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. 2020 Sep;81(3):411-419.
doi: 10.1016/j.jinf.2020.05.073. Epub 2020 Jun 3.

SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes

N S N Graham  1 , C Junghans  2 , R Downes  3 , C Sendall  3 , H Lai  1 , A McKirdy  4 , P Elliott  5 , R Howard  6 , D Wingfield  7 , M Priestman  8 , M Ciechonska  8 , L Cameron  9 , M Storch  8 , M A Crone  8 , P S Freemont  8 , P Randell  10 , R McLaren  11 , N Lang  12 , S Ladhani  13 , F Sanderson  14 , D J Sharp  1
Affiliations

SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes

N S N Graham et al. J Infect. 2020 Sep.

Abstract

Objectives: To understand SARS-Co-V-2 infection and transmission in UK nursing homes in order to develop preventive strategies for protecting the frail elderly residents.

Methods: An outbreak investigation involving 394 residents and 70 staff, was carried out in 4 nursing homes affected by COVID-19 outbreaks in central London. Two point-prevalence surveys were performed one week apart where residents underwent SARS-CoV-2 testing and had relevant symptoms documented. Asymptomatic staff from three of the four homes were also offered SARS-CoV-2 testing.

Results: Overall, 26% (95% CI 22-31) of residents died over the two-month period. All-cause mortality increased by 203% (95% CI 70-336) compared with previous years. Systematic testing identified 40% (95% CI 35-46) of residents as positive for SARS-CoV-2, and of these 43% (95% CI 34-52) were asymptomatic and 18% (95% CI 11-24) had only atypical symptoms; 4% (95% CI -1 to 9) of asymptomatic staff also tested positive.

Conclusions: The SARS-CoV-2 outbreak in four UK nursing homes was associated with very high infection and mortality rates. Many residents developed either atypical or had no discernible symptoms. A number of asymptomatic staff members also tested positive, suggesting a role for regular screening of both residents and staff in mitigating future outbreaks.

Keywords: COVID-19; Care home; Coronavirus; Diagnostic testing; Nursing home; SARS-CoV-2.

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Conflict of interest statement

Declaration of Competing Interest Dr. Wingfield reports he is an NHS General Practitioner with Partnership responsibility for care at two of the nursing homes considered in the paper. Dr. McLaren reports ‘other’ from NHSE GP GMS Contract, ‘other’ from Care UK, ‘other’ from Ganymeade, grants from NHS Hammersmith and Fulham CCG. Outside the submitted work; he is Chair of the Hammersmith & Fulham GP Federation. This organisation looks to support NHS GP practices in the borough and holds a contract to provide out of hospital services in partnership with them. He is a GP trainer on the Imperial GP VTS Scheme and his trainee is Dr. Cornelia Junghans-Minton who is a co-author. He is a GP Partner in Hammersmith and Fulham Partnership and we have been in active discussion with Imperial about providing integrated care to our shared patients. We anticipate that this will involve enhanced support of Nursing Home Residents.

Figures

Fig 1
Fig. 1
Timeline of COVID-19 outbreak and associated mortality. Panel A – deaths per day throughout the outbreak timeline from 1 March to 1 May 2020 in all four homes, with key dates denoted. Colours relate to the presence of COVID-19 on medical certificate of cause of death (MCCD). Homes were closed to visitors on 16 March; a limited number of tests were made available for symptomatic testing on 2 April by Public Health England; systematic testing within the outbreak investigation commenced on 15 April. Panel B – deaths per day in each nursing home separately. Dates of first positive COVID-19 test (T1) and death-certificate coded COVID-19 death (D1) in each home are shown. Panel C – cumulative number of deaths of all causes, including non-COVID-19, throughout the two-month period (red). Historic average number of deaths throughout the same period in 2018 and 2019 is shown in grey for comparison.
Fig 2
Fig. 2
COVID-19 Symptoms, Outcomes and Comorbidities. (A) Relationship of COVID-19 symptoms in two weeks preceding swabbing with SARS-CoV-2 test result. ‘Confusion’ refers to altered mental status or behaviour. GI symptoms refers to diarrhoea and/or vomiting. (B) Relationship of comorbidities to all-cause mortality; CVD: cardiovascular disease; CKD: chronic kidney disease; lung disease refers to chronic lung disease.
Fig 3
Fig. 3
Association of symptoms with a positive SARS-CoV-2 rt-PCR result. Relationship of symptom in preceding two weeks to a positive SARS-CoV-2 result in all residents tested (n = 313), displayed as adjusted odds ratios with 95% confidence intervals. Significant predictors in model indicated by ** P<0.01; *** P<0.001.
Fig 4
Fig. 4
SARS-CoV-2 variants in nursing homes. Maximum likelihood phylogenetic tree showing SARS-CoV-2 sequence variation across and within the four nursing homes, in the UK context, by date of sample result. The Wuhan-Hu-1 2019 reference strain is shown to the far left. Coloured dots represent the sequences originating from residents (n=18) and staff (n=1, see asterisk), alongside 400 publicly shared sequences from England, Wales, Scotland and Northern Ireland (in grey, see supplementary). Phylogenetic analysis and figure obtained using Nextstrain.
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References

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