key: cord-351974-1najtyui authors: Smith, E.; Aldus, C. F.; Brainard, J.; Dunham, S.; Hunter, P. R.; Steel, N.; Everden, P. title: Testing for SARS-CoV-2 in care home staff and residents in English care homes: A service evaluation date: 2020-08-05 journal: nan DOI: 10.1101/2020.08.04.20165928 sha: doc_id: 351974 cord_uid: 1najtyui Background COVID-19 has especially affected care home residents. Aim To evaluate a nurse-led Enhanced Care Home Team (ECHT) enhanced SARS-CoV-2 testing strategy. Design and setting Service evaluation in care homes in Norfolk UK. Method Residents and staff received nose and throat swab tests (7 April to 29 June 2020). Resident test results were linked with symptoms on days 0-14 after test and mortality to 13 July 2020. Results Residents (n=518) in 44 homes and staff (n=340) in 10 care homes were tested. SARS-CoV-2 positivity was identified in 103 residents in 14 homes and 49 staff in seven homes. Of 103 SARS-CoV-2+ residents, just 38 had typical symptom(s) at time of test (new cough and/or fever). Amongst 54 residents who were completely asymptomatic when tested, 12 (22%) developed symptoms within 14 days. Compared to SARS-CoV-2 negative residents, SARS-CoV-2+ residents were more likely to exhibit typical symptoms (new cough (n=26, p=0.001); fever (n=24, p=<0.001)) or as generally-unwell (n=18, p=0.001). Of 38 resident deaths, 21 (55%) were initially attributed to SARS-CoV-2, all of whom tested SARS-CoV-2+. One death not initially attributed to SARS-CoV-2 also tested positive. Conclusion Testing identified asymptomatic and pre-symptomatic SARS-CoV-2+ residents and staff. Being generally-unwell was common amongst symptomatic residents and may indicate SARS-CoV-2 infection in older people in the absence of more typical symptoms. Where a resident appears generally unwell SARS-CoV-2-infection should be suspected. Protocols for testing involved integrated health and social care teams. Older people residing in care homes are extremely vulnerable to SARS-CoV-2 infection. 1 2 Transmission of SARS-CoV-2 may be possible up to two-days prior to the appearance of typical symptoms yet older patients frequently have atypical presentation, 3-5 making recognition and control of infection in care homes difficult. Coupled with this, care homes in the UK have been consistently under-resourced, 6 staff are largely unregistered, 7 and training and support for healthcare support workers is limited. 7, 8 Carers commonly work across settings on casual contracts. 9 Allocation of SARS-CoV-2-tests and personal protective equipment (PPE) supply was initially focussed on clinical settings in the UK. The British National Health Service (NHS) has a low per capita inpatient bed base (compared to other high income countries) which means pressure is high to discharge vulnerable patients to social care settings. 10, 11 To protect NHS bed-capacity, patients were moved from hospitals to care homes untested until 16 April. 12 A national strategy to support formal testing of symptomatic residents and care home workers started from 15 April 2020. Whole care home testing in affected homes started from 15 May 2020, 12 and voluntary screening from 11 June 2020. SARS-CoV-2 has highlighted serious gaps in data intelligence surrounding care homes, 13 with regional test results typically not available to local authorities until 2 July 2020. 12 The county of Norfolk lies in the East of England, UK. North Norfolk is one of seven local authority districts within Norfolk and has a total population of approximately 200,000. It has devolved administration for many public services including primary care (North Norfolk Primary Care; NNPC). 14 North Norfolk has the oldest median age, at 53.8 years, of any local authority area in England and Wales. 15 This compares with median age of 45 years across Norfolk, and 40.2 years for the UK. 15 Of the 89 registered residential homes for the elderly in North Norfolk, 57 receive enhanced nursing care services (as described below) from NNPC. In the UK approximately 13.7% of people aged 85 and over live in care homes. 16 17 ECHT comprises five nurses (two advanced nurse practitioners (ANP), three nurse practitioners (NP)) and a paramedic. With NNPC GPs, ECHT provides holistic care through consistent GP review of the mental and physical health of their care home patients. Their objectives are to reduce unplanned hospital admissions or . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 5, 2020. . https://doi.org/10.1101/2020.08.04.20165928 doi: medRxiv preprint generally unwell, confused or agitated, fatigue, GI disturbance, rash, falls) or any mention of any other symptom (other) at the time of testing were extracted from medical records by an ANP. In addition, for SARS-CoV-2-positive residents who were asymptomatic at the point of test, data on any symptoms recorded in the 14-day post-test period were extracted. Cause of death data were obtained from residents medical records and death certificates. Data were pseudonymised and provided to the investigators by ECHT. Analyses were conducted using STATA (StataCorp v. 16). Data for residents and staff tests comprised unique ID, care home ID, date of SARS-CoV-2 test(s) and test outcome(s). Data for residents also included age, sex and symptoms (SARS-CoV-2-positive residents only). Residents' results were reported for individuals but staff test results were reported by home ID. Residents who ever had a SARS-CoV-2-positive test were considered SARS-CoV-2positive. The number of potential residents per home was based on the number of care home beds. Estimates of the number of staff tested was based on care home manager report of the proportion of staff tested, the number of staff employed in each home, and number of tests reported. Cases were asymptomatic if they had no symptoms at the point of test or in the subsequent 14-day period. Cases were presymptomatic if they had no symptoms at the point of test but developed symptoms in the subsequent 14-day period. SARS-CoV-2 was accepted as the cause of death where SARS-CoV-2 was certified as a cause of death. SARS-CoV-2 results for residents (n=518) of 44 care homes who received one or more SARS-CoV-2 test and staff tests (n=545) across 10 care homes in North Norfolk were included. In homes where screening was adopted, 461 of 708 (65.1%) potential residents and an estimated 340 of 434 potential staff (78.3%) were tested. Residents received 618 tests (mean 1.2, range 1 to 4) each and staff 545 (mean 1.6; range unknown) tests each. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 5, 2020. . https://doi.org/10.1101/2020.08.04.20165928 doi: medRxiv preprint Figure 1 . Flow of testing and screening for residents and staff across care homes Table 1 describes demographic and clinical presentations of residents by SARS-CoV-2 test outcome. The mean age of tested residents was 86.8 years (SD 9.6, range 42-104). More residents were female (n=364, 70%) and females were older (mean 87.6 years; Student's ttest P=0.0013). Most homes (n=30, 68%) had no SARS-CoV-2-infections. In 14 care homes where SARS-CoV-2 was identified, 103 (25.6% residents tested; 17.2% beds) and 49 (14.4% staff (estimated); 9% of staff tests) were SARS-CoV-2-positive. Where both staff and residents were tested, there was close correlation between positive resident and staff groups with SARS-CoV-2-positive staff and resident groups in 6 homes . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 5, 2020. . https://doi.org/10.1101/2020.08.04.20165928 doi: medRxiv preprint and SARS-CoV-2-negative staff and residents in three. In one care home, three staff but no patients were SARS-CoV-2-positive. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 5, 2020. . https://doi.org/10.1101/2020.08.04.20165928 doi: medRxiv preprint SARS-CoV-2-positive residents were similar in age to SARS-CoV-2-negative residents (p=0.237) and more likely to be male (Pearson's χ 2, p=0.012). Of were pre-symptomatic and developed one or more symptoms during the following 14-days. Clinical presentations are shown ( Mortality Table 2 describes the distribution of SARS-CoV-2 cases, test outcomes and deaths by care home. 38 deaths were recorded. Death attributed to SARS-CoV-2 (n=21, 55%) occurred across eight homes. Non-SARS-CoV-2 deaths (n=17, 45%) included dementia (n=7); old age or expected death (n=3); multi-organ failure (n=1); bronchopneumonia (n=1); intracranial haematoma (n=1) and unknown causes (n=4). All deaths attributed to SARS-CoV-2 tested positive for SARS-CoV-2. One of 17 deaths not attributed to SARS-Co-V-2 was positive for SARS-CoV-2. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 5, 2020. . https://doi.org/10.1101/2020.08.04.20165928 doi: medRxiv preprint CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 5, 2020. Overall 54 (52.4%) SARS-CoV-2-positive residents were asymptomatic at the point of test. Of these, 42 (78%) did not subsequently develop symptoms (true asymptomatic) and 12 (22%) developed symptoms (pre-symptomatic). The high proportions of asymptomatic or pre-symptomatic cases underline the value of screening to break chains of transmission. ECHT were able to rapidly develop and implement early SARS-CoV-2-testing. Early screening of residents and staff after ingress into care homes identified prevalence of truly asymptomatic infections and symptom presentation in residents relatively early in the UK COVID-19 outbreak. Staff results were reported by home (not individual) and therefore numbers of staff tested are estimated. Prevalence of staff infection and the possible relationship between staff prevalence and resident prevalence could be explored. The potential value of better information on staff working practices (knowing who works in other settings) was evidenced. In addition, resident estimates are based on bed number. Bed capacity is close to but not consistently at 100%. Many residents may not be tested for ethical or clinical reasons. The Vivaldi study, a telephone survey of care home managers exploring whole-home testing across 9,081 care homes in England (26 May to 19 June 2020), found 20% of residents and . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 5, 2020. . True asymptomatic cases were also reported from the Diamond Princess cruise ship (17.9%), 25 Japanese citizens evacuated from Wuhan (30.8%), 26 and in a care facility for older people in the USA (6.3%). 27 A comparable US study of 11 care homes identified 55.4% (n=507) asymptomatic cases. 28 World Health Organisation advice is that transmission from asymptomatic persons is less likely than from symptomatic people. 29 Under this study, 21 of 38 (55%) deaths were attributed to SARS-CoV-2. In the period 10 April 2020 to 26 June 2020 the UK Care Quality Commission (CQC) reported 12,211 (34.8%) and 133 (24.5%) all-cause deaths attributed to SARS-CoV-2 of residents of care homes in England and Norfolk respectively. 30 Over the period 10 April 2020 to 29 May . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 1 1 2020, Carterwood et al. estimated that Norfolk had 84 fewer deaths than expected given the local prevalence of SARS-CoV-2. 31 A high proportion of deaths (21/38, 55%) attributed to SARS-CoV-2 infection in this study is expected because screening was typically conducted in homes where infection was confirmed. Mortality data for care homes in North Norfolk cannot be disaggregated from other areas of Norfolk so it is not possible to deduce whether the ECHT intervention reduced mortality. Enhanced SARS-CoV-2-testing and screening enabled identification of SARS-CoV-2-related deaths that might otherwise have gone unrecognised. SARS-CoV-2 screening in care homes supported accurate attribution of mortality. Asymptomatic or atypical presentation is common amongst SARS-CoV-2-positive care home residents. Where a resident appears generally unwell or has any new symptom, SARS-CoV-2-infection should be suspected. Where SARS-CoV-2-infection is found, residents and staff should be screened. Early testing and screening of staff and residents in care homes can accurately identify outbreaks, prevalence of infection and death, and cause of death. Integrated health and social care teams working closely with care homes are well-placed to implement rapid screening services. Protocols for early screening which include local integrated health and social care teams should be developed. Comparative evaluation of this service was difficult because relevant data were non-existent: we did not know which staff work across settings or how many infections or deaths had occurred in neighbouring care homes. Integrated health and social care datasets that support urgent and local service development and evaluation should be commissioned. Spread of COVID-19 can be reduced by early detection and monitoring regimes in residential care homes for the elderly, but how to best achieve early disease detection in these settings remains unclear. Understanding both typical and atypical symptom prevalence in both residents and staff may be vital to breaking chains of transmission. Early in the UK COVID-19 outbreak, an integrated nursing support team was able to quickly implement a testing regime that thus documented a range of presentations among both residents and staff and especially helped to identify residents who were pre-symptomatic or asymptomatic. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 5, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 5, 2020. . https://doi.org/10.1101/2020.08.04.20165928 doi: medRxiv preprint England and Wales see 20 000 excess deaths in care homes The implications of silent transmission for the control of COVID-19 outbreaks Asymptomatic Transmission, the Achilles' Heel of Current Strategies to Control Covid-19 Comparative pathogenesis of COVID-19, MERS, and SARS in a nonhuman primate model The King's Fund. How serious are the pressures in social care? 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