Table 1 shows the resident characteristics of the 99 interviewed residents, as well as the test coverage per ward and the results.
Table 1: Resident characteristics by ward level (1-5) from the LTCF (n=99).
|
Ward 1
|
Ward 2
|
Ward 3
|
Ward 4
|
Ward 5
|
Total
|
|
n/Na
|
%
|
n/Na
|
%
|
n/Na
|
%
|
n/Na
|
%
|
n/Na
|
%
|
n/Na
|
%
|
Sex
|
|
|
|
|
|
|
|
|
|
|
|
|
Female
|
13/18
|
72
|
12/19
|
63
|
15/18
|
83
|
14/17
|
82
|
18/27
|
66
|
72/99
|
73
|
Age in years (mean, standard deviation)
|
83, 8.8
|
|
84, 7.5
|
|
84, 8.5
|
|
90, 4.1
|
|
87, 4.7b
|
|
86, 7.1
|
|
Tested
|
|
|
|
|
|
|
|
|
|
|
|
|
Yes
|
5/18
|
28
|
4/19
|
21
|
14/18
|
78
|
6/17
|
35
|
17/27
|
63
|
46/99
|
47
|
Positivec
|
1/5
|
20
|
3/4
|
75
|
7/14
|
50
|
1/6
|
17
|
7/17
|
41
|
19/46
|
41
|
Mortality
|
0/18
|
0
|
1/19
|
5
|
1/18
|
6
|
0/17
|
0
|
3/27
|
11
|
5/99
|
5
|
a) Unless stated otherwise.
b) Age was known for 25 residents only
c) Based on the number of residents who were tested.
|
The ages of the residents ranged from 64 to 97 years. Out of the 99 residents, 46 (47%) were tested for COVID-19 of whom nineteen (41%) tested positive. More tests were done on wards three and five, because COVID-19 was first detected here. Out of the twelve randomly tested asymptomatic residents, three (25%) tested positive for COVID-19.
At the moment of writing this manuscript, five (5%) residents have died. All deceased residents tested positive for COVID-19.
Symptoms
Out of the nineteen residents who tested positive for COVID-19, sixteen (84%) reported any signs and symptoms of disease. Out of these sixteen symptomatic residents, we were unable to fully evaluate the symptoms of three (19%) residents, as they were hospitalized and passed away before the interviews took place. The most common signs and symptoms in the remaining thirteen positive residents were fever (54%), subfebrile temperature (47%), and cough (39%). Other, less frequently reported symptoms, were fatigue (15%), malaise (15%), vomiting (8%), loss of appetite (8%), nausea (8%), and dizziness (8%). A heatmap of these reported symptoms within symptomatic COVID-19 positively tested residents is shown below (table 2).
Additionally, another eighteen residents reported an increase in temperature, with seven reporting fever and eleven reporting subfebrility, but tested negative for COVID-19.
Table 2. A heatmap of reported symptoms from symptomatic COVID-19 positive residents, March 2020 (n=16).
![](data:image/png;base64,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)
a. Resident was hospitalized.
b. Resident has died.
Present symptoms are depicted with a black cell. Fever is defined as a temperature of 38.0 degrees Celsius or higher, whereas subfebrile temperature is defined as a temperature below 38.0 degrees Celsius. Three residents were hospitalized before an interview could be conducted, and are depicted with grey cells. Out of the five residents who tested positive for COVID-19 and passed away, four reported any symptoms of disease.
CT values
The CT values of positively tested symptomatic residents (N=16) and asymptomatic residents (N=3) are shown in Figure 1. CT values ranged from 19 up to 35; median CT values were 33 and 29 for asymptomatic and symptomatic residents respectively. Symptomatic residents appeared to have a slightly higher load (lower CT value) compared to asymptomatic residents.
Genome sequencing
Complete genome sequencing of the SARS-CoV-2 virus from eleven residents from the LTCF in South Limburg was performed. In addition, three random samples from the regional hospital were sequenced. All accession numbers for the sequences are shown in table 3.
Table 3. Sequencing names and accession numbers, March 2020 (n=14).
Name
|
Accession number
|
Location
|
Collection date
|
Data source
|
Limburg_7
|
EPI_ISL_415464
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_13
|
EPI_ISL_461001
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_14
|
EPI_ISL_461002
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_15
|
EPI_ISL_461003
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_66
|
EPI_ISL_461051
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_67
|
EPI_ISL_461052
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_68
|
EPI_ISL_461053
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_69
|
EPI_ISL_461054
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_70
|
EPI_ISL_461055
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_71
|
EPI_ISL_461056
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_72
|
EPI_ISL_461057
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_73
|
EPI_ISL_461058
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_74
|
EPI_ISL_461059
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Limburg_75
|
EPI_ISL_461060
|
Europe / Netherlands / Limburg
|
March 2020
|
GISAID
|
Figure 2 shows the part of the phylogenetic tree in which the sequence of the LTCF residents and the hospitalized patients are located. This figure shows that the sequences from the LTCF residents in Sittard and the hospitalized patients are part of the same cluster, pointing towards potential transmission within the nursing home. The sequences also cluster with sequences found in Heinsberg. The full phylogenetic tree can be found in the supplementary (additional file 1). The accession numbers are shown in table 3.
Outbreak control measures
As of March 8th 2020, additional infection control measures were implemented by the LTCF. In collaboration with the Public Health Service South Limburg, an outbreak management team was installed. Wards three and five, the wards on which the first residents tested positive for COVID-19, were isolated, meaning residents were not allowed to leave their rooms, and visitors were banned from entering these wards. Admission of new residents was temporarily halted throughout the LTCF. All suspect residents (residents with respiratory complaints with and without fever) and confirmed COVID-19 residents, as defined by the case definition as of March 2nd [5], as well as residents with (at least) subfebrility, were put into isolation, whilst all other residents were closely monitored by taking their temperature twice during regular moments of care in the morning and the evening, and checking for new or unusual signs and symptoms of disease, including coughing, subfebrility, and shortness of breath. Additionally, all planned group activities on all wards, such as group physical exercise and eating together in the dining room, were cancelled, and residents were served meals in their own rooms.
Visitors were still allowed to enter the other wards, but the number of visitors was limited to two per day. Upon entry, each visitor was required to report any signs and symptoms of disease and previous visits to areas with a high risk of transmission, including the Heinsberg region. In addition, visitors were told to keep a distance of at least 1.5 metres from the resident when visiting. Visitors reporting signs and symptoms of disease during the two weeks prior to their visit were not allowed to visit. However, when residents tested positive for COVID-19 on these remaining wards (wards one, two, and four) as well, a total visitor ban was also introduced for these wards.
HCWs worked in set teams and wore gowns, surgical mouth masks, and gloves when they expected to get in close contact (within 1.5 meters) with COVID-19 positive residents or their surroundings. Additionally, hand hygiene among HCWs was intensified. HCWs were regularly briefed with updates on a closed online portal, by team meetings with social distancing, and by newsletters shared via internal e-mail.
Since the implementation of these infection control measures, only one additional resident tested positive for COVID-19 on the 31st of March, and no more residents have been hospitalized or have died due to complications from COVID-19. As a result, this LTCF was among the first 37 of 139 LTCFs in our region to allow visitors again.