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      Universal screening for the SARS-CoV-2 virus on hospital admission in an area with low COVID-19 prevalence

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          Abstract

          Asymptomatic persons contribute to widespread transmission of the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) and the coronavirus disease 2019 (COVID-19) pandemic. 1 Published reports from areas of high COVID-19 incidence in the United States suggest that a significant percentage of asymptomatic persons are in healthcare systems. In 2 New York City (NYC) hospitals, 13.7% of asymptomatic pregnant women admitted for delivery tested positive for SARS-CoV-2 virus. 2 Similarly, the nursing facility in Washington state with the earliest death from COVID-19 infection and the first healthcare worker infected in the United States, reported >50% positivity of their asymptomatic residents for the virus. 3 Universal screening of healthcare populations may prevent in-hospital transmission of SARS-CoV-2 virus. However, testing resources and personal protective equipment (PPE) supplies to effectively isolate positive asymptomatic persons are currently limited, resulting in provider safety concerns. Upon developing real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) tests in-house with >98% sensitivity, as well as increasing the availability of PPE at our institution, we initiated universal screening of patients on hospital admission using nasopharyngeal swabs to identify and isolate asymptomatic positive patients to prevent in-hospital transmission of SARS-CoV-2. We report our experience with universal screening of asymptomatic hospitalized persons, including a comparison of demographics between symptomatic and asymptomatic populations. Methods On April 27, 2020, our 1,000-bed academic center instituted universal SARS-CoV-2 testing of patients on hospital admission. Clinicians performed COVID-19 symptom screening using clinical criteria reported in the literature. 4 They designated patients as symptomatic or asymptomatic when ordering the test. An infectious diseases physician conducted chart review of asymptomatic positive patients to confirm accuracy of classification. Asymptomatic patients were not isolated; test turnaround time was 6–24 hours. Statistical analyses were performed with the Fischer exact tests and paired t tests to compare asymptomatic and symptomatic positive patients using SAS version 9.4 software (SAS Institute, Cary, NC). Results Between April 27, 2020, and May 18, 2020, when the hospital averaged at 60%–70% capacity, we performed 1,811 SARS-CoV-2 tests on nasopharyngeal specimens: 1,335 (74%) were asymptomatic, 420 (23%) were symptomatic, 56 (3%) were incorrectly ordered. Of the 1,755 tests in this analysis, overall positivity for SAR-CoV-2 virus was 79 (4.5%). Of 79 patients, 12 were asymptomatic (15%) and 67 were symptomatic (85%). Of 1,335 asymptomatic patients, 12 tested positive, for a rate of ~ 1%. Of 420 symptomatic patients, 67 tested positive, for a rate of 16%. No test converted to positive among asymptomatic patients while hospitalized. A comparative analysis of patients with positive SARS-CoV2 tests is listed in Table 1. The mean age of asymptomatic patients was 37 years (SD, 19.71) versus a mean age of 59 years (SD, 13.08) among symptomatic patients (P = .0020). Hispanic patients were more likely to be asymptomatic (7 of 12) than symptomatic (9 of 67) at the time of testing (58% vs 13%; P = .0017). We observed no difference in positivity rate on admission of asymptomatic versus symptomatic patients (P = .21). In addition, 5 asymptomatic positive women were pregnant (5 of 12, 42%); no symptomatic patients were pregnant (P ≤ .0001). A baby born to an asymptomatic SARS-CoV-2–positive mother tested positive at 48 hours of life, and 1 asymptomatic, SARS-CoV-2–positive, immunocompromised patient was receiving chemotherapy for breast cancer. One asymptomatic patient developed a fever during hospitalization, and another was readmitted within 14 days of testing positive, both of these events were not considered to be related to COVID-19. Table 1. Comparative Analysis Between Asymptomatic and Symptomatic Patients With Positive SARS-CoV-2 Virus Tests Demographic Characteristics of Asymptomatic Patients,SARS-CoV-2–Positive Patients(N = 12, 0.62%) Demographic Characteristics of Symptomatic Patients,SARS-CoV-2–Positive Patients(N = 67, 3.5%) P Value Mean age, y (range) 37 (0–67)(SD, 19.71) Mean age, y (range) 59 (12–78)(SD, 13.08) .0020 No. (%) No. (%) Race/ethnicity Race/ethnicity, y (range)  Hispanic 7 (58)  Hispanic 9 (13) .0017  African American 4 (33)  African American 36 (54) .22  Caucasian 1 (8)  Caucasian 14 (21) .44  Other 0 (0)  Other 8 (12) Gender Gender  Male 5 (42)  Male 42 (63) .21  Female 7 (58)  Female 25 (37)  Pregnant 5/7 (42)  Pregnant 0/25 (0) ≤.0001 Note. SD, standard deviation. Discussion Universal screening for the detection of SARS-CoV-2 at our institution revealed that during the study period, the number of asymptomatic persons admitted to the hospital was relatively small. Our health system had a relatively low number of confirmed SARS-CoV-2–positive COVID-19 patients (n = 82) admitted during the observed 3-week interval, compared to 4,000 patients admitted to an NYC hospital reporting the use of convalescent serum for the treatment of COVID-19 in a similar time frame. 5 Although low prevalence of asymptomatic patients has limited generalizability to areas with higher rates of infection, it is valuable information for patients, healthcare workers, and epidemiology programs in similar areas of COVID-19 prevalence. During our study period, 7.6% of all admitted patients were Hispanic and 43.5% were African American, yet 11 of 12 (91.7%) asymptomatic patients who screened positive were African American or Hispanic. A similar trend was observed in other studies. 6,7 Furthermore, a higher proportion of pregnant women have asymptomatic infection, which supports screening of peripartum women. Consistent with the literature, asymptomatic patients were younger than those who presented to our healthcare system with COVID-19 symptoms. 8 The potential benefits of universal SARS-CoV-2 screening are many and are likely to increase with escalating COVID-19 incidence. In hospitalized patients, detection of asymptomatic infection can guide hospital isolation practices, bed assignments, and the use of PPE. 2 For healthcare workers, it might improve workforce depletion by unnecessary quarantine, reduce transmission in asymptomatic cases, contain the virus in healthcare settings, and protect hospital staff from infection. In the community, mass testing can identify asymptomatic cases and assist in eliminating the SARS-CoV-2 virus, as reported in a village near Venice, Italy. 9 However, there are barriers to universal screening. Current testing capacity and test turnaround time, staffing shortages, and availability of healthcare workers skilled to perform nasopharyngeal swabbing currently limit widespread feasibility. Patient discomfort from nasopharyngeal sample collection is another potential barrier to universal screening. This study has several limitations. The sample size was small, and the study was conducted at a single center. In an area with high prevalence of COVID-19 infection, asymptomatic screening would likely identify more asymptomatic cases. However, sensitivity of a test in asymptomatic persons cannot be precisely defined. We add to the body of literature on SARS-CoV-2 testing of asymptomatic patients at the time of hospital admission. More data on universal screening is necessary to evaluate the clinical impact on healthcare systems and to define optimal screening strategies of high-risk groups for asymptomatic COVID-19 infection.

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          Epidemiological and Clinical Predictors of COVID-19

          Abstract Background Rapid identification of COVID-19 cases, which is crucial to outbreak containment efforts, is challenging due to the lack of pathognomonic symptoms and in settings with limited capacity for specialized nucleic acid–based reverse transcription polymerase chain reaction (PCR) testing. Methods This retrospective case-control study involves subjects (7–98 years) presenting at the designated national outbreak screening center and tertiary care hospital in Singapore for SARS-CoV-2 testing from 26 January to 16 February 2020. COVID-19 status was confirmed by PCR testing of sputum, nasopharyngeal swabs, or throat swabs. Demographic, clinical, laboratory, and exposure-risk variables ascertainable at presentation were analyzed to develop an algorithm for estimating the risk of COVID-19. Model development used Akaike’s information criterion in a stepwise fashion to build logistic regression models, which were then translated into prediction scores. Performance was measured using receiver operating characteristic curves, adjusting for overconfidence using leave-one-out cross-validation. Results The study population included 788 subjects, of whom 54 (6.9%) were SARS-CoV-2 positive and 734 (93.1%) were SARS-CoV-2 negative. The median age was 34 years, and 407 (51.7%) were female. Using leave-one-out cross-validation, all the models incorporating clinical tests (models 1, 2, and 3) performed well with areas under the receiver operating characteristic curve (AUCs) of 0.91, 0.88, and 0.88, respectively. In comparison, model 4 had an AUC of 0.65. Conclusions Rapidly ascertainable clinical and laboratory data could identify individuals at high risk of COVID-19 and enable prioritization of PCR testing and containment efforts. Basic laboratory test results were crucial to prediction models.
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            Characteristics of asymptomatic patients with SARS-CoV-2 infection in Jinan, China

            Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) is continuously and rapidly circulating at present. Asymptomatic patients have been proven to be contagious and thus pose a significant infection control challenge. Here we describe the characteristics of asymptomatic patients with SARS-CoV-2 infection in Jinan, Shandong province, China. A total of 47 patients with confirmed COVID-19 were recruited. Among them, 11 patients were categorized as asymptomatic cases. We found that the asymptomatic patients in Jinan were relatively young and were mainly clustered cases. The laboratory indicators and lung lesion on chest CT were mild. No special factors were found accounting for the presence or absence of symptoms. The presence of asymptomatic patients increased the difficulty of screening. It is necessary to strengthen the identification of such patients in the future.
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              Author and article information

              Journal
              Infect Control Hosp Epidemiol
              Infect Control Hosp Epidemiol
              ICE
              Infection Control and Hospital Epidemiology
              Cambridge University Press (New York, USA )
              0899-823X
              1559-6834
              23 July 2020
              : 1-2
              Affiliations
              Division of Infectious Diseases, Virginia Commonwealth University , Richmond, Virginia
              Author notes
              Author for correspondence: Sangeeta R. Sastry, E-mail: Sangeeta.Sastry@ 123456vcuhealth.org
              Article
              S0899823X2000358X
              10.1017/ice.2020.358
              7411438
              32698924
              © The Society for Healthcare Epidemiology of America 2020

              This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

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              Tables: 1, References: 9, Pages: 2
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