key: cord-329898-g6og7oid
authors: Song, Rok; Kim, Hee-Sook; Yoo, Seok-Ju; Lee, Kwan; Park, Ji-Hyuk; Jang, Joon Ho; Ahn, Gyoung-Sook; Kim, Jun-Nyun
title: COVID-19 in Nursing Facilities: Experience in Republic of Korea
date: 2020-08-17
journal: Osong Public Health Res Perspect
DOI: 10.24171/j.phrp.2020.11.4.04
sha: 
doc_id: 329898
cord_uid: g6og7oid

OBJECTIVES: Coronavirus disease 2019 (COVID-19) outbreaks in nursing facilities can easily lead to a high rate of infection and fatality. A surge in newly infected cases in the first quarter of 2020 in Gyeongsan-si, in the Republic of Korea, was followed by several outbreaks in nursing facilities in the same area. The aim of this study is to report on the epidemiological investigation and the management to reduce the infection rate in nursing facilities for older adults. METHODS: The municipal government and the Korea Centers for Disease Control and Prevention performed an epidemiological investigation into 5 nursing facilities that reported a high number of COVID-19 infection cases from February to May 2020. COVID-19 infected cases in the facilities were investigated to identify the infection routes, and the fatality rate of the 5 facilities. RESULTS: The 5 facilities had a combined fatality rate of 12.2% (9 deceased among the 74 infected cases). The median age of the deceased was 87 years old (range: 82–91). The infection was first identified on February 27(th), 2020, peaked on March 6(th), and was last detected on March 24(th), 2020. CONCLUSION: Difficulties specific to such facilities included the delay in the recognition of symptoms and limitation in distancing. Tailored strategies such as daily monitoring of symptoms and proactive COVID-19 screening of quarantined residents, contributed to a decline in the infections in the facilities.

Since the outbreak of Coronavirus disease 2019 (COVID-19), various clinical features related to the novel coronavirus have been identified. The virus is highly infectious, and particularly fatal in older adults, and individuals with multiple chronic co-morbidities [1] . Globally, as several outbreaks occurred in senior nursing facilities, many residents were infected with COVID-19 and died [2] . In the Republic of Korea, as of May 16 th , 2020, the fatality rate among those aged ≥ 60 years was over 2% (2.79% in those aged 60-69 years, 10.78% in those aged 70-79 years, and 25.92% in those aged above 80 years), whereas the fatality rate among those < 60 years was below 1% (0.76% in those 50-59 years, 0.21% in those 40-49 years, and 0.17% in those 30-39 years) [3] .

Gyeongsan-si, a city with a total area of 411.76 km 2 , a population of 274,375, is located next to Daegu metropolitan city. Gyeongsan-si has 53 nursing facilities for the older adults.

Many citizens are commuting between Gyeongsan-si and Daegu every day.

As of May 16 th , 2020 in Daegu, a city with a total area of 883 km 2 and a population of 2,433,568, the number of COVID-19 infected people was 6,869. This number of infections accounted for 62.41 % of the total number of infection cases in the Republic of Korea. There were 730 infected cases in Seoul, the capital of the country, with a total area of 605 km 2 , and a population of 9,733,655 [3] .

During the first quarter of 2020, there was a surge in newly confirmed cases in Daegu and its neighboring cities in Gyeongsangbuk-do, a province in South East Korea. An exponential increase in the number of COVID-19 patients in those cities was mainly attributed to viral transmission amongst the members of a religious group who stimulated the transmission in communities and hospitals [4] . This sudden, and massive increase in confirmed COVID-19 cases led to several outbreaks in nursing facilities in the province. This is a report of the investigation into 5 nursing facilities in Gyeongsan-si and the management to control the infection.

An epidemiological investigation was conducted into 5 nursing facilities that reported a considerably high number of COVID-19 infected patients and thus required close management. Most of the older adults in those facilities had a mild-to-severe senile dementia or were bedridden with chronic underlying diseases. Two of the facilities were for residents only and 3 were for both residents and daytime users commuting from their homes.

The municipal government and the community health center (CHC) of Gyeongsan-si investigated and managed the nursing facilities with the support and guidance of the epidemiological intelligence response team from the Korea Centers for Disease Control and Prevention (KCDC).

The cases were investigated during the outbreak in the nursing facilities and followed until May 16 th , 2020. In this report, the term "quarantine" was used to indicate that cases were selected as control targets and classified as contacts by the quarantine authorities, based on their history of contact with a confirmed patient. The term "isolation" was used when the cases were confirmed to have been infected and were segregated in a medical institute as patients [5] .

As of May 16 th , 2020, a total of 74 COVID-19 infection cases were identified among 296 nursing facility users and workers.

Facilities A, B, and C were for both daytime users and residents, and facilities D and E were for residents only.

Facility A had a total of 55 people: 17 residents, 16 daytime users, and 22 workers. Among them, 18 were COVID-19 infected (9 residents, 5 daytime users, and 4 workers; Table   1 ). The first infection case, identified on March 5 th , 2020, was a 91-year-old daytime user with abdominal pain and diarrhea.

All the facility users and workers were tested for COVID-19 on the same day, and another 16 were determined to be infected. among the workers ( Table 1 ). The first case of COVID-19

infection, identified on March 4 th , 2020, was a 95-year-old daytime user with respiratory symptoms. All the facility users and workers were tested on the same day, and another 7 cases were confirmed positive for COVID-19. Facility B is a multistory building, but the infection was limited to 1 floor where daytime users and residents shared a dining and entertainment hall. One resident in Facility B deceased due to COVID-19 ( Figure   1 ). No further infections were determined in Facility B.

Facility C had a total of 51 people: 10 residents, 20 daytime users, and 21 workers. Among them, 5 residents, 10 daytime users, and 3 workers were infected with COVID-19 ( Table 1 ).

The first infection cases, identified on March 3 rd , 2020, included an 81-year-old daytime user with myalgia, cough, and sputum, whose daughter was COVID-19 positive, and an 88-yearold daytime user with a mild fever. All the facility users and workers were tested on the same day, and another 12 were The identified contacts were all tested for COVID-19

infection. If the test result was negative, the residents in contact were quarantined for 2 weeks in the facility.

Many of the facility users were active senile dementia patients sharing common living spaces which limited social distancing practice and workers had several designated people to take care of. Consequently, the contacts who needed to be investigated included a cohort of almost all the residents and the workers on the same floor, or even in the whole facility.

The duration of quarantine was extended by 2 weeks in the cohort with the identification of new COVID-19 infected cases.

Assigning 1 person per room was not feasible due to limited space in the nursing facilities, so the residents in contact were quarantined together in designated areas or on the same floor.

If a person was identified to have particularly close and/or frequent contact with an infected patient, or had symptoms related to COVID-19, that person was quarantined alone in a room, and designated caregivers were assigned with PPE (such as level D protection suits) to care for them. Consequently, all of those who were quarantined received COVID-19 testing at least once or twice a week, like regular screening. The CHC sent staffs to test the symptomatic residents and workers. As residents were transported to hospitals and new COVID-19 infection cases and symptomatic residents were identified, the allocation of rooms to the residents had to be changed appropriately. There was a need to secure at least 1 or 2 empty room(s) in each of the facilities.

The purpose was to have space to isolate COVID-19 infected patients and symptomatic individuals temporarily until they were sent out to hospitals or tested for the infection.

With simultaneous outbreaks in many of the nursing facilities in Gyeongsan-si, a lot of caregivers were identified as the contact. The workers with no symptoms related to COVID-19 were asked if they wanted to be quarantined at home for 2 weeks or continue working in the facilities to attend the residents. The workers who agreed to work were assigned to take care of the residents who they were in contact with. They stayed in the facilities for an entire quarantine period without commuting where possible or commuted from and to their homes only, self-segregated themselves from the rest of their family members, and kept home-staying hours to a minimum. When taking care of the residents, they wore PPE to protect themselves and the residents as they were all identified as the contacts. The workers were monitored for their body temperatures and symptoms, and they were separated from the other workers or residents who had not been in any contact with COVID-19 infected patients. If any COVID-19 symptoms appeared, they were tested and moved out of the nursing facilities.

The nursing facility users shared common spaces where social distancing was limited, and reinforcement of mask The 5 facilities showed the same pattern from when the first COVID-19 screening was performed for the facilities. As the first COVID-19 infection case was identified, numerous residents who were mostly asymptomatic or with unrecognized symptoms, had already been infected. In addition, the infection route between the individuals nor the primary case was not 

The authors have no conflicts of interest to declare for this report.

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Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington

Epidemiologic characteristics of early cases with 2019 novel coronavirus (2019-nCoV) disease in Korea