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Asymptomatic and Presymptomatic Severe Acute Respiratory Syndrome Coronavirus 2 Infection Rates in a Multistate Sample of Skilled Nursing Facilities

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To identify the key insights or developments described in this article
1 Credit CME

Asymptomatic transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be a major contributing factor in skilled nursing facility (SNF) outbreaks. However, limited knowledge exists regarding the prevalence of asymptomatic and presymptomatic infection in this setting. Although an estimated 40% to 45% of SARS-CoV-2 infections in the general population are asymptomatic at time of testing,1 a small number of US and international reports have documented higher asymptomatic rates in SNFs.25 We examined asymptomatic and presymptomatic infection rates in a large multistate sample of US SNFs, and examined variation in case counts by SARS-CoV-2 prevalence in the counties where SNFs are located.

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Article Information

Accepted for Publication: August 24, 2020.

Corresponding Author: Elizabeth M. White, PhD, APRN, Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 S Main St, Box G-S121-6, Providence, RI 02912 (elizabeth_white@brown.edu).

Published Online: October 19, 2020. doi:10.1001/jamainternmed.2020.5664

Author Contributions: Dr White had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: White, Santostefano, Feifer, Gravenstein, Mor.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: White, Kosar, Gravenstein.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: White, Santostefano, Feifer, Kosar.

Obtained funding: Mor.

Administrative, technical, or material support: White, Santostefano, Feifer, Blackman, Gravenstein.

Supervision: Feifer, Gravenstein, Mor.

Conflict of Interest Disclosures: Dr White reported grants from National Institute on Aging during the conduct of the study and personal fees from PACE Organization of Rhode Island outside the submitted work. Mr Kosar reported grants from National Institute on Aging during the conduct of the study. Dr Gravenstein reported grants from the National Institutes of Health during the conduct of the study. Dr Mor reported personal fees from naviHealth outside the submitted work. No other disclosures were reported.

Funding/Support: This research was supported by the National Institute on Aging (3P01AG027296-11S1, PI: Dr Mor).

Role of the Funder/Sponsor: The National Institute on Aging had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Richard Castor, Cliff Boyd, Joe Montgomery, and Denine Hastings of Genesis HealthCare; and Jeffrey Hiris from Brown University for their extensive data management support. They were not compensated.

References
1.
Oran  DP , Topol  EJ .  Prevalence of asymptomatic SARS-CoV-2 infection: a narrative review.   Ann Intern Med. 2020; [Epub ahead of print]. doi:10.7326/M20-3012PubMedGoogle Scholar
2.
Dora  AV , Winnett  A , Jatt  LP ,  et al.  Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans—Los Angeles, California, 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(21):651-655. doi:10.15585/mmwr.mm6921e1PubMedGoogle ScholarCrossref
3.
Comas-Herrera  A , Zalakaín  J , Litwin  C , Hsu  AT , Lane  N , Fernández  JL . Mortality associated with COVID-19 outbreaks in care homes: early international evidence. 2020; https://ltccovid.org/wp-content/uploads/2020/05/Mortality-associated-with-COVID-3-May-final-5.pdf. Accessed May 7, 2020.
4.
Arons  MM , Hatfield  KM , Reddy  SC ,  et al; Public Health–Seattle and King County and CDC COVID-19 Investigation Team.  Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility.   N Engl J Med. 2020;382(22):2081-2090. doi:10.1056/NEJMoa2008457PubMedGoogle ScholarCrossref
5.
Bigelow  BF , Tang  O , Barshick  B ,  et al.  Outcomes of universal COVID-19 testing following detection of incident cases in 11 long-term care facilities.   JAMA Intern Med. 2020. doi:10.1001/jamainternmed.2020.3738PubMedGoogle Scholar
6.
White  EM , Kosar  CM , Feifer  RA ,  et al  Variation in SARS-CoV-2 prevalence in US skilled nursing facilities.   JAGS. Published online July 16, 2020. doi:10.1111/jgs.16752Google Scholar
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