Nursing Home Outbreaks Research Articles

Modeling the Impacts of Antiviral Prophylaxis Strategies in Mitigating Seasonal Influenza Outbreaks in Nursing Homes.

Antiviral chemoprophylaxis is recommended for use during influenza outbreaks in nursing homes to prevent transmission and severe disease among non-ill residents. Centers for Disease Control and Prevention (CDC) guidance recommends prophylaxis be initiated for all non-ill residents once an influenza outbreak is detected and be continued for at least 14 days and until 7 days after the last laboratory-confirmed influenza case is identified. However, not all facilities strictly adhere to this guidance and the impact of such partial adherence is not fully understood. We developed a stochastic compartmental framework to model influenza transmission within an average-sized US nursing home. We compared the number of symptomatic illnesses and hospitalizations under varying prophylaxis implementation strategies, in addition to different levels of prophylaxis uptake and adherence by residents and healthcare personnel (HCP). Prophylaxis implemented according to current guidance reduced total symptomatic illnesses and hospitalizations among residents by a median of 12% and 36%, respectively, compared with no prophylaxis. We did not find evidence that alternative implementations of prophylaxis were more effective: compared to full adoption of current guidance, partial adoption resulted in increased symptomatic illnesses and/or hospitalizations, and longer or earlier adoption offered no additional improvements. In addition, increasing uptake and adherence among nursing home residents was effective in reducing resident illnesses and hospitalizations, but increasing HCP uptake had minimal indirect impacts for residents. The greatest benefits of influenza prophylaxis during nursing home outbreaks will likely be achieved through increasing uptake and adherence among residents and following current CDC guidance.

COVID-19 measures implemented for nursing home staff and their perspectives on the importance of the measures: A qualitative study

BackgroundMeasures against COVID-19 in nursing homes affected not only clients but also staff. However, staff perspectives on the importance of these measures remain underexplored. ObjectiveTo investigate measures related to staff during the COVID-19 pandemic, staff perspectives of important measures and the involvement of staff in deciding on these measures. DesignA qualitative study. Setting(s)We analysed minutes of nursing home outbreak teams in the Netherlands and conducted group meetings with Dutch nursing home staff in different positions, prioritizing measures and discussing staff’ involvement in deciding on the measures. Participants were recruited purposefully. ParticipantsThe minutes of 41 nursing home organizations were collected during March–November, 2020. Four group meetings were organized in the same period, each with 5 to 7 participants, resulting in 23 participants. MethodsThe meeting minutes were analysed using qualitative content analysis, whereas reflexive thematic analysis was used for the group meeting data. The group meetings were conducted online and structured by the Nominal Group Technique to discuss the importance of measures for staff. ResultsMeasures implemented for staff focused on prevention of COVID-19 transmission, (suspension of) educational activities, testing, additional tasks and staffing capacity, promoting well-being, and other means of support. The implemented measures overlapped with the measures considered important by staff. In addition, staff considered measures on decision-making support and communication to be important. Staff prioritized the measures in the group meetings because they affected their well-being, workforce scheduling, decision-making, or infection prevention. Furthermore, the group meetings revealed that decision-making shifted from mainly implementing national measures to more context-adjusted decision-making in the staff's or clients’ situations. ConclusionsWe showed that although nursing home staff were not always involved in decision-making during the first COVID-19 wave, there was overlap between the measures implemented by the organizations and measures considered important by staff. We suggest that organizations should be encouraged to explore ways of promoting timely involvement of staff in decision-making; for example, through monitoring staff needs and well-being and giving staff more autonomy to deviate from standard measures during future outbreaks or medical emergencies.

Implementation of COVID-19 measures for Dutch nursing home staff and their insights

Abstract Background Measures against COVID-19 in nursing homes impacted both clients and staff, yet the importance of measures from the staff's perspective remain underexplored. This study examined measures related to staff during the COVID-19 pandemic, staff perspectives of their importance and the involvement of staff in deciding these measures. Methods In this qualitative study, the minutes of 41 nursing home outbreak teams in the period March to November 2020 were analyzed and 4 group meetings were conducted between June-November 2020. Qualitative content analysis was used for the minutes data, whereas reflexive thematic analysis was used for the group meeting data. Results Measures implemented for staff focused on prevention of COVID-19 transmission, (suspension of) educational activities, testing, additional tasks and staffing capacity, promoting well-being, and other means of support. The results showed overlap between the implemented measures and the measures considered important by staff, except for measures on decision-making support and communication, which were considered important by staff but not listed among the implemented measures. Measures were prioritized by staff because they affected their well-being, workforce scheduling, decision making, or preventing infections. Furthermore, the group meetings revealed that decision making shifted from mainly implementing national guidelines to more context -adjusted decision making in the staff's or clients’ situation. Conclusions Although there was overlap regarding measures taken, our findings suggest that organizations should be encouraged to explore ways of timely involvement of staff in decision making when implementing measures in future pandemics. During the COVID-19 pandemic, information about the pandemic response strategies and policies were shared with policymakers and nursing home organizations to learn from each other and make more informed decisions about how to respond to the pandemic. Key messages • The information gained through the group meetings can lead to an improved fit between implemented measures and staffs’ working procedures during future pandemics. • Decision making support and communication should receive more attention according to staff during future pandemics.

Immunovirological and environmental screening reveals actionable risk factors for fatal COVID-19 during post-vaccination nursing home outbreaks

Coronavirus Disease 2019 (COVID-19) vaccination has resulted in excellent protection against fatal disease, including in older adults. However, risk factors for post-vaccination fatal COVID-19 are largely unknown. We comprehensively studied three large nursing home outbreaks (20–35% fatal cases among residents) by combining severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) aerosol monitoring, whole-genome phylogenetic analysis and immunovirological profiling of nasal mucosa by digital nCounter transcriptomics. Phylogenetic investigations indicated that each outbreak stemmed from a single introduction event, although with different variants (Delta, Gamma and Mu). SARS-CoV-2 was detected in aerosol samples up to 52 d after the initial infection. Combining demographic, immune and viral parameters, the best predictive models for mortality comprised IFNB1 or age, viral ORF7a and ACE2 receptor transcripts. Comparison with published pre-vaccine fatal COVID-19 transcriptomic and genomic signatures uncovered a unique IRF3 low/IRF7 high immune signature in post-vaccine fatal COVID-19 outbreaks. A multi-layered strategy, including environmental sampling, immunomonitoring and early antiviral therapy, should be considered to prevent post-vaccination COVID-19 mortality in nursing homes.

Outbreaks of SARS-CoV-2 Infections in Nursing Homes during Periods of Delta and Omicron Predominance, United States, July 2021–March 2022

SARS-CoV-2 infections among vaccinated nursing home residents increased after the Omicron variant emerged. Data on booster dose effectiveness in this population are limited. During July 2021-March 2022, nursing home outbreaks in 11 US jurisdictions involving >3 infections within 14 days among residents who had received at least the primary COVID-19 vaccine(s) were monitored. Among 2,188 nursing homes, 1,247 outbreaks were reported in the periods of Delta (n = 356, 29%), mixed Delta/Omicron (n = 354, 28%), and Omicron (n = 536, 43%) predominance. During the Omicron-predominant period, the risk for infection within 14 days of an outbreak start was lower among boosted residents than among residents who had received the primary vaccine series alone (risk ratio [RR]0.25, 95% CI0.19-0.33). Once infected, boosted residents were at lower risk for all-cause hospitalization (RR0.48, 95% CI0.40-0.49) and death (RR0.45, 95% CI0.34-0.59) than primary vaccine-only residents.

Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) outbreaks in nursing homes involving residents who had completed a primary coronavirus disease 2019 (COVID-19) vaccine series-13 US jurisdictions, July-November 2021.

Among nursing home outbreaks of coronavirus disease 2019 (COVID-19) with ≥3 breakthrough infections when the predominant severe acute respiratory coronavirus virus 2 (SARS-CoV-2) variant circulating was the SARS-CoV-2 δ (delta) variant, fully vaccinated residents were 28% less likely to be infected than were unvaccinated residents. Once infected, they had approximately half the risk for all-cause hospitalization and all-cause death compared with unvaccinated infected residents.

Efficiency of Diagnostic Test for SARS-CoV-2 in a Nursing Home.

Background: there is no consensus on how to optimally use diagnostic tests in each stage of COVID-19 pandemic. The objective of this research is to determine the efficiency of sorting positive antibody test quarterly. Methods: this research uses a retrospective, observational study. COVID-19 diagnostic tests performed and avoided refer to a Spanish nursing home. Population: 261 employees and 107 residents. A quarterly antibody test was performed on subjects who had tested positive during the first wave of coronavirus, and a antibody rapid test on the remaining subjects. Results: during the first wave, 24.0% of the employees and 51.4% of the residents had a positive antibody test. Seronegativization was observed in 7.6% of employees and 1.6% of residents. An employee was infected with COVID-19 in September 2020, followed by a nursing home outbreak in October: 118 Polymerase Chain Reactions tests were avoided in residents and 18 in employees, which in turn prevented 15 workers from going on sick leave and the quarantine of 59 residents. This represents savings of about $15,000. Conclusions: our study supports the need to know and apply the strategies for early detection, surveillance and control of COVID-19 for future outbreaks. We conclude that surveillance for positive COVID-19 serology among long-term care staff and residents may be a cost-effective strategy during a pandemic.

Relationship between nursing home COVID-19 outbreaks and staff neighborhood characteristics.

The COVID-19 pandemic has been particularly deadly for residents of nursing homes and other long-term care facilities. This paper analyzes COVID-19 deaths at nursing homes during the first wave of the pandemic in the United States during the spring and early summer 2020. By combining data on facility-level COVID-19 deaths during this period with data on the neighborhoods where nursing home staff reside for a sample of eighteen states, this paper finds that staff neighborhood characteristics were a large and significant predictor of COVID-19 nursing home deaths. Even after controlling for the county where a facility is located, one standard deviation increases in average staff neighborhood (Census tract) population density, public transportation use, and non-white share were associated with 1.3 (p < .001), 1.4 (p < .001), and 0.9 (p < .001) additional deaths per 100 beds, respectively. These effects are larger than all facility management or quality variables, and larger than the effect of the nursing home’s own neighborhood characteristics. These results suggest COVID-19 outbreaks in staff communities can have large consequences for the facilities where they work, even in highly-rated facilities, and that disparities in nursing home outbreaks may be related to differences in the types of neighborhoods nursing home staff live in.

Absence of COVID-19 Disease Among Chronically Ventilated Nursing Home Patients.

ObjectiveTo describe the experience of COVID-19 disease among chronically ventilated and nonventilated nursing home patients living in 3 separate nursing homes.DesignObservational study of death, respiratory illness and COVID-19 polymerase chain reaction (PCR) results among residents and staff during nursing home outbreaks in 2020.Setting and Participants93 chronically ventilated nursing home patients and 1151 nonventilated patients living among 3 separate nursing homes on Long Island, New York, as of March 15, 2020. Illness, PCR results, and antibody studies among staff are also reported.MeasurementsData were collected on death rate among chronically ventilated and nonventilated patients between March 15 and May 15, 2020, compared to the same time in 2019; prevalence of PCR positivity among ventilated and nonventilated patients in 2020; reported illness, PCR positivity, and antibody among staff.ResultsTotal numbers of deaths among chronically ventilated nursing home patients during this time frame were similar to the analogous period 1 year earlier (9 of 93 in 2020 vs 8 of 100 in 2019, P = .8), whereas deaths among nonventilated patients were greatly increased (214 of 1151 in 2020 vs 55 of 1189 in 2019, P < .001). No ventilated patient deaths were clinically judged to be COVID-19 related. No clusters of COVID-19 illness could be demonstrated among ventilated patients. Surveillance PCR testing of ventilator patients failed to reveal COVID-19 positivity (none of 84 ventilator patients vs 81 of 971 nonventilator patients, P < .002). Illness and evidence of COVID-19 infection was demonstrated among staff working both in nonventilator and in ventilator units.Conclusions and ImplicationsCOVID-19 infection resulted in illness and death among nonventilated nursing home residents as well as among staff. This was not observed among chronically ventilated patients. The mechanics of chronic ventilation appears to protect chronically ventilated patients from COVID-19 disease.

Introduction of the BNT162b2 vaccine during a COVID-19 nursing home outbreak

BackgroundCoronavirus disease 2019 (COVID-19) outbreaks often occur in nursing homes and prompt frequent surveillance testing for SARS-CoV-2. A single dose of the BNT162b2 vaccine reduces viral load and transmission. In this study, we describe the real-world efficacy of BNT162b2 single-dose vaccination during a COVID-19 outbreak at a Veterans Affairs Community Living Center (CLC). MethodsFrom 12/2/20 to 5/14/21, twice weekly antigen testing was used to detect COVID-19 among 146 residents at the CLC. Residents without a prior history of COVID-19 who agreed to immunization were vaccinated with the BNT162b2 vaccine on 12/16/20 and 1/6/21. Single-dose vaccine efficacy was determined for days 1-21 and days 14-21 after the first vaccine dose. ResultsThe outbreak occurred from 12/2/20 to 1/7/21 with an attack rate of 30.8% (45/146); 46.7% (21/45) of the cases were due to asymptomatic COVID-19. One unit accounted for 77.8% (35/45) of the cases. In the vaccine analysis, 116 residents were a median age of 74.5 years and 93.1% (108/116) had ≥ 1 comorbid condition. Between the first and second dose, 15.5% (15/97) of vaccinated residents, and 21.2% (4/19) of unvaccinated residents developed COVID-19 (P = .81). One week after the second dose, no cases of COVID-19 occurred. ConclusionsAlbeit limited by the small numbers, a single dose of the BNT162b2 vaccine was not efficacious at preventing COVID-19 during this nursing home outbreak.

COVID-19 Cases and Death in Nursing Homes: The Role of Racial and Ethnic Composition of Facilities and Their Communities

ObjectivesTo examine the extent to which the racial and ethnic composition of nursing homes (NHs) and their communities affects the likelihood of COVID-19 cases and death in NHs, and whether and how the relationship between NH characteristics and COVID-19 cases and death varies with the racial and ethnic composition of the community in which an NH is located. Methods and DesignCenters for Medicare & Medicare Services Nursing Home COVID-19 data were linked with other NH- or community-level data (eg, Certification and Survey Provider Enhanced Reporting, Minimum Data Set, Nursing Home Compare, and the American Community Survey). Setting and Participants: NHs with more than 30 occupied beds (N=13,123) with weekly reported NH COVID-19 records between the weeks of June 7, 2020, and August 23, 2020. Measurements and model: Weekly indicators of any new COVID-19 cases and any new deaths (outcome variables) were regressed on the percentage of black and Hispanic residents in an NH, stratified by the percentage of blacks and Hispanics in the community in which the NH was located. A set of linear probability models with NH random effects and robust standard errors were estimated, accounting for other covariates. ResultsThe racial and ethnic composition of NHs and their communities were both associated with the likelihood of having COVID-19 cases and death in NHs. The racial and ethnic composition of the community played an independent role in the likelihood of COVID-19 cases and death in NHs, even after accounting for the COVID-19 infection rate in the community (ie, daily cases per 1000 people in the county). Moreover, the racial and ethnic composition of a community modified the relationship between NH characteristics (eg, staffing) and the likelihoods of COVID-19 cases and death. Conclusions and ImplicationsTo curb the COVID-19 outbreaks in NHs and protect vulnerable populations, efforts may be especially needed in communities with a higher concentration of racial and ethnic minorities. Efforts may also be needed to reduce structural racism and address social risk factors to improve quality of care and population health in communities of color.

Are presymptomatic SARS-CoV-2 infections in nursing home residents unrecognised symptomatic infections? Sequence and metadata from weekly testing in an extensive nursing home outbreak.

BackgroundSars-CoV-2 outbreaks resulted in a high case fatality rate in nursing homes (NH) worldwide. It is unknown to which extent presymptomatic residents and staff contribute to the spread of the virus.AimsTo assess the contribution of asymptomatic and presymptomatic residents and staff in SARS-CoV-2 transmission during a large outbreak in a Dutch NH.MethodsObservational study in a 185-bed NH with two consecutive testing strategies: testing of symptomatic cases only, followed by weekly facility-wide testing of staff and residents regardless of symptoms. Nasopharyngeal and oropharyngeal testing with RT-PCR for SARs-CoV-2, including sequencing of positive samples, was conducted with a standardised symptom assessment.Results185 residents and 244 staff participated. Sequencing identified one cluster. In the symptom-based test strategy period, 3/39 residents were presymptomatic versus 38/74 residents in the period of weekly facility-wide testing (P-value < 0.001). In total, 51/59 (91.1%) of SARS-CoV-2 positive staff was symptomatic, with no difference between both testing strategies (P-value 0.763). Loss of smell and taste, sore throat, headache or myalga was hardly reported in residents compared to staff (P-value <0.001). Median Ct-value of presymptomatic residents was 21.3, which did not differ from symptomatic (20.8) or asymptomatic (20.5) residents (P-value 0.624).ConclusionsSymptoms in residents and staff are insufficiently recognised, reported or attributed to a possible SARS-CoV-2 infection. However, residents without (recognised) symptoms showed the same potential for viral shedding as residents with symptoms. Weekly testing was an effective strategy for early identification of SARS-Cov-2 cases, resulting in fast mitigation of the outbreak.

Performance Evaluation of Serial SARS-CoV-2 Rapid Antigen Testing During a Nursing Home Outbreak

To address high COVID-19 burden in U.S. nursing homes, rapid SARS-CoV-2 antigen tests have been widely distributed in those facilities. However, performance data are lacking, especially in asymptomatic people. To evaluate the performance of SARS-CoV-2 antigen testing when used for facility-wide testing during a nursing home outbreak. A prospective evaluation involving 3 facility-wide rounds of testing where paired respiratory specimens were collected to evaluate the performance of the BinaxNOW antigen test compared with virus culture and real-time reverse transcription polymerase chain reaction (RT-PCR). Early and late infection were defined using changes in RT-PCR cycle threshold values and prior test results. A nursing home with an ongoing SARS-CoV-2 outbreak. 532 paired specimens collected from 234 available residents and staff. Percentage of positive agreement (PPA) and percentage of negative agreement (PNA) for BinaxNOW compared with RT-PCR and virus culture. BinaxNOW PPA with virus culture, used for detection of replication-competent virus, was 95%. However, the overall PPA of antigen testing with RT-PCR was 69%, and PNA was 98%. When only the first positive test result was analyzed for each participant, PPA of antigen testing with RT-PCR was 82% among 45 symptomatic people and 52% among 343 asymptomatic people. Compared with RT-PCR and virus culture, the BinaxNOW test performed well in early infection (86% and 95%, respectively) and poorly in late infection (51% and no recovered virus, respectively). Accurate symptom ascertainment was challenging in nursing home residents; test performance may not be representative of testing done by nonlaboratory staff. Despite lower positive agreement compared with RT-PCR, antigen test positivity had higher agreement with shedding of replication-competent virus. These results suggest that antigen testing could be a useful tool to rapidly identify contagious people at risk for transmitting SARS-CoV-2 during nascent outbreaks and help reduce COVID-19 burden in nursing homes. None.

The impact of social and physical distancing measures on COVID-19 activity in England: findings from a multi-tiered surveillance system.

BackgroundA multi-tiered surveillance system based on influenza surveillance was adopted in the United Kingdom in the early stages of the coronavirus disease (COVID-19) epidemic to monitor different stages of the disease. Mandatory social and physical distancing measures (SPDM) were introduced on 23 March 2020 to attempt to limit transmission.AimTo describe the impact of SPDM on COVID-19 activity as detected through the different surveillance systems.MethodsData from national population surveys, web-based indicators, syndromic surveillance, sentinel swabbing, respiratory outbreaks, secondary care admissions and mortality indicators from the start of the epidemic to week 18 2020 were used to identify the timing of peaks in surveillance indicators relative to the introduction of SPDM. This timing was compared with median time from symptom onset to different stages of illness and levels of care or interactions with healthcare services.ResultsThe impact of SPDM was detected within 1 week through population surveys, web search indicators and sentinel swabbing reported by onset date. There were detectable impacts on syndromic surveillance indicators for difficulty breathing, influenza-like illness and COVID-19 coding at 2, 7 and 12 days respectively, hospitalisations and critical care admissions (both 12 days), laboratory positivity (14 days), deaths (17 days) and nursing home outbreaks (4 weeks).ConclusionThe impact of SPDM on COVID-19 activity was detectable within 1 week through community surveillance indicators, highlighting their importance in early detection of changes in activity. Community swabbing surveillance may be increasingly important as a specific indicator, should circulation of seasonal respiratory viruses increase.

Case Report: Managing a COVID-19 Nursing Home Outbreak A Physician’s Perspective

I am the medical director and sole physician at a 35-bed nursing home in Western Galilee in Israel. At the end of December 2020, the nursing home experienced a COVID outbreak in which nineteen residents were infected. Four of them were symptomatic, and two died. Ten staff members, including our administrator, likewise caught the disease, and five of them were symptomatic. All recovered. The first part of this paper will examine why, despite all our precautions, the outbreak occurred when it did, and why it spread extensively within the home. The second part will describe how the nursing home functioned after the outbreak, until its residents recovered.

A COVID-19 Nursing Home Cluster Linked to a Household Transmission: An Epidemiological, Clinical and Phylogenetic Investigation

Background: Residents in nursing homes are at risk of high morbidity and mortality due to coronavirus disease 2019 (COVID-19). We report the first nursing home COVID-19 outbreak linked to a nursing staff’s household transmission through clinical, epidemiological, laboratory and phylogenetic investigations.Methods: Serial point prevalence testing was conducted among the residents and staff following identification of the index case (a symptomatic resident) with SARS-CoV-2 infection. Active contact tracing, screening of close contacts, whole genome sequencing and phylogenetic analysis were conducted to identify the source and extent of the outbreak.Results: Among the 108 residents and 56 healthcare workers (HCW) in the nursing home, 14 (13%) residents and two (3.6%) HCW were diagnosed with COVID-19, with case fatality rate of 28.6% (4/14) among the residents. Five residents were symptomatic (35.7%) and the others were asymptomatic (64.3%) before the point prevalence survey. The genomic virus typing in this nursing home outbreak was lineage B.6 which is rare among other GISAID clades globally but common regionally. Among the family contacts of the two infected healthcare workers, only one member was infected and had recent travel history.Interpretation: Nursing staffs can be a potential source of infection in nursing home. Through prompt active case finding, and infection prevention and control measures, the outbreak can be contained. Minimising community and household contacts among nursing care staffs may reduce the risk of SARS-CoV-2 introduction into nursing home.Funding: None.Conflict of Interest: The authors declared no conflict of interest.Ethical Approval: Data were collected under the Infectious Disease Act for outbreak investigation and approved by Ministry of Health, Singapore.

Unraveling the Modes of Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) During a Nursing Home Outbreak: Looking Beyond the Church Superspreading Event.

BackgroundAn outbreak of COVID-19 in a nursing home in the Netherlands, following an on-site church service held on March 8 th, 2020, triggered an investigation to unravel sources and chain(s) of transmission.MethodsEpidemiological data were collected from registries and through a questionnaire among church attendees. Symptomatic residents and healthcare workers (HCWs) were tested for SARS-CoV-2 by RT-PCR and subjected to whole genome sequencing (WGS). Sequences from a selection of people from the same area were included as community reference.ResultsAfter the church service, 30 of 39 attendees (77%) developed symptoms; 14 were tested and were positive for COVID-19 (11 residents and 3 non-residents). In the following five weeks, 62 of 300 residents (21%) and 30 of 640 HCWs (5%) tested positive for COVID-19; 21 of 62 residents (34%) died. The outbreak was controlled through a cascade of measures. WGS of samples from residents and HCWs identified a diversity of sequence types, grouped into eight clusters. Seven resident church attendees all were infected with distinct viruses, four of which belonged to two larger clusters in the nursing home.ConclusionsAlthough initial investigation suggested the church service as source of the outbreak, detailed analysis showed a more complex picture, most consistent with widespread regional circulation of the virus in the weeks before the outbreak, and multiple introductions into the nursing home before the visitor ban. The findings underscore the importance of careful outbreak investigations to understand SARS-CoV-2 transmission to develop evidence-based mitigation measures.

Association Between CMS Quality Ratings and COVID-19 Outbreaks in Nursing Homes - West Virginia, March 17-June 11, 2020.

Nursing homes are high-risk settings for outbreaks of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1,2). During the COVID-19 pandemic, U.S. health departments worked to improve infection prevention and control (IPC) practices in nursing homes to prevent outbreaks and limit the spread of COVID-19 in affected facilities; however, limited resources have hampered health departments' ability to rapidly provide IPC support to all nursing homes within their jurisdictions. Since 2008, the Centers for Medicare & Medicaid Services (CMS) has published health inspection results and quality ratings based on their Five-Star Quality Rating System for all CMS-certified nursing homes (3); these ratings might be associated with facility-level risk factors for COVID-19 outbreaks. On April 17, 2020, West Virginia became the first state to mandate and conduct COVID-19 testing for all nursing home residents and staff members to identify and reduce transmission of SARS-CoV-2 in these settings (4). West Virginia's census of nursing home outbreaks was used to examine associations between CMS star ratings and COVID-19 outbreaks. Outbreaks, defined as two or more cases within 14 days (with at least one resident case), were identified in 14 (11%) of 123 nursing homes. Compared with 1-star-rated (lowest rated) nursing homes, the odds of a COVID-19 outbreak were 87% lower among 2- to 3-star-rated facilities (adjusted odds ratio [aOR]=0.13, 95% confidence interval [CI]=0.03-0.54) and 94% lower among 4- to 5-star-rated facilities (aOR=0.06, 95% CI=0.006-0.39). Health departments could use star ratings to help identify priority nursing homes in their jurisdictions to inform the allocation of IPC resources. Efforts to mitigate outbreaks in high-risk nursing homes are necessary to reduce overall COVID-19 mortality and associated disparities. Moreover, such efforts should incorporate activities to improve the overall quality of life and care of nursing home residents and staff members and address the social and health inequities that have been recognized as a prominent feature of the COVID-19 pandemic in the United States (5).

Using Serologic Testing to Assess the Effectiveness of Outbreak Control Efforts, Serial Polymerase Chain Reaction Testing, and Cohorting of Positive Severe Acute Respiratory Syndrome Coronavirus 2 Patients in a Skilled Nursing Facility.

We characterized serology following a nursing home outbreak where residents were serially tested by RT-PCR and positive residents were cohorted. When tested 46-76 days later, 24/26 RT-PCR-positive residents were seropositive; none of the 124 RT-PCR-negative residents had confirmed seropositivity, supporting serial SARS-CoV-2 RT-PCR testing and cohorting in nursing homes.

SWARM: A regional health system’s intervention approach to COVID-19 outbreaks in nursing and adult care homes in rural eastern North Carolina

Background: Incessant, COVID-19 outbreaks occurring in nursing and adult care homes are a serious public health concern that continues to create significant healthcare crisis management challenges. Adult care facilities often lack in-house capacity and capability to safely treat its ill residents, while hospitals are strained to balance the influx of patients, allocate scarce resources and protect healthcare workers.Objectives: This project sought to implement a regional, community engaged, intervention model to assist nursing and adult care homes in reducing or preventing outbreaks and risks associated with COVID-19 in rural eastern North Carolina (N.C.).Methods: Design/Setting: Through collaborations between Vidant Health (VH), health departments and a network of community partners, a shared intervention plan was created and implemented to monitor nursing and adult care homes for COVID-19-related outbreaks across 29 counties in rural eastern N.C. A “Strike” team or “Swarm (SWARM) approach was developed as an operationalized concept for rapidly responding to nursing and adult care home outbreaks while providing an array of services and interventions to help prevent the spread of COVID-19. Comparative analysis was conducted between the mean number of COVID-19-related cases, deaths and length of outbreak time in VH service contracted, SWARM facilities (n = 12) and all other non-service contracted, or non-SWARM facilities (n = 155) in N.C.Results: Nursing and adult care homes under service contract using our SWARM approach experienced fewer average number of COVID-19-related resident ill cases (24.4 vs 29.0), and deaths (1.2 vs. 3.9). The length of outbreak recovery time was far less among SWARM facilities than non-participating, non-SWARM facilities (17.1 vs. 25.4; p &lt; .034).Conclusions: By actively monitoring key indicators, engaging in daily communication with local partners and providing rapid response, VH’s SWARM approach provides a proactive method for preventing further spread of COVID-19 in adult care facilities and communities.