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

On February 28, 2020, four cases of Covid-19 were confirmed among residents of King County; 1 person had presumed travel-related exposure, and 3 were identified by testing hospitalized patients who had severe respiratory illness (e.g., pneumonia) and who had tested negative for influenza and other respiratory pathogens. One of these was the index patient from Facility A; one was a Facility A staff member. When the index case was identified on February 28, at least 45 residents and staff dispersed across Facility A had symptoms of respiratory illness; PHSKC was notified of this increase by the facility on February 27.

Figure 1. Figure 1. Confirmed Cases of Covid-19 Linked to Facility A.

Shown are cases of Covid-19 in Washington that had been epidemiologically linked to Facility A as of March 18, 2020.

Table 1. Table 1. Demographic and Clinical Characteristics of Persons with Confirmed Covid-19 Linked to Facility A.

As of March 18, a total of 167 persons with Covid-19 that was epidemiologically linked to Facility A had been identified (Figure 1); 144 were residents of King County and 23 were residents of Snohomish County. Cases of Covid-19 occurred among facility residents (101 persons), health care personnel (50), and visitors (16) (Table 1). Among facility residents, 118 were tested; 101 results were positive and 17 negative. Most affected persons had respiratory illness consistent with Covid-19; however, chart review of facility residents found that in 7 cases no symptoms had been documented. Clinical presentation ranged from mild (no hospitalization) to severe, including 35 deaths by March 18. Reported dates of symptom onset ranged from February 15 to March 13. The median age of the patients was 83 years (range, 51 to 100) among facility residents, 62.5 years (range, 52 to 88) among visitors, and 43.5 years (range, 21 to 79) among facility personnel; 112 patients (67.1%) were women (Table 1). The hospitalization rates for residents, visitors, and staff were 54.5%, 50.0%, and 6.0%, respectively. As of March 18, the preliminary case fatality rate was 33.7% for residents and 6.2% for visitors; no staff members had died. Most (94.1% of 101) facility residents had chronic underlying health conditions, with hypertension (67.3%), cardiac disease (60.4%), renal disease (40.6%), diabetes mellitus (31.7%), pulmonary disease (31.7%), and obesity (30.7%) being most common. Of the coexisting conditions evaluated, hypertension was the only underlying condition present in 7 facility residents with Covid-19. The 50 health care personnel with confirmed Covid-19 worked in the following occupational categories: physical therapist, occupational therapist assistant, speech pathologist, environmental care (housekeeping, maintenance), nurse, certified nursing assistant, health information officer, physician, and case manager.

Figure 2. Figure 2. Timeline Showing Long-Term Care Facilities in King County with One or More Confirmed Cases of COVID-19.

The first nine long-term care facilities (e.g., nursing homes or assisted living facilities) in King County with one or more confirmed cases of Covid-19 are shown according to the date of the first confirmed case. Facilities are those identified as of March 9, 2020. The direction of potential introduction of Covid-19 from one facility to another is unknown.

Through ongoing surveillance and outreach to provide technical assistance with infection prevention and control to long-term care facilities (e.g., nursing homes, assisted living), a total of 30 King County facilities with at least one confirmed Covid-19 case, including Facility A, were identified by March 18. Of the first 8 facilities affected after Facility A, at least 3 had clear epidemiologic links to Facility A (Figure 2). Two of the facilities with definitive epidemiologic links had staff working both at that facility and at Facility A; the third facility had received two patient transfers from Facility A. Information received from surveys of long-term care facilities and on-site visits identified factors that were likely to have contributed to the vulnerability of these facilities, including staff who had worked while symptomatic; staff who worked in more than one facility; inadequate familiarity with and adherence to PPE recommendations; challenges to implementing proper infection control practices, including inadequate supplies of PPE and other items (e.g., alcohol-based hand sanitizer); delayed recognition of cases because of a low index of suspicion; limited availability of testing; and difficulty identifying persons with Covid-19 on the basis of signs and symptoms alone. Examples of specific PPE challenges included an initial lack of available eye protection, frequent changes in PPE types because supply chains were disrupted and PPE was being obtained through various donations or suppliers, and a need for a designated staff member to observe PPE use to ensure that staff were consistent with safe PPE handling (e.g., not touching or adjusting face protection, primarily face masks, during extended use). Working collaboratively, state and local health departments and CDC staff provided five focused PPE trainings for facility staff, including donning and doffing demonstrations and practice, and three additional basic infection control visits, including hand hygiene assessments, audits of PPE use, and reviews of environmental cleaning and disinfection practices.

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