By Dr Sarah House and Eric Fewster

In early April 2020, we became aware of the increasing problems that care homes were facing with increasing COVID infections and deaths across the UK. We started to look into the UK Government and particularly the Public Health England guidance, that was available to the care homes on how to prevent and control infections. We quickly became concerned because we realised that the guidance was not clear, it seemed to miss critical components, was not particularly accessible and in some cases not practical enough. 

With inputs from a range of experts, who collectively have a mix of experience from medicine/health, care homes, water/sanitation/hygiene, outbreak infection prevention & control (specifically from Ebola, SARS, cholera and Lassa Haemorrhagic Fever outbreaks) and emergency response, a simple, practical, all-in-one place guidance document was prepared. This is as a practical tool for use by care home management.

Care Homes Strategy for Infection Prevention & Control of Covid-19 Based on Clear Delineation of Risk Zones

(see https://ltccovid.org/2020/05/01/resource-care-homes-strategy-for-infection-prevention-control-of-covid-19-based-on-clear-delineation-of-risk-zones-update/.)

This care homes strategy is based around some fundamental aspects of what we believe, through our outbreak experience, needs to happen to make care homes safer environments during the COVID-19 outbreak and to save lives of both residents and staff:

1. Understanding that asymptomatic / pre-symptomatic transmission is a major contributor to the spread of Covid-19 in care homes, where the source of this transmission comes from outside (mostly via staff, but also residents being taken in from hospitals and visitors).
2. Clear delineation of zones of risk for the entire building, differentiating between contaminated (red), may be contaminated (amber) and clean (green), which is reinforced through staff allocation & rotation – facilitating nudges for IPC actions.
3. Hand disinfection for all points between risk zones (even where gloves remain on).

The more we have communicated with care home networks, care home management, residential centres and a Health Trusts directly, we have realised:

1. That many are finding the guidance provided so far by the UK Government and PHE/NHS, confusing, not always clear and hard to access.
2. That where our strategy has been used, that they have found the zoning concept and the in-one-place, practical guidance very useful – as one respondent with widespread responsibility for IPC across a Hospital Trust said – the zoning strategy is “spot on”.

So, we decided to look in more depth at what guidance was available to them, to understand why it is so unclear and to map its strengths and weaknesses, so we can continue to advocate for the UK Government, Public Health England, and the NHS Trusts to urgently improve their guidance. The mapping can be found here: https://www.bushproof.com/wp-content/uploads/2020/05/Mapping-Govt-IPC-strategies-for-COVID-19-in-care-homes.pdf

Mapping of UK Government guidance on IPC – what we found:

What we have found is:

1. Within the various government guidance and strategy documents, there are a range of individual useful strategic actions being proposed that will contribute to infection prevention and control in care homes and other residential settings.
2. But they are scattered through several documents and hence hard to access, there are various gaps as well as inconsistencies and in a few cases inaccuracies in facts (see below).
3. There seems to be no overall coherence to the guidance to care homes and residential settings and they do not provide an overarching concept to help care home management in thinking about the routes for transmission and how to block them – An effort was made by the PHE to prepare the document “COVID-19: How to work safely in care homes” (17 April updated on the 27 April) – which is helpful, simple and practical for PPE, but it only skimps over other aspects of IPC. 
4. The government webpage for guidance for homeless shelters has still not had any guidance uploaded since the page was set up on the 25 March 2020 – https://www.gov.uk/government/publications/covid-19-guidance-on-services-for-people-experiencing-rough-sleeping/covid-19-guidance-for-hostel-or-day-centre-providers-of-services-for-people-experiencing-rough-sleeping

For example, the main IPC document of the Public Health England, NHS, Public Health Scotland, Public Health Agency, Public Health Wales, Health Protection Scotland – “COVID-19: infection prevention and control (IPC) guidance” (24 April, updated 27 April), has statements that are factually wrong. In the Section 3.1 on ‘Routes of Transmission’, pg 11:  

“Infection control advice is based on the reasonable assumption that the transmission characteristics of COVID-19 are similar to those of the 2003 SARS-CoV outbreak”;

and

“The incubation period is from 1 to 14 days (median 5 days). Assessment of the clinical and epidemiological characteristics of COVID-19 cases suggests that, similar to SARS, most patients will not be infectious until the onset of symptoms. In most cases, individuals are usually considered infectious while they have symptoms; how infectious individuals are, depends on the severity of their symptoms and stage of their illness”.

This is factually incorrect and should have been known by this point, as several studies had come out of other countries, from care homes and residential contexts, that had identified the issue of pre- and asymptomatic transmission – for example: USA, Singapore, Germany, Canada etc. See the table at the end for the references. 

Basing their guidance and procedures on this factually incorrect principle, risks giving people a false sense of security and risks lives.

The biggest gaps within the UK Government / PHE / NHS and partner’s guidance:

1. The lack of recognition of the critical role that asymptomatic and pre-symptomatic transmission has in the spread of COVID-19 in care homes and the resultant deaths – and the need to consider this as core to the IPC strategy.
2. A lack of a coherent zoning approach to the IPC of this outbreak – SARS-CoV-2 – needs more thought and actions in IPC than just PPE, testing and standard hospital and health care-based IPC procedures. Zoning worked well for SARS-CoV-1, and therefore with this virus (SARS-CoV-2) which is more transmissible, these principles should be even more applicable now[1].
3. Gaps in emphasis on understanding the transmission routes throughout the care homes and emphasis on gloves-on hand hygiene as well as when gloves are off – just wearing PPE does not prevent you transmitting the virus.
4. The focus on suspected cases being when someone has the standard symptoms of a new cough and high temperature – neither of which are the most common symptoms for older people, who may have neither.
5. A lack of a one-stop document with clear practical guidance for care homes and other residential settings to be able to implement on the ground. 

What urgently needs to happen:

The UK Government, PHE, NHS Trusts and other actors who have responsibilities for providing guidance on IPC in care homes and other residential settings, including hostels or hotel accommodation for people who are homeless, to urgently update their guidance in the following ways:

1. A simple, one-document, step-by-step, practical guide on what needs to be done.
2. To have this document formally supersede the previous array of other documents, so as to not confuse care home and other managers with mixed messages.
3. The guidance should be built on an overarching concept, such as the Zoning concept (known in academic circles as Traffic Control Bundling) that makes the care home and other managers, think about the homes as a whole, and to work out the key routes for transmission and how to block them.
4. The guidance must be based on the understanding of the role of pre- and asymptomatic transmission in addition to symptomatic transmission and to work out barriers to prevent it.
5. To make sure that the recently planned advice – that the government has said the NHS Trusts will be providing to the care homes – and the training for the people who give that advice – is based on clear and structured and practical guidance as noted above.  

Evidence on pre-symptomatic and asymptomatic transmission

Research	Main lessons to take away
Wei, W.E. et al (2020) Presymptomatic Transmission of SARS-CoV-2 – Singapore, January 23 – March 16, 2020. Morbidity and Mortality Weekly Report, CDC. Available here: https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6914e1-H.pdf	The evidence of pre-symptomatic transmission in Singapore supports the likelihood that viral shedding can occur in the absence of symptoms and before symptom onset.
Kimball et al (2020) Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility – King County, Washington, March 2020. Morbidity and Mortality Weekly Report, CDC. Available here: https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6913e1-H.pdf	Experience from a skilled nursing facility found that 30% of those residents that were tested were positive, but of these over half (57%) did not have symptoms at the time of the test (yet 7 days after testing, 10 out of the 13 had developed symptoms). This study suggests that symptom-based screening in long-term care facilities could fail to identify approximately half of residents with COVID-19.
Arons, M.M. et al (2020) Presymtomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. The New England Journal of Medicine. Available here: https://www.nejm.org/doi/pdf/10.1056/NEJMoa2008457?articleTools=true	Experience from a skilled nursing facility found 63% of residents tested positive, and over half of those (57%) did not have symptoms at the time of the test. Infection control strategies solely focusing on symptomatic residents were not enough to prevent introduction of the virus into the facility.
Gandhi, M.P.H. et al (2020) Asymptomatic transmission, the Achilles’ Heel of Current Strategies to Control Covid-19. The New England Journal of Medicine. Available here: https://www.nejm.org/doi/pdf/10.1056/NEJMe2009758?articleTools=true	Viral loads with SARS-CoV-1 (virus from 2003) were associated with symptom onset, peak a median of 5 days later than viral loads with SARS-CoV-2 (virus from 2020). This is what made symptom-based detection of infection more effective in the case of SARS CoV-1. With the current virus (SARS-CoV-2), people that don’t have symptoms can carry the virus and be infective – e.g. 17 of 24 specimens (71%) from pre-symptomatic persons had viable virus by culture 1 to 6 days before the development of symptoms.
Baggett, T. P et al (2020) Prevalence of SARS-CoV-2 Infection in Residents of a Large Homeless Shelter in Boston,JAMA. Published online April 27, 2020. doi:10.1001/jama.2020.6887, https://jamanetwork.com/journals/jama/fullarticle/2765378	A total of 147 participants (36.0%) had PCR test results positive for SARS-CoV-2. Among individuals with PCR test results positive for SARS-CoV-2 – cough (7.5%), shortness of breath (1.4%), and fever (0.7%) were all uncommon, and 87.8% were asymptomatic. The majority of individuals with newly identified infections had no symptoms and no fever at the time of diagnosis, suggesting that symptom screening in homeless shelters2 may not adequately capture the extent of disease transmission in this high-risk setting. These results support PCR testing of all asymptomatic shelter residents if a symptomatic individual with COVID-19 is identified in the same shelter.

---

[1] Yen, M.Y. et al (2006) Using an integrated infection control strategy during outbreak control to minimize nosocomial infection of severe acute respiratory syndrome among healthcare workers. Journal of Hospital Infection, Volume 62, Issue 2, February 2006, Pages 195-199. https://www.sciencedirect.com/science/article/pii/S0195670105001258; Yen, M.Y. et al (2011) Taiwan’s traffic control bundle and the elimination of nosocomial severe acute respiratory syndrome among healthcare workers. Journal of Hospital Infection, Volume 77, Issue 4, April 2011, Pages 332-337. https://www.sciencedirect.com/science/article/pii/S019567011000530X; Yen, M.Y. et al (2020) Recommendations for protecting against and mitigating the COVID-19 pandemic in long-term care facilities. Journal of Microbiology, Immunology and Infection. https://www.sciencedirect.com/science/article/pii/S1684118220300979?via%3Dihub;