Public health investigation highlights urgent need for coronavirus testing in care homes

27 May 2020

  • 26% of residents across four nursing homes died between March and May, three times the rate in previous years
  •  High rates of coronavirus infection (40%) were detected, and 60% of those infected were asymptomatic or had atypical symptoms
  •  Specific, tailored measures are needed to manage coronavirus infection in care homes, including comprehensive and repeated testing

Dr Carol Routledge, Director of Research at Alzheimer’s Research UK, which part-funded the study through its support of the UK DRI, said:

“We urgently need to understand the way that Covid-19 is spreading in care homes so we can better protect residents, staff, and their families.

“With over two thirds of people in care homes living with dementia, it’s great to see dementia researchers joining efforts to understand the Covid-19 outbreak in these facilities. Recent studies suggest that people with dementia are at higher risk of severe Covid-19 symptoms, and this is an additional source of worry for them and their families.

“The government must be doing all it can to limit infections and prevent further Covid-19 deaths in care homes.

“While this study has collected important data relevant to an ongoing health crisis, the findings have not yet been reviewed by outside experts. This peer review, an important step in medical research, will also be vital for helping to inform government policy.”

A team of academics from the UK Dementia Research Institute (UK DRI) has worked with GPs, infectious diseases experts, a geriatric clinical outreach team and Local Authority colleagues to undertake a coronavirus outbreak investigation in four London nursing homes. The multidisciplinary team was convened by Hammersmith & Fulham Council’s Director of Public Health, after large numbers of residents at one of the homes became unwell at the end of March.

Using a robotic testing platform developed by the UK DRI team earlier in the month, 313 residents and a selection of staff were tested for the virus to assess infection rates and identify the particular challenges facing nursing homes in controlling an outbreak. A report from the investigation, authored by UK DRI researchers and published as a preprint on MedRxiv, found that comprehensive and repeated testing of both residents and staff are vital to controlling infection rates in nursing homes.

416,000 people in the UK live in care homes, where Covid-19 has led to very high levels of illness and death. The World Health Organisation has estimated that as many as half of all Covid-19 deaths in Europe are in care homes. However, little information is available to understand the details of outbreaks in the care home context.

The team, which included academics from the UK DRI’s Care Research and Technology centre based at Imperial College London and the University of Surrey, tested the residents at two time points a week apart, with systematic testing starting on 15 April. Clinical and demographic information was also collected and studied.

A sample of asymptomatic nursing home staff in a variety of roles were also tested to clarify the role that unrecognised staff infections may play in viral transmission. Test results were reported back to residents and care staff promptly to inform decisions on how to minimise further infection.

All of the nursing homes involved had experienced an outbreak of Covid-19, and together saw 103 deaths across a total population of 394 residents between 1 March and 1 May. This was three times the death rate in previous years. Around half of the deaths were attributed to Covid-19 on the death certificate, and over half of those who died had dementia.

Testing found that 40 per cent of residents were positive for coronavirus, with 60 per cent of these being asymptomatic or displaying only atypical symptoms. Four per cent of the asymptomatic staff sample tested positive, suggesting that staff are likely to be a factor in transmitting infection. Viral sequencing showed multiple distinct clusters of SARS-CoV-2 in the same nursing home.

The study found that Covid-19 often presented in an atypical way – if at all – in nursing home residents: respiratory symptoms such as a cough or shortness of breath often existed already in patients and hallmark signs such as fever were often absent. Many residents, particularly those with the highest care needs, displayed no symptoms at all in the lead up to death. This means that usual approaches to infection control that rely on the identification of symptoms, contact tracing and isolation, are ineffective.

Professor Bart de Strooper, Director of the UK Dementia Research Institute, said:
“This investigation demonstrates how systematic testing is vital to our understanding of the virus, how it is transmitted, and how it can be contained. By recognising that many people in nursing homes are becoming unwell, often with no symptoms, infection control measures can be adapted, having an immediate impact.

“The UK DRI exists to transform the lives of people with dementia, so when we saw an opportunity to deliver a rapid project to benefit vulnerable older people, we mobilised resource and technology to make sure we could get results fast.

“Our team had already created a new high-throughput coronavirus testing platform in just nine days last month and the speed of this project has been no less staggering. A little over a week after the first conversation with colleagues about introducing testing in nursing homes, every resident had been tested in four homes.”