May 1st, 2020

Podcast 265: COVID-19 in skilled nursing facilities

(7 votes, average: 4.14 out of 5)

We (Dr. Danielle Bowen Scheurer and Joe Elia) talk with Dr. John Jernigan of the CDC COVID-19 Investigation Team, which recently published its findings on the spread of COVID-19 in a Seattle-area skilled nursing facility.

Most intriguingly, over half the patients who tested positive were asymptomatic at the time of their first testing, and a few hadn’t developed any symptoms a week after their positive tests.

The results are instructive to those working in facilities such as this, whose patients are vulnerable to bad outcomes.

Running time: 17 minutes

Links:

New England Journal of Medicine report

MMWR report

Links to other interviews in this series:

  1. Dr. Anthony Fauci
  2. Dr. Susan Sadoughi
  3. Dr. Matthew Young
  4. Dr. Julian Flores
  5. Dr. Kristi Koenig
  6. Dr. Renee Salas
  7. Drs. Andre Sofair and William Chavey
  8. Dr. Comilla Sasson

Transcript 

TRANSCRIPT

Joe Elia:__________You’re listening to Clinical Conversations. I’m Joe Elia. I’m joined this time by Dr. Danielle Bowen Scheurer, a colleague from earlier podcasts. Dr. Scheurer is a hospitalist and professor of medicine at the Medical University of South Carolina where she serves as chief of quality, safety, experience, and population health. That’s kind of a full plate, Danielle. Welcome back.

Dr. Scheurer:__________Thanks.

Joe Elia:__________We’re talking about COVID-19 again this week. It’s the disease whose effects you can see just by looking out the window: People walking in the streets with masks now seem unremarkable. And speaking of streets, there are hardly any cars out there.

What you can’t easily see, however, is who’s infected and who isn’t, and that’s the point of our interview with Dr. John Jernigan of the Centers for Disease Control and Prevention. He and his team have studied an early focus of the pandemic in the US — a skilled nursing facility in King County of Washington State, which neighbors Snohomish County where another such facility had just recorded the country’s apparent first outbreak. Their recent reports in MMWR and the New England Journal of Medicine show how difficult this disease is to screen for.

Dr. Jernigan is an epidemiologist with the CDC COVID-19 Investigation Team, and he also has a teaching appointment at Emory University School of Medicine, both in Atlanta.

Welcome to Clinical Conversations, Dr. Jernigan.

Dr. Jernigan:__________Thank you so much. Pleasure to be with you today.

Dr. Scheurer:__________Hi, Dr. Jernigan. It’s Danielle Scheurer. I’ve read your study with a lot of enthusiasm. It’s very interesting and impactful, so we just wanted to kind of walk through it and ask a couple of questions. So in summary, your team tested almost 90 residents in this facility with really good technique and of those who tested positive, over half had no symptoms at the time of testing and even a few hadn’t developed symptoms even a week after the testing. So as this was all unfolding and you’re reflecting on what you found, how surprised were you and your team with these results?

Dr. Jernigan:__________Thank you, Danielle, for that question. We were pretty surprised. As a little background, I was part of the CDC team that was deployed to Seattle when the outbreaks were first recognized there, when the first cases in Seattle were being recognized. I was in charge of a team that was over infection control for both acute care and long-term care, but it became apparent pretty quickly that long-term care was the place where we were seeing large and rapid outbreaks. So we began to support the investigation of some of those outbreaks as a way of helping prevent transmission.

One of the early observations: we sort of learned that some of the cases we were finding didn’t seem to have a lot in the way of symptoms. This was a very important issue because most of our infection control strategies rely on symptoms to identify residents or patients who might have infection and where to guide your testing and where to guide your isolation and prevention strategy. So we said we need to find out how widespread this is.

So we started doing these point-prevalence surveys. As you point out, we were quite surprised to learn that over half of the infections that we identified in these populations were asymptomatic at the time of the testing. This is a big problem in infection control. How can you separate those that are infected from those that are not if you can’t really tell based upon your symptoms? So we were quite surprised, to answer your question.

Joe Elia:__________The takeaway from your studies, in my mind, seems to be if I can caricature it: “Listen, clinicians, this disease doesn’t announce itself. You have to assume everyone is positive.” Is that fair?

Dr. Jernigan:__________In this particular population in this particular setting, I think that once you identify a case in your facility, yes, you need to assume that every resident in that facility may be infected. If that’s the case then you have sort of two choices going forward in terms of any transmission. One, you treat everybody in the facility the same way with regard to use of, for example, personal protective equipment, which can be a burdensome thing to do. It requires a lot of personal protective equipment, which is an issue.

As you know, there have been shortages nationwide, and particularly for many long-term care facilities, they have had trouble getting enough personal protective equipment. So that’s one issue. Basically isolate everybody, treat everybody a if they’re infected. Or you test everybody so that you can tell, as you point out, who’s infected, who’s not. Separate those that are infected into a certain cohort so you can put them in the same place in the building, assign certain staff to them, focus a lot of your personal protective equipment use there. Then for residents who are not infected to another place where hopefully you can protect them a little bit better.

Dr. Scheurer:__________And a follow-up on that, in your experience, how prepared do you think most facilities are to do quick and reliable widescale testing?

Dr. Jernigan:__________So this has been a real issue. As you know, there have been testing shortages and in fact when we first made this observation that was a big problem. We felt like testing all residents — and for that matter all healthcare providers — could be very helpful but testing availability really didn’t allow that. Now even at a week since that time testing availability has improved substantially, and so some skilled nursing facilities find themselves in states and other jurisdictions who have testing capacity that will allow taking this approach. Others are still struggling to do that. We hope that testing capacity will continue to improve such that if it turns out that this strategy does prove to be effective that more and more facilities will be able to utilize this strategy.

Dr. Scheurer:__________Even the ability to do the actual test aside, the collection methods are pretty cumbersome as well, right?

Dr. Jernigan:__________It is pretty labor intensive to collect the specimen. Even that is potentially changing a little bit with changes and recommendations of how tests can be performed, whether or not you have to do a nasopharyngeal swab, which is originally that’s what the recommendation was. So it takes a certain skillset and level of training to acquire those. CDC has just amended its recommendation such that swabs to the anterior nares are probably acceptable, which simplifies things a little bit in terms of being able to collect the specimen, but still you have to have the swabs, and you have to have the viral transport media, and you have to have a laboratory who can process these specimens and process them quickly. So there have been challenges in all of those elements. It can be a pretty difficult thing to do. I will say that I believe that capacity is improving pretty rapidly.

Dr. Scheurer:__________Which is great and definitely welcome news for the vulnerable population. Can you expound also a little bit about how you guys define symptoms and how that definition is changing and evolving?

Dr. Jernigan:__________Right. So when we started out this investigation not much was really known about this disease. Originally, the symptoms that were used to guide testing and to identify people who had been exposed and who you thought might be infected were essentially fever, cough, and shortness of breath. So we used essentially that for our definition of kind of typical symptoms.

But part of this investigation (and many others) is showing that there are lots of other less typical symptoms that are a manifestation of this disease. So on the one hand, you have people with sort of kind of the classic, cough, fever, shortness of breath. On the other end of the spectrum you have people who have no symptoms and then in between you have lots of other things.

We think especially in the early phases the illness can present quite subtly with maybe just a headache or myalgias or a little bit of chills, sometimes a little nausea, sore throat. What we’ve learned since then, which wasn’t appreciated when we started the study, the sudden loss of smell or sense of taste may be associated with this. So the sort of menu of symptoms that can be a manifestation of early parts of this illness has expanded pretty substantially.

Dr. Scheurer:__________Do you think there is a logical role for serologic testing in long-term care facilities right now or in the future.

Dr. Jernigan:__________So I’m glad you asked that question. I think there is potential great promise from use of serology to help guide these sorts of strategies, but I don’t think we are there yet. There are a number of different platforms out there. Some perform better than others. There’s also the question of what the presence of antibodies means. Are they neutralizing antibodies or not? Does the presence of these antibodies confer a protection against reinfection? What are the correlates of protection? I think these are all ongoing questions that we need to answer. I think there are many, many people out there working very hard to answer these questions and we hope they will have answers in the relatively near-term. I think at this moment today, our stance — and I guess this is my personal opinion — is that I don’t think we’re ready to use the results of serologic testing to make clinical or infection control or public health decisions. We might be there very soon, but I don’t think we’re there today.

Joe Elia:__________The editorial in the New England Journal of Medicine argues that we must be especially cautious until we can test widely and reliably. Did your team have a reaction to the editorial? Did they share their…

Dr. Jernigan:__________No. We have no interaction with the authors. We saw it when it was published or shortly before. If your question is more broadly about how to relax social distancing measures, et cetera and so forth and the relationship between available testing and that, I’m really not the person to focus on that. My focus is specifically on infection control and long-term care facilities and the relationship of testing and testing availability to that with regard to controlling transmission in long-term care facilities, which, by the way is a really high priority thing, as I think I might have mentioned already.

When SARS COV2 is introduced into these settings it can spread very rapidly and very widely and it can cause great morbidity and mortality in this very vulnerable population. But in addition, more than just protecting these residents and these patients it’s important for the regional healthcare system. What we observed in Seattle is that a large outbreak in even a single skilled nursing facility puts great strain on local hospitals in terms of their ICU bed capacity, et cetera and so forth. What’s more is that when a patient in a long-term care facility gets admitted to a hospital with COVID-19 sometimes it’s difficult to get them discharged, because long-term care facilities may be reticent to accept someone who is positive and may still be shedding virus, et cetera. So not just to protect those residents but it’s also to protect the local healthcare system.

So I think preventing transmission here in these settings should be a high priority. So back to the question of the relationship of that priority and testing. We think that our results suggest that testing can be an important tool to help control spread in these settings, and we agree with the writers of the editorial that the sooner that we can make improved testing capacity to the point that we can use it in these settings in that way the better.

Joe Elia:__________Thank you. I just wanted to ask a final question. What were your team’s reactions to the findings that you made? Were they astonished to see this?

Dr. Jernigan:__________I would say we were very surprised. The potential implications of the findings were immediately obvious to us. It seemed clear that a test-based strategy may be a very important approach and yet we were concerned that testing capacity at that point in time was not sufficient to allow that. We’ve been working since that time to partner with facilities and public health jurisdictions that have been increasing their test capacity and to partner with them in implementing this strategy and learning along with them about the best ways to actually go about implementing it.

For example, if you go out and you test everybody once, is that sufficient? There’s some early clues that that may not be sufficient, because if you test anybody on a given day and they’re negative it could be that they’re actually infected but they’re still in their incubation period and not shedding virus — at least to the extent that can be picked up by the test. That suggests that you may need to go back and do a repeat test and make sure that you haven’t missed any of those patients who are incubating. The findings from our study sort of hinted early on that that in fact was the case. So we were working with these partners to implement the strategy and learn lessons as we go with regard to the best way to implement it, the most efficient way to implement it, what the barriers to implementation are, what the facilitators to successful implementation are, and hopefully we can parlay all that information into better and refined guidance from CDC on how to proceed with this prevention strategy.

Joe Elia:__________My last question was going to be, what do you think your team would like to see as a result of your work? I think you’ve just answered that question.

Dr. Jernigan:__________Yes. I think that’s right. We would like to see testing availability that allows long-term care facilities the option of using a test-based infection control strategy. They have the resources they need to not only do the testing but it’s important to emphasize that they need to have the resources to take the appropriate action based upon the test and be planning about how to cohort patients or cohort residents, and make sure they have appropriate PPE, all these sorts of things. All the testing in the world…you can do all the testing in the world but it won’t help you if you can’t take the appropriate action that should be taken based upon the results.

Joe Elia:__________We want to thank you for your time with us today, Dr. Jernigan.

Dr. Scheurer:__________Thank you so much.

Dr. Jernigan:__________Thank you.

Joe Elia:__________That was our 265th conversation. This and all the others are available free at Podcasts.JWatch.org. We come to you from the NEJM Group. The executive producer is Kristin Kelly. I’m Joe Elia.

Dr. Scheurer:__________And I’m Danielle Scheurer.

Joe Elia:__________Thanks for listening.

2 Responses to “Podcast 265: COVID-19 in skilled nursing facilities”

  1. Guillermo de Larrechea says:

    Hola. Soy Director médico de una Residencia de larga estadía en la ciudad de Rosario, Argentina. Su interesante trabajo está generando grandes discusiones entre las autoridades sanitarias locales. Se está evaluando realizar pruebas al personal y a los residentes. Cuál sería la más aconsejable en relación costo/beneficio en este caso?. Muchas gracias. Saludos cordiales.

    {Google translation of the above: Hi. I am the Medical Director of a long-term residence in the city of Rosario, Argentina. His interesting work is generating great discussions among local health authorities. Testing staff and residents is being evaluated. What would be the most advisable in relation to cost / benefit in this case? Thank you. Best regards.]

  2. Habib J Komari says:

    Excellent venue & discussion .

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