Covid-19 Serial Killers: Unaddressed Congregate Situations Are THE Reservoirs Of Infection

NEJM |  A new approach that expands Covid-19 testing to include asymptomatic persons residing or working in skilled nursing facilities needs to be implemented now. Despite “lockdowns” in these facilities, coronavirus outbreaks continue to spread, with 1 in 10 nursing homes in the United States (>1300 skilled nursing facilities) now reporting cases, with the likelihood of thousands of deaths.⁶ Mass testing of the residents in skilled nursing facilities will allow appropriate isolation of infected residents so that they can be cared for and quarantine of exposed residents to minimize the risk of spread. Mass testing in these facilities could also allow cohorting⁷ and some resumption of group activities in a nonoutbreak setting. Routine rRT-PCR testing in addition to symptomatic screening of new residents before entry, conservative guidelines for discontinuation of isolation,⁷ and periodic retesting of long-term residents, as well as both periodic rRT-PCR screening and surgical masking of all staff, are important concomitant measures.

There are approximately 1.3 million Americans currently residing in nursing homes.⁸ Although this recommendation for mass testing in skilled nursing facilities could be initially rolled out in geographic areas with high rates of community Covid-19 transmission, an argument can be made to extend this recommendation to all U.S.-based skilled nursing facilities now because case ascertainment is uneven and incomplete and because of the devastating consequences of outbreaks. Immediately enforceable alternatives to mass testing in skilled nursing facilities are few. The public health director of Los Angeles has recommended that families remove their loved ones from nursing homes,⁹ a measure that is not feasible for many families.

Asymptomatic transmission of SARS-CoV-2 is the Achilles’ heel of Covid-19 pandemic control through the public health strategies we have currently deployed. Symptom-based screening has utility, but epidemiologic evaluations of Covid-19 outbreaks within skilled nursing facilities such as the one described by Arons et al. strongly demonstrate that our current approaches are inadequate. This recommendation for SARS-CoV-2 testing of asymptomatic persons in skilled nursing facilities should most likely be expanded to other congregate living situations, such as prisons and jails (where outbreaks in the United States, whose incarceration rate is much higher than rates in other countries, are increasing), enclosed mental health facilities, and homeless shelters, and to hospitalized inpatients. Current U.S. testing capability must increase immediately for this strategy to be implemented.