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Table 1.  Results, Known Case Burden, and Timing of Testing by Facility
Results, Known Case Burden, and Timing of Testing by Facility
Table 2.  Two-Week Cumulative Hospitalization or Mortality Among Long-term Care Residents With Follow-up Dataa
Two-Week Cumulative Hospitalization or Mortality Among Long-term Care Residents With Follow-up Dataa
1.
Wang  L, He  W, Yu  X,  et al.  Coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up.   J Infect. 2020;80(6):639-645. doi:10.1016/j.jinf.2020.03.019PubMedGoogle ScholarCrossref
2.
Kimball  A, Hatfield  KM, Arons  M,  et al; Public Health—Seattle & King County; CDC COVID-19 Investigation Team.  Asymptomatic and presymptomatic SARS-CoV-2 infections in residents of a long-term care skilled nursing facility—King County, Washington, March 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(13):377-381. doi:10.15585/mmwr.mm6913e1PubMedGoogle ScholarCrossref
3.
Arons  MM, Hatfield  KM, Reddy  SC,  et al; Public Health–Seattle and King County and CDC COVID-19 Investigation Team.  Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility.   N Engl J Med. 2020;382(22):2081-2090. doi:10.1056/NEJMoa2008457PubMedGoogle ScholarCrossref
4.
Centers for Medicare & Medicaid Services. Long Term Care Facility Reporting on COVID-19. Published 2020. Accessed June 5, 2020. https://www.cms.gov/files/document/covid-nursing-home-reporting-numbers-5-31-20.pdf
5.
Wang  W, Xu  Y, Gao  R,  et al.  Detection of SARS-CoV-2 in different types of clinical specimens.   JAMA. 2020;323(18):1843-1844. doi:10.1001/jama.2020.3786PubMedGoogle Scholar
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    Research Letter
    July 14, 2020

    Outcomes of Universal COVID-19 Testing Following Detection of Incident Cases in 11 Long-term Care Facilities

    Author Affiliations
    • 1Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 2Department of Cardiology, St Agnes Hospital, Baltimore, Maryland
    JAMA Intern Med. Published online July 14, 2020. doi:10.1001/jamainternmed.2020.3738

    Residents in long-term care facilities are at particularly high risk of infection and poor outcomes associated with coronavirus disease 2019 (COVID-19).1,2 Early in the course of the pandemic, testing recommendations by the Centers for Disease Control advised testing residents and staff solely based on the presence of typical symptoms. Despite these efforts, there have been widespread outbreaks across long-term care facilities in the US, with high mortality rates.

    Methods

    We performed universal testing of untested residents across 11 Maryland long-term care facilities that (1) had previously undergone targeted testing through the local health department based on individual residents’ symptoms and (2) had known positive cases. Nasopharyngeal swab samples were collected, and reverse transcriptase–polymerase chain reaction analysis was used to detect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA. Symptom status (any fever >99 °F, cough, diarrhea, respiratory decompensation, or other acute clinical status changes) at the time of universal testing was recorded based on discussion with facility staff. We used descriptive statistics to report the prevalence of positive test results and symptom status at the time of testing. Two-week telephone follow-up was conducted at 7 facilities following point-prevalence testing to obtain information regarding hospitalization and mortality status of all tested residents. This study was reviewed by the Johns Hopkins institutional review board and deemed exempt as public health surveillance activity.

    Results

    Targeted symptom-based testing identified 153 cases prior to point-prevalence surveys at 11 facilities within 20 days of detection of the index case. Among the remaining 893 residents who were universally tested, 354 (39.6%) tested positive for SARS-CoV-2 RNA. Thus, universal screening increased the total number of detected COVID-19 cases across all sites from 153 to 507; of these, 281 (55.4%) were asymptomatic (Table 1).

    There was 2-week follow-up available for 426 of the residents tested at 7 facilities (177 positive for COVID-19, 249 negative). Among the 177 cases who were identified with universal testing, 154 (87.0%) were asymptomatic. Among those who tested positive and were asymptomatic at testing, 20 (13.0%) were hospitalized, and 7 (4.6%) died within 14 days of testing. Among the 23 residents who tested positive and were symptomatic at testing, 4 (17.4%) were hospitalized, and 2 (8.7%) died within 14 days of testing (Table 2).

    Discussion

    In this study of 11 Maryland long-term care facilities, an additional 354 cases (39.6% of those tested) were identified with universal testing, despite initial targeted, symptom-based testing. These results underscore the importance of universal testing because symptom-based approaches may miss a substantial number of cases.2,3 Unrecognized asymptomatic cases among residents could perpetuate transmission within facilities.

    According to data from the Center for Medicare & Medicaid Services, the overall case fatality among residents of long-term care facilities is about 33%.4 The short-term mortality rate found in the present study among residents who underwent universal testing was much lower, suggesting that true COVID-associated mortality rates in long-term care facilities may be lowered by increased testing and case detection.

    This study has limitations. Symptom status was only available at the time of testing and based on reports from facility staff. Follow-up data were only available for 7 of the 11 universally tested sites. Finally, there may be false negatives associated with nasopharyngeal swab samples.5

    Long-term care facilities have emerged as “hot spots” for SARS-CoV-2 infection and mortality globally. Using symptom-based testing alone to identify positive residents is not adequate to assess case burden and inform outbreak-control efforts in these settings. Additional testing resources are urgently needed to identify the true burden of COVID-19 and curb transmission in long-term care settings.

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    Article Information

    Accepted for Publication: June 23, 2020.

    Corresponding Author: Morgan J. Katz, MD, MHS, Department of Medicine, Division of Infectious Disease, Johns Hopkins University School of Medicine, 5200 Eastern Ave, Mason F. Lord Bldg, Baltimore, MD 21224 (mkatz26@jhmi.edu).

    Published Online: July 14, 2020. doi:10.1001/jamainternmed.2020.3738

    Author Contributions: Dr Katz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Bigelow, Tang, Peters, Sisson, Peairs, Katz.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Bigelow, Tang, Peters, Peairs.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Bigelow, Tang, Peters.

    Administrative, technical, or material support: Barshick, Sisson, Peairs.

    Supervision: Barshick, Peters, Katz.

    Conflict of Interest Disclosures: Dr Katz reports grants from CDC, personal fees from FutureCare, grants from AHRQ, and personal fees from Roche outside the submitted work. No other disclosures were reported.

    Additional Contributions: The authors thank the Johns Hopkins Ambulatory testing team, facility staff, and residents for their important contributions. This work was performed as a public health initiative to assist the Maryland Department of Health in their response to the spread of COVID-19.

    Additional Information: Deidentified data from this study with a data dictionary is available; please email mkatz26@jhmi.edu for data access request.

    References
    1.
    Wang  L, He  W, Yu  X,  et al.  Coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up.   J Infect. 2020;80(6):639-645. doi:10.1016/j.jinf.2020.03.019PubMedGoogle ScholarCrossref
    2.
    Kimball  A, Hatfield  KM, Arons  M,  et al; Public Health—Seattle & King County; CDC COVID-19 Investigation Team.  Asymptomatic and presymptomatic SARS-CoV-2 infections in residents of a long-term care skilled nursing facility—King County, Washington, March 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(13):377-381. doi:10.15585/mmwr.mm6913e1PubMedGoogle ScholarCrossref
    3.
    Arons  MM, Hatfield  KM, Reddy  SC,  et al; Public Health–Seattle and King County and CDC COVID-19 Investigation Team.  Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility.   N Engl J Med. 2020;382(22):2081-2090. doi:10.1056/NEJMoa2008457PubMedGoogle ScholarCrossref
    4.
    Centers for Medicare & Medicaid Services. Long Term Care Facility Reporting on COVID-19. Published 2020. Accessed June 5, 2020. https://www.cms.gov/files/document/covid-nursing-home-reporting-numbers-5-31-20.pdf
    5.
    Wang  W, Xu  Y, Gao  R,  et al.  Detection of SARS-CoV-2 in different types of clinical specimens.   JAMA. 2020;323(18):1843-1844. doi:10.1001/jama.2020.3786PubMedGoogle Scholar
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