One care home, 129 cases, 23 deaths, in eleven days

On 28 February 2020, a case of COVID-19 was confirmed in a woman resident
of a skilled nursing facility in King County, Washington. **By 9 March there
were 129 cases** connected to that one building, and 23 people had died.

What the first case looked like

A 73-year-old woman with coronary artery disease, insulin-dependent type 2
diabetes, obesity, chronic kidney disease, hypertension and congestive heart
failure. She had **cough, fever and shortness of breath requiring oxygen for
five days inside the facility**, and **reported no travel and no known contact
with a case.**

On admission to hospital she had a fever of 103.3°F (39.6°C), was
tachycardic, and was in hypoxaemic respiratory failure. She was
intubated the next day. A CT scan showed diffuse bilateral infiltrates;
**the multiplex viral respiratory panel and bacterial cultures were all
negative.** Specimens were taken for SARS-CoV-2 four days after admission
and returned positive on 28 February. She died on 2 March.

Two things had already happened before anyone tested for this virus. **The
facility had been experiencing a cluster of febrile respiratory illness since
mid-February**, with several residents testing negative for influenza — a
warning that was legible only afterwards. And she spent **five days on oxygen
in a shared building** before being transferred.

How it left the building

**Staff members working in multiple facilities contributed to intra- and
interfacility spread.**

18 of the 129 cases (14%) were in residents of the next county north — **17
of them staff**, and one visitor.

The infected staff were not one job: **physical therapist, occupational
therapist assistant, environmental care worker, nurse, certified nursing
assistant, health information officer, physician, case manager.** Everyone who
moves through the building, and some of them moved through other buildings too.

That is a structural feature of the sector rather than a local failing. Staff
work across facilities because that is how the shifts are organised, and it
turns each home into a node rather than an island.

What was recommended

• Identify and exclude potentially infected staff members — and visitors
• Restrict visitation except in compassionate care situations
• Ensure early recognition of potentially infected patients
• Implement appropriate infection control measures

The order matters. The first item is about the people who leave and come back
every day, which is the route this outbreak actually used — and "preserve the
health care workforce" appears in the same sentence as "protect residents",
because a home that loses its staff to infection cannot care for anyone.

Source: Centers for Disease Control and Prevention, MMWR.