On March 18, 2020, this report was posted on-line as an MMWR Early Launch.
Please notice: This report has been corrected.
Temet M. McMichael, PhD1,2,3; Shauna Clark1; Sargis Pogosjans, MPH1; Meagan Kay, DVM1; James Lewis, MD1; Atar Baer, PhD1; Vance Kawakami, DVM1; Margaret D. Lukoff, MD1; Jessica Ferro, MPH1; Claire Brostrom-Smith, MSN1; Francis X. Riedo, MD4; Denny Russell5; Brian Hiatt5; Patricia Montgomery, MPH6; Agam Ok. Rao, MD3; Dustin W. Currie, PhD2,3; Eric J. Chow, MD2,3; Farrell Tobolowsky, DO2,3; Ana C. Bardossy, MD2,3; Lisa P. Oakley, PhD2,3; Jesica R. Jacobs, PhD3,7; Noah G. Schwartz, MD2,3; Nimalie Stone, MD3; Sujan C. Reddy, MD3; John A. Jernigan, MD3; Margaret A. Honein, PhD3; Thomas A. Clark, MD3; Jeffrey S. Duchin, MD1; Public Well being – Seattle & King County, EvergreenHealth, and CDC COVID-19 Investigation Workforce (View creator affiliations)
What’s already identified about this subject?
Coronavirus illness (COVID-19) may cause extreme sickness and demise, notably amongst older adults with continual well being circumstances.
What’s added by this report?
Introduction of COVID-19 right into a long-term residential care facility in Washington resulted in circumstances amongst 81 residents, 34 employees members, and 14 guests; 23 individuals died. Limitations in efficient an infection management and prevention and employees members working in a number of amenities contributed to intra- and interfacility unfold.
What are the implications for public well being follow?
Lengthy-term care amenities ought to take proactive steps to guard the well being of residents and protect the well being care workforce by figuring out and excluding doubtlessly contaminated employees members, proscribing visitation besides in compassionate care conditions, guaranteeing early recognition of probably contaminated sufferers, and implementing acceptable an infection management measures.
On February 28, 2020, a case of coronavirus illness (COVID-19) was recognized in a lady resident of a long-term care expert nursing facility (facility A) in King County, Washington.* Epidemiologic investigation of facility A recognized 129 circumstances of COVID-19 related to facility A, together with 81 of the residents, 34 employees members, and 14 guests; 23 individuals died. Limitations in efficient an infection management and prevention and employees members working in a number of amenities contributed to intra- and interfacility unfold. COVID-19 can unfold quickly in long-term residential care amenities, and individuals with continual underlying medical circumstances are at higher danger for COVID-19–related extreme illness and demise. Lengthy-term care amenities ought to take proactive steps to guard the well being of residents and protect the well being care workforce by figuring out and excluding doubtlessly contaminated employees members and guests, guaranteeing early recognition of probably contaminated sufferers, and implementing acceptable an infection management measures.
On February 27, Public Well being – Seattle and King County (PHSKC) was notified by a neighborhood well being care supplier of a affected person whose symptom historical past and scientific presentation met the revised testing standards† for COVID-19, which included testing of individuals with extreme respiratory sickness of unknown etiology (1). The affected person was a lady aged 73 years with a historical past of coronary artery illness, insulin-dependent sort II diabetes mellitus, weight problems, continual kidney illness, hypertension, and congestive coronary heart failure, who resided in facility A together with roughly 130 residents who have been cared for by 170 well being care personnel. Starting in mid-February, the power had skilled a cluster of febrile respiratory sicknesses. Speedy influenza check outcomes have been obtained from a number of residents; all have been destructive. The affected person had cough, fever, and shortness of breath requiring oxygen for five days at facility A. She reported no journey or identified contact with anybody with COVID-19. On February 24, she was transported to a neighborhood hospital due to worsening respiratory signs and hypoxemia.
Upon hospital admission, the affected person was febrile to 103.3°F (39.6°C), tachycardic, and was discovered to have hypoxemic respiratory failure. On February 25, she required intubation and mechanical air flow. Computed tomography scan confirmed diffuse bilateral infiltrates; nonetheless, multiplex viral respiratory panel and bacterial cultures of sputum and bronchoalveolar lavage fluid have been destructive. 4 days after hospital admission, nasopharyngeal and oropharyngeal swabs and sputum specimens have been collected to check for SARS-CoV-2; outcomes have been reported constructive for all specimens on February 28. The affected person died on March 2.
Following notification of the index case of COVID-19, PHSKC and CDC instantly started investigating the cluster of respiratory sickness in facility A to gather data on signs, severity, comorbidities, journey historical past, and shut contacts to identified COVID-19 circumstances by interviewing sufferers or a proxy for circumstances through which the affected person couldn’t be interviewed. Diagnostic testing by real-time reverse transcription–polymerase chain response (RT-PCR) (2–5) was carried out for sufferers and employees members assembly scientific case standards for COVID-19 (1). As of March 9, a complete of 129 COVID-19 circumstances have been confirmed amongst facility residents (81 of roughly 130), employees members, together with well being care personnel (34), and guests (14). Well being care personnel with confirmed COVID-19 included the next occupations: bodily therapist, occupational therapist assistant, environmental care employee, nurse, licensed nursing assistant, well being data officer, doctor, and case supervisor. General, 111 (86%) circumstances occurred amongst residents of King County (81 facility A residents, 17 employees members, and 13 guests) and 18 (14%) amongst residents of Snohomish County (straight north of King County) (17 employees members and one customer).
Reported symptom onset dates for facility residents and employees members ranged from February 16 to March 5. The median affected person age was 81 years (vary = 54–100 years) amongst facility residents, 42.5 years (vary = 22–79 years) amongst employees members, and 62.5 years (vary = 52–88 years) amongst guests; 84 (65.1%) sufferers have been ladies (Desk). General, 56.8% of facility A residents, 35.7% of tourists, and 5.9% of employees members with COVID-19 have been hospitalized. Preliminary case fatality charges amongst residents and guests as of March 9 have been 27.2% and seven.1%, respectively; no deaths occurred amongst employees members. The commonest continual underlying circumstances amongst facility residents have been hypertension (69.1%), cardiac illness (56.8%), renal illness (43.2%), diabetes (37.0%), weight problems (33.3%), and pulmonary illness (32.1%). Six residents and one customer had hypertension as their solely continual underlying situation.
As a part of the response effort, roughly 100 long-term care amenities in King County have been contacted by way of an emailed survey utilizing REDCap (6), and data was requested about residents or employees members identified to have COVID-19 or clusters of respiratory sickness amongst residents and employees members. As well as, countywide databases of emergency medical service transfers from long-term care amenities to acute care amenities have been reviewed day by day for proof of circumstances or clusters of significant respiratory sickness. Routine lively surveillance stories to PHSKC for influenza-like sickness clusters from long-term care amenities have been employed to determine clusters of sickness per COVID-19. All long-term care amenities with proof of a cluster of respiratory sickness have been contacted by phone for extra data, together with an infection management methods in place and availability of non-public protecting gear (PPE). Primarily based on this data, the long-term care amenities have been prioritized by danger for COVID-19 introduction and unfold, and highest precedence amenities have been visited by response personnel for provision of emergency on-site testing and an infection management evaluation, assist, and coaching. As of March 9, at the least eight different King County expert nursing and assisted dwelling amenities had reported a number of confirmed COVID-19 circumstances.
Data obtained from the survey and on-site visits recognized elements that seemingly contributed to the vulnerability of those amenities, together with 1) employees members who labored whereas symptomatic; 2) employees members who labored in multiple facility; 3) insufficient familiarity and adherence to straightforward, droplet, and phone precautions and eye safety suggestions; 4) challenges to implementing an infection management practices together with insufficient provides of PPE and different objects (e.g., alcohol-based hand sanitizer) §; 5) delayed recognition of circumstances due to low index of suspicion, restricted testing availability, and problem figuring out individuals with COVID-19 based mostly on indicators and signs alone.