This review was posted on behalf of Lauren Albert, IU School of Medicine student, and reviewed by Dr. Kathleen Unroe, IU School of Medicine Associate Professor, geriatrician, and IU Center for Aging Research Scientist.

Intro

• 4 nursing homes in the United Kingdom monitored transmission and clinical features of COVID-19 infection of their residents, March 10-May 1, 2020.

Testing

• Prior to April 15, 2020, a maximum of 5 symptomatic patients were tested in each nursing home to confirm COVID-19 outbreak.
• Post April 15^th, a comprehensive swabbing of residents and staff via oropharyngeal and nasopharyngeal testing began, which was revised to bilateral anterior nasal swabbing on April 29, 2020 (n = 313).
• Viral sequencing (n = 19) was utilized to evaluate intra-facility COVID-19 strain relatedness.

Results

• Within the 394 residents evaluated, 26% of residents died and nursing facilities saw a 203% increase in all-cause deaths between March 1-May 1, 2020.
• Men had a significantly increased risk of death (48% of deaths; men composed 38% of the overall sample)
• Residents had an average of three comorbidities: dementia (57%) and cardiovascular disease (51%) were the most common.
  • Cardiovascular disease was the only comorbidity associated with increased mortality (65% of those who died).
• Of the 313 residents tested, 126 (40%) tested positive for SARS-CoV-2 at the first testing point (April 15^th) and 5 more were positive at testing a week later.
• 23 SARS-CoV-2 negative patients displayed one or more typical COVID-19 symptoms.
• 43% (n = 54) of positive patients were asymptomatic at testing, while 70% of symptomatic patients displayed fever and cough / breathlessness.
• Residents with new-onset anorexia were four times more likely to have a SARS-CoV-2 infection.
• 60% of SARS-CoV-2 positive residents were asymptomatic or only had atypical symptoms in the two weeks prior to testing.
  • Of the 49 asymptomatic positive residents tested April 15^th, only 5% later became symptomatic.
• Viral sequencing was unable to determine the direction of transmission between positive residents and asymptomatic positive staff (4%; 3 of 70 tested).

Takeaways

• Over a third of positive residents were asymptomatic and did not later develop symptoms of SARS-CoV-2 infection.
• New onset-anorexia was strongly associated with SARS-CoV-2, as was cough / breathlessness.
• Authors conclude that the levels of both asymptomatic residents and residents with atypical symptoms found in these 4 facilities suggest the symptom-driven UK national criteria of fever and cough may have contributed to delays in the institution of infection control in nursing facilities during the early stages of the outbreak.
• Further research is needed into frequency of resident and staff testing and to inform infection control guidelines within the skilled nursing facility.

Graham N, Junghans C, Downes R, et al. SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes. J Infect. Published online June 3, 2020. doi:10.1016/j.jinf.2020.05.073