We hosted a confidential helpline to address concerns about COVID-19 prevention among staff in 12 nursing homes in Orange County, California. We fielded 301 inquiries from April 2021-April 2022, most commonly involving questions about vaccines (40%), nursing home COVID-19 prevention (28%), SARS-CoV-2 variants (18%), symptom reporting (10%), and home and community COVID-19 prevention (5%). During COVID-19 surges, staff dominantly expressed fear, anger, and exhaustion. During nadirs, sentiment shifted towards optimism and acceptance.

Objective

Quantify the frequency and drivers of unreported coronavirus disease 2019 (COVID-19) symptoms among nursing home (NH) staff.

Design

Confidential telephone survey.

Setting

The study was conducted in 70 NHs in Orange County, California, December 2020-February 2022.

Participants

The study included 120 NH staff with COVID-19.

Methods

We designed a 40-item telephone survey of NH staff to assess COVID-19 symptom reporting behavior and types of barriers [monetary, logistic, and emotional (fear or stigma)] and facilitators of symptom reporting using 5-point Likert scales. Summary statistics, reliability of survey constructs, and construct and discriminant validity were assessed.

Results

Overall, 49% of surveys were completed during the 2020-2021 COVID-19 winter wave and 51% were completed during severe acute respiratory coronavirus virus 2 (SARS-CoV-2) δ (delta)/ (omicron) waves, with a relatively even distribution of certified nursing assistants, licensed vocational or registered nurses, and nonfrontline staff. Most COVID-19 cases (71%) were detected during mandated weekly NH surveillance testing and most staff (67%) had ≥1 symptom prior to their test. Only 34% of those with symptoms disclosed their symptom to a supervisor. Responses were consistent across 8 discrete survey constructs with Cronbach α > 0.70. In the first wave of the pandemic, fear and lack of knowledge were drivers of symptom reporting. In later waves, adequate staffing and sick days were drivers of symptom reporting. COVID-19 help lines and encouragement from supervisors facilitated symptom reporting and testing.

Conclusions

Mandatory COVID-19 testing for NH staff is key to identifying staff COVID-19 cases due to reluctance to speak up about existing symptoms. Active encouragement from supervisors to report symptoms and stay home when ill was a major driver of symptom reporting and resultant infection prevention and worker safety measures.

Pooling of samples can increase throughput and reduce costs for large-scale SARS-CoV-2 testing when incidence is low. In a cross-sectional study of serial SARS-CoV-2 sampling of staff and residents at three nursing homes, laboratory labor constraints limited the feasibility of pooling prior to the maximal incidence that favored cost savings. IMPORTANCE This study highlights the pragmatic considerations surrounding SARS-CoV-2 sample pooling beyond accuracy and costs. We performed a cost analysis to determine the percent positivity at which pooling would reduce costs versus single testing. We found that the need for a stable amount of daily work hours staffed by a highly trained workforce was a major limitation in pooling as test positivity increased. For the COVID-19 pandemic and future pandemic threats, laboratories should carefully consider the thresholds at which sample pooling is beneficial, with a particular focus on the impact on laboratory staff.

The CLEAR Trial recently found that decolonization reduced infections and hospitalizations in MRSA carriers in the year following hospital discharge. In this secondary analysis, we explored whether decolonization had a similar benefit in the subgroup of trial participants who harbored USA300, using two different definitions for the USA300 strain-type.

Background

Clinical testing detects a fraction of carbapenem-resistant Enterobacteriaceae (CRE) carriers. Detecting a greater proportion could lead to increased use of infection prevention and control measures but requires resources. Therefore, it is important to understand the impact of detecting increasing proportions of CRE carriers.

Methods

We used our Regional Healthcare Ecosystem Analyst-generated agent-based model of adult inpatient healthcare facilities in Orange County, California, to explore the impact that detecting greater proportions of carriers has on the spread of CRE.

Results

Detecting and placing 1 in 9 carriers on contact precautions increased the prevalence of CRE from 0% to 8.0% countywide over 10 years. Increasing the proportion of detected carriers from 1 in 9 up to 1 in 5 yielded linear reductions in transmission; at proportions >1 in 5, reductions were greater than linear. Transmission reductions did not occur for 1, 4, or 5 years, varying by facility type. With a contact precautions effectiveness of ≤70%, the detection level yielding nonlinear reductions remained unchanged; with an effectiveness of >80%, detecting only 1 in 5 carriers garnered large reductions in the number of new CRE carriers. Trends held when CRE was already present in the region.

Conclusion

Although detection of all carriers provided the most benefits for preventing new CRE carriers, if this is not feasible, it may be worthwhile to aim for detecting >1 in 5 carriers.

Background: More than half of nursing home (NH) residents harbor a multidrug-resistant organism (MDRO), and MDRO contamination of the environment is common. Whether NH decolonization of residents reduces MDRO contamination remains unclear. The PROTECT trial was a cluster-randomized trial of decolonization versus routine care in 28 California NHs from April 2017 through December 2018. Decolonization involved chlorhexidine bathing plus nasal iodophor (Monday–Friday, every other week), and it reduced resident nares and skin MDRO colonization by 36%. Methods: We swabbed high-touch objects in resident rooms and common areas for MDROs before and after the 3-month decolonization phase-in (April–July 2017). Five high-touch objects (bedrail, call button and TV remote, doorknob, light switch, and bathroom handles) were swabbed in 3 resident rooms per NH based on care needs (Alzheimer’s disease and related dementias (ADRD), ie, total care; ADRD, ambulatory care; and short stay). Five high-touch objects were also swabbed in the common area (nursing station, table, chair, railing, and drinking fountain). Swabs were processed for methicillin-resistant S. aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae, and carbapenem-resistant Enterobacteriaceae (CRE). We used generalized linear mixed models to assess the impact of decolonization on MDRO environmental contamination when clustering by NH and room and adjusting for room type and object because unclustered and unadjusted results are likely to be inaccurate. Results: A high proportion of rooms were contaminated with any MDRO in control NHs: 43 of 56 (77%) in the baseline period and 46 of 56 (82%) in the intervention period. In contrast, decolonization NHs had similar baseline contamination (45 of 56, 80%) but lower intervention MDRO contamination (29 of 48, 60%). When evaluating the intervention impact using multivariable models, decolonization was associated with significantly less room contamination for any MDRO (OR, 0.25; 95% CI, 0.06–0.96; P = .04) and MRSA (OR, 0.16; 95% CI, 0.05–0.55; P = .004) but nonsignificant reductions in VRE contamination (OR, 0.86; 95% CI, 0.23–3.13) and ESBL contamination (OR, 0.13; 95% CI, 0.01–1.62). CRE was not modeled due to rare counts (2 rooms total). In addition, room type was important, with common areas associated with 5-fold, 9-fold, and 3-fold higher contamination with any MDRO, MRSA, and VRE, respectively, compared with short-stay rooms. Conclusions: The high burden of MDROs in NHs calls for universal prevention strategies that can protect all residents. Although decolonization was associated with an 84% reduction in odds of MRSA contamination of inanimate room objects, significant reductions in VRE or ESBL contamination were not seen, possibly due to the lower proportion of baseline contamination due to these organisms. Multimodal strategies are needed to address high levels of MDRO contamination in NHs.Funding: NoneDisclosures: Gabrielle Gussin: Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.

Importance

Multidrug-resistant organisms (MDROs) can spread across health care facilities in a region. Because of limited resources, certain interventions can be implemented in only some facilities; thus, decision-makers need to evaluate which interventions may be best to implement.

Objective

To identify a group of target facilities and assess which MDRO intervention would be best to implement in the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, a large regional public health collaborative in Orange County, California.

Design, setting, and participants

An agent-based model of health care facilities was developed in 2016 to simulate the spread of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE) for 10 years starting in 2010 and to simulate the use of various MDRO interventions for 3 years starting in 2017. All health care facilities (23 hospitals, 5 long-term acute care hospitals, and 74 nursing homes) serving adult inpatients in Orange County, California, were included, and 42 target facilities were identified via network analyses.

Exposures

Increasing contact precaution effectiveness, increasing interfacility communication about patients' MDRO status, and performing decolonization using antiseptic bathing soap and a nasal product in a specific group of target facilities.

Main outcomes and measures

MRSA and CRE prevalence and number of new carriers (ie, transmission events).

Results

Compared with continuing infection control measures used in Orange County as of 2017, increasing contact precaution effectiveness from 40% to 64% in 42 target facilities yielded relative reductions of 0.8% (range, 0.5%-1.1%) in MRSA prevalence and 2.4% (range, 0.8%-4.6%) in CRE prevalence in health care facilities countywide after 3 years, averting 761 new MRSA transmission events (95% CI, 756-765 events) and 166 new CRE transmission events (95% CI, 158-174 events). Increasing interfacility communication of patients' MDRO status to 80% in these target facilities produced no changes in the prevalence or transmission of MRDOs. Implementing decolonization procedures (clearance probability: 39% in hospitals, 27% in long-term acute care facilities, and 3% in nursing homes) yielded a relative reduction of 23.7% (range, 23.5%-23.9%) in MRSA prevalence, averting 3515 new transmission events (95% CI, 3509-3521 events). Increasing the effectiveness of antiseptic bathing soap to 48% yielded a relative reduction of 39.9% (range, 38.5%-41.5%) in CRE prevalence, averting 1435 new transmission events (95% CI, 1427-1442 events).

Conclusions and relevance

The findings of this study highlight the ways in which modeling can inform design of regional interventions and suggested that decolonization would be the best strategy for the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County.

Background: Addressing the high burden of multidrug-resistant organisms (MDROs) in nursing homes is a public health priority. High interfacility transmission may be attributed to inadequate infection prevention practices, shared living spaces, and frequent care needs. We assessed the contribution of roommates to the likelihood of MDRO carriage in nursing homes. Methods: We performed a secondary analysis of the SHIELD OC (Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, CA) Project, a CDC-funded regional decolonization intervention to reduce MDROs among 38 regional facilities (18 nursing homes, 3 long-term acute-care hospitals, and 17 hospitals). Decolonization in participating nursing homes involved routine chlorhexidine bathing plus nasal iodophor (Monday through Friday, twice daily every other week) from April 2017 through July 2019. MDRO point-prevalence assessments involving all residents at 16 nursing homes conducted at the end of the intervention period were used to determine whether having a roommate was associated with MDRO carriage. Nares, bilateral axilla/groin, and perirectal swabs were processed for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae, and carbapenem-resistant Enterobacteriaceae (CRE). Generalized linear mixed models assessed the impact of maximum room occupancy on MDRO prevalence when clustering by room and hallway, and adjusting for the following factors: nursing home facility, age, gender, length-of-stay at time of swabbing, bedbound status, known MDRO history, and presence of urinary or gastrointestinal devices. CRE models were not run due to low counts. Results: During the intervention phase, 1,451 residents were sampled across 16 nursing homes. Overall MDRO prevalence was 49%. In multivariable models, we detected a significant increasing association of maximum room occupants and MDRO carriage for MRSA but not other MDROs. For MRSA, the adjusted odds ratios for quadruple-, triple-, and double-occupancy rooms were 3.5, 3.6, and 2.8, respectively, compared to residents in single rooms (P = .013). For VRE, these adjusted odds ratios were 0.3, 0.3, and 0.4, respectively, compared to residents in single rooms (P = NS). For ESBL, the adjusted odds ratios were 0.9, 1.1, and 1.5, respectively, compared to residents in single rooms (P = nonsignificant). Conclusions: Nursing home residents in shared rooms were more likely to harbor MRSA, suggesting MRSA transmission between roommates. Although decolonization was previously shown to reduce MDRO prevalence by 22% in SHIELD nursing homes, this strategy did not appear to prevent all MRSA transmission between roommates. Additional efforts involving high adherence hand hygiene, environmental cleaning, and judicious use of contact precautions are likely needed to reduce transmission between roommates in nursing homes. Funding: None Disclosures: Gabrielle M. Gussin, Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.