key: cord-273604-0w5shxmf
authors: Psevdos, George; Papamanoli, Aikaterini; Barrett, Nancy; Bailey, Lisa; Thorne, Monique; Ford, Florence; Lobo, Zeena
title: Halting a SARS-CoV-2 Outbreak in a U.S. Veterans Affairs Nursing Home
date: 2020-11-03
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2020.10.022
sha: 
doc_id: 273604
cord_uid: 0w5shxmf

A Veterans Affairs long term care facility on Long Island New York was confronted with a COVID-19 outbreak in late March to Mid-April 2020. Faced with a dwindling supply of PPE, the Infection Control team distributed supplies saved for a possible Ebola outbreak; A COVID unit was created within the nursing home facilitating the geographic isolation of cases; universal testing of residents and employees allowed for the implementation of proper quarantine measures. It was a multidisciplinary team approach led by the Infection Control team that successfully contained this outbreak.

reported. 5 In a review of over 9,000 nursing homes from the US, COVID-19 outbreaks were more related to facility size, location-with Massachusetts and New Jersey having the greatest number of affected facilities-and greater percentage of African American residents. 6 The last mentioned fact mirrors a critical health disparity seen in this pandemic at large, namely African Americans contracting SARS CoV-2 at higher rates and are more likely to die. 7 Although nationally the virus spreads like wildfire in nursing homes (among residents and working staff), the Department of Veterans Affairs (VA) reported lower COVID-19 rates in their affiliated nursing homes in a U.S. Congressional hearing. 8 We discuss here our experience in facing a COVID-19 outbreak in our VA affiliated nursing homes.

Northport Veterans Affairs Medical Center provides hospital-based acute medical and psychiatric care for U.S Veterans, as well as long-term/extended nursing home and residential mental health program care. The nursing homes are structured as community living centers (CLCs), with a 139 total bed capacity. There are four CLCs, CLC1 to 4, which include mental health (CLC3) and hospice care units (CLC4). The COVID-19 outbreak involved CLC 1 and CLC2, both totaling 80 beds. Veterans are eligible to live in the CLCs if they have service-connected disability (70% or more)-a disability assigned to them by the Department of Veterans Affairs based on injury or illness that incurred, or, was aggravated during active military service. CLC 1 and 2 units admit Veterans with complex underlying medical issues that can include immobility due to stroke and cardiovascular disease, continuous oxygen requirement due to chronic obstructive lung disease, end stage renal disease on dialysis, complex wound care, chemotherapy, prolonged intravenous antibiotic therapy, and other rehabilitation needs. patients, five remained asymptomatic, nine got hospitalized, six died. The mortality rate was 24%. No coinfection with influenza or other respiratory viruses was identified. Table 1 summarizes the demographic characteristics, medical history and laboratory findings of the patients. The median age was 74 years, with no difference in age between recovered and diseased., 73 vs. 77, P: 0.105. Simplified acute physiology score (SAPS) II was higher in the deceased group (P:0.001) and so were D-dimer (admission and peak levels), C-reactive protein, lactate dehydrogenase, and peak ferritin and procalcitonin levels. See table 1. During this outbreak, 11 HCPs were diagnosed with COVID 19 and all recovered. Among the patients who recovered, 13 had persistent positive nasopharyngeal RT-PCR for average 32 days (range 19 to 52 days) since diagnosis. Seven out of these thirteen were tested for SARS-CoV-2 IgG antibody (Abbott, Lake Forrest, IL) and were all positive.

The median incubation period for a symptomatic SARS-CoV-2 infection is 5 days; symptoms can appear within 12 days of infection. 11 how effective the creation of a COVID unit inside the nursing home can be; cohorting of cases allowed for residents to stay in familiar grounds, enabled the restriction of staff movement between the wards, and overall reduced the potential of viral transmission. 13 Universal testing of residents (first aiming close neighboring residents and then every resident) and HCPs was another principal measure to successfully interrupt the outbreak. Eckardt et al, demonstrated that a productive structured 14-day interval universal testing in their long-term care facility aided to contain the spread of the virus in a six-week period. 14 Implementing the measures described above we managed to suppress the outbreak within 3 weeks in both CLC 1 &2. At this writing there are no active COVID-19 cases in our CLCs.

We followed the CDC's proposed test-based strategy to remove COVID-19 precaution/isolation measures. This had the unfortunate effect of keeping residents longer on strict isolation as their RT-PCR tests remained positive, even though they had recovered or remained asymptomatic and had also developed an IgG antibody. The CDC has since updated their guidelines regarding discontinuation of transmission-based precautions, no longer requiring a testbased strategy for asymptomatic or patients with mild disease. 15 Prolonged positive SARS-CoV-2 RT-PCRs, up to five weeks, have been reported in many studies; the RNA detected in these cases is likely from nonviable virus. A proposed way of how to interpret the PCR test in these cases is to utilize the cycle threshold (Ct) value .16 This value is not reported to the clinician but can be reported upon request. It is part of the RT-PCR test, with a specified threshold for a positive result, and it is inversely related with the viral load. A Ct value of >34 likely denotes non transmissible disease. 16 Exploring this potential strategy in more rigorous studies could shorten duration of isolation, conserve tests, reagents, and PPE.

In conclusion, SARS-CoV-2 infection can spread rapidly within skilled nursing facilities and can potentially cause high morbidity and mortality. Swift detection by rapid RT-PCR testing of all asymptomatic carriers (residents and employees via universal testing) and implementation of strict infection control and isolation measures are pivotal in containing and thus eliminating a COVID-19 outbreak. Indeed, the infection control team working closely with the dedicated nursing home staff, are both the unsung heroes of the robust and unyielding defense against a formidable virus.

Legends: Table 1 : Demographics, Laboratory findings, Outcomes of COVID-19 CLC cohort 

WHO declares COVID-19 a pandemic

Epidemiology of Covid-19 in a long-term care facility in King County

COVID-19 and the elderly: insights into pathogenesis and clinical decision-making

Characteristics of U.S. Nursing Homes with COVID-19 cases

COVID-19 and African Americans JAMA 2020

VA touts lower CLC COVID-19 rates vs. community nursing homes

Centers for Disease Control and Prevention. Testing guidance for nursing homes. Interim SARS-CoV-2 testing guidelines for nursing home residents and healthcare personnel

The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application

Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility

Universal and Serial Laboratory Testing for SARS-CoV-2 at a Long-Term Care Skilled Nursing Facility for Veterans

Hospital affiliated long term care facility COVID-19 containment strategy by using prevalence testing and infection control practices

Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings

Acknowledgements: The authors would like to thank our Veterans, and the nursing home staff, the facility leadership, the laboratory staff for their help during this pandemic.

COVID ACEI ace inhibitor, ARB angiotensin receptor blocker, BMI body mass index, CAD coronary artery disease, CHF congestive heart failure, COPD chronic obstructive lung disease, CRP C-reactive protein, LDH lactate , NEG negative, dehydrogenase, SAPS II simplified acute physiologic score II, SBP systolic blood pressure