The New England Journal of Medicine has released its analysis of COVID-19 outbreaks that have materialized in numerous Washington long-term care facilities, beginning with the first facility referenced as “Facility A”. The report begins with numbers:

On February 28, 2020, four cases of Covid-19 were confirmed among residents of King County; 1 person had presumed travel-related exposure, and 3 were identified by testing hospitalized patients who had severe respiratory illness (e.g., pneumonia) and who had tested negative for influenza and other respiratory pathogens. One of these was the index patient from Facility A; one was a Facility A staff member. When the index case was identified on February 28, at least 45 residents and staff dispersed across Facility A had symptoms of respiratory illness; PHSKC was notified of this increase by the facility on February 27. As of March 18, a total of 167 persons with Covid-19 that was epidemiologically linked to Facility A had been identified (Fig. 1); 144 were residents of King County and 23 were residents of Snohomish County. Cases of Covid-19 occurred among facility residents (101 persons), health care personnel (50), and visitors (16) (Table 1). Among facility residents, 118 were tested; 101 results were positive and 17 negative. Most affected persons had respiratory illness consistent with Covid-19; however, chart review of facility residents found that in 7 cases no symptoms had been documented.

Clinical presentation ranged from mild (no hospitalization) to severe, including 35 deaths by March 18. Reported dates of symptom onset ranged from February 15 to March 13. The median age of the patients was 83 years (range, 51 to 100) among facility residents, 62.5 years (range, 52 to 88) among visitors, and 43.5 years (range, 21 to 79) among facility personnel; 112 patients (67.1%) were women (Table 1). The hospitalization rates for residents, visitors, and staff were 54.5%, 50.0%, and 6.0%, respectively. As of March 18, the preliminary case fatality rate was 33.7% for residents and 6.2% for visitors; no staff members had died. Most (94.1% of 101) facility residents had chronic underlying health conditions, with hypertension (67.3%), cardiac disease (60.4%), renal disease (40.6%), diabetes mellitus (31.7%), pulmonary disease (31.7%), and obesity (30.7%) being most common. Of the coexisting conditions evaluated, hypertension was the only underlying condition present in 7 facility residents with Covid-19.

After summarizing the trajectory of the virus from the first cases China reported on December 31, 2019 to the first patient who resided at Facility A reported on February 28, 2020, the report then traces the spread of the virus to other long-term facilities in Washington after the first cases were reported at Facility A:

Of the first 8 facilities affected after Facility A, at least 3 had clear epidemiologic links to Facility A. Two of the facilities with definitive epidemiologic links had staff working both at that facility and at Facility A; the third facility had received two patient transfers from Facility A. Information received from surveys of long-term care facilities and on-site visits identified factors that were likely to have contributed to the vulnerability of these facilities, including staff who had worked while symptomatic; staff who worked in more than one facility; inadequate familiarity with and adherence to PPE recommendations; challenges to implementing proper infection control practices, including inadequate supplies of PPE and other items (e.g., alcohol-based hand sanitizer); delayed recognition of cases because of a low index of suspicion; limited availability of testing; and difficulty identifying persons with Covid-19 on the basis of signs and symptoms alone. Examples of specific PPE challenges included an initial lack of available eye protection, frequent changes in PPE types because supply chains were disrupted and PPE was being obtained through various donations or suppliers, and a need for a designated staff member to observe PPE use to ensure that staff were consistent with safe PPE handling (e.g., not touching or adjusting face protection, primarily face masks, during extended use)….

…The vulnerability of long-term care facilities to respiratory disease outbreaks, including influenza and other commonly circulating human coronaviruses such as the common cold, is well recognized. As this report shows, the spread of Covid-19 reflected the same vulnerability in at least one long-term care facility. In total, 167 confirmed cases of Covid-19 had been identified among residents, personnel, and visitors as of March 18, and 30 skilled nursing and assisted living facilities in King County had identified at least one confirmed case of Covid-19. Staff working in multiple facilities while ill and transfers of patients from one facility to another potentially introduced Covid-19 into some of these facilities. The transmission within Facility A and to other facilities in the area posed a serious threat to the medically vulnerable population residing within long-term care facilities and strained the local acute care hospitals….

…Publicly available information on staffing and quality measures shows no indication that baseline practices at Facility A placed residents at greater risk than residents at other similar facilities….

…The experience described here indicates that outbreaks of Covid-19 in long-term care facilities can have a considerable impact on vulnerable older adults and local health care systems. The findings also suggest that once Covid-19 has been introduced into a long-term care facility, it has the potential to spread rapidly and widely. This can cause serious adverse outcomes among facility residents and staff, which underscores the importance of proactive steps to identify and exclude potentially infected staff and visitors, early recognition of potentially infected patients, and implementation of appropriate infection prevention and control measures. Lessons learned from this initial cluster can provide valuable guidance for long-term care facilities in other parts of the United States.

For more information, you can read the full report here: