TY  - JOUR
TI  - Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility
AU  - Melissa Arons
AU  - Kelly M Hatfield
AU  - Sujan Reddy
AU  - Anne Kimball
AU  - Allison James
AU  - Jesica R. Jacobs
AU  - Joanne Taylor
AU  - Kevin B. Spicer
AU  - Ana C. Bardossy
AU  - Lisa P. Oakley
AU  - Sukarma Tanwar
AU  - Jonathan Dyal
AU  - Josh Harney
AU  - Zeshan Chisty
AU  - Jeneita M. Bell
AU  - Mark Methner
AU  - Prabasaj Paul
AU  - Christina M. Carlson
AU  - Heather P. McLaughlin
AU  - Natalie J. Thornburg
AU  - Suxiang Tong
AU  - Azaibi Tamin
AU  - Ying Tao
AU  - Anna Uehara
AU  - Jennifer L. Harcourt
AU  - Shauna Clark
AU  - Claire Brostrom-Smith
AU  - Libby C. Page
AU  - Meagan Kay
AU  - James Lewis
AU  - Patty Montgomery
AU  - Nimalie D. Stone
AU  - Thomas A. Clark
AU  - Margaret A. Honein
AU  - Jeffrey S. Duchin
AU  - John A. Jernigan
PY  - 2020
JO  - New England Journal of Medicine
DO  - 10.1056/nejmoa2008457
UR  - https://doi.org/10.1056/nejmoa2008457
AB  - 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.
ER  -