059. doi:10.1001/jama.2020.6775PubMedGoogle ScholarCrossref
    6.
    Centers for Disease Control and Prevention. Testing guidelines for nursing homes: interim SARS-CoV-2 testing guidelines for nursing home residents and healthcare personnel. Updated July 21, 2020. Accessed July 15, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html
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