Clinical Presentation, Course, and Risk Factors Associated with Mortality in a Severe Outbreak of COVID-19 in Rhode Island, USA, April–June 2020

Abstract

Long-term care facilities (LTCFs) have had a disproportionally high mortality rate due to COVID-19. We describe a rapidly escalating COVID-19 outbreak among 116 LTCF residents in Rhode Island, USA. Overall, 111 (95.6%) residents tested positive and, of these, 48 (43.2%) died. The most common comorbidities were hypertension (84.7%) and cardiovascular disease (84.7%). A small percentage (9%) of residents were asymptomatic, while 33.3% of residents were pre-symptomatic, with progression to symptoms within a median of three days following the positive test. While typical symptoms of fever (80.2%) and cough (43.2%) were prevalent, shortness of breath (14.4%) was rarely found despite common hypoxemia (95.5%). The majority of patients demonstrated atypical symptoms with the most common being loss of appetite (61.3%), lethargy (42.3%), diarrhea (37.8%), and fatigue (32.4%). Many residents had increased agitation (38.7%) and anxiety (5.4%), potentially due to the restriction measures or the underlying mental illness. The fever curve was characterized by an intermittent low-grade fever, often the first presenting symptom. Mortality was associated with a disease course beginning with a loss of appetite and lethargy, as well as one more often involving fever greater than 38 °C, loss of appetite, altered mental status, diarrhea, and respiratory distress. Interestingly, no differences in age or comorbidities were noted between survivors and non-survivors. Taking demographic factors into account, treatment with anticoagulation was still associated with reduced mortality (adjusted OR 0.16; 95% C.I. 0.06–0.39; p < 0.001). Overall, the clinical features of the disease in this population can be subtle and the symptoms are commonly atypical. However, clinical decline among those who did not survive was often rapid with patients expiring within 10 days from disease detection. Further studies are needed to better explain the variability in clinical course of COVID-19 among LTCF residents, specifically the factors affecting mortality, the differences observed in symptom presentation, and rate of clinical decline.

Patient Factors and Hospital Outcomes Associated With Atypical Presentation in Hospitalized Older Adults With COVID-19 During the First Surge of the Pandemic

“…In the reported cohort, short-term hospital outcomes of hospital mortality, hospital LOS, and hospital readmission were similar between OAs presenting typically versus atypically. This adds another piece of evidence to the literature, which currently presents an inconsistent picture where most ( 6 , 12 ), but not all ( 13 ), studies show that atypical presentation is related to hospital mortality. On the other hand, patients with typical presentation were more likely than patients with atypical presentation to receive ICU-level care, probably because of the respiratory concerns associated with typical presentations.…”

“…In a smaller and older sample (73 hospitalized OAs, aged 80 and older) in New York State ( 8 ), atypical presentations included altered mental status (36%), generalized weakness (38%), and falls (14%). One hundred and eleven residents of long-term care facilities in the United States presented most commonly with loss of appetite (61.3%), lethargy (42.3%), and increased agitation (38.7%) ( 6 ). In a study ( 7 ) of 817 OA patients presenting to the emergency department in the United States with COVID-19, delirium was the sixth most common of all presenting symptoms (28% of the sample), and 16% had delirium as their primary symptom.…”

“…Short-term outcomes of patients presenting atypically versus typically have been minimally examined, with hospital mortality receiving the most attention. Most existing studies ( 6 , 12 ) indicate that hospital mortality is related to atypical presentation, although one study ( 13 ) found that there was no significant difference between typical and atypical presentations in mortality or hospital length of stay (LOS). Other outcomes such as receipt of intensive care unit (ICU)-level care or hospital readmission status across typical versus atypical presentations have not been examined.…”

Asymptomatic SARS-CoV-2 infection: A systematic review and meta-analysis

“…These studies included a total of 104,058 laboratory-confirmed COVID-19 cases, of which 25,050 exhibited no symptoms at the time of testing and 7,220 remained asymptomatic. We identified 170 studies that reported asymptomatic infections ( 11 – 13 , 17 – 183 ), 332 studies that reported silent infections at the time of testing ( 10 – 12 , 14 , 17 – 20 , 23 – 27 , 31 , 32 , 35 – 40 , 42 – 44 , 46 , 47 , 49 , 50 , 52 , 53 , 56 – 58 , 60 – 66 , 68 , 69 , 73 – 75 , 77 – 79 , 81 , 84 , 87 , 90 – 94 , 97 , 99 , 101 , 103 , 104 , 106 , 111 , 113 – 116 , 118 , 119 , 121 – 123 , 125 , 127 , 128 , …”

Excess Mortality After COVID-19 in Swedish Long-Term Care Facilities

“…Smaller studies, conducted in age groups similar to ours, showed more comparable mortality rates. 15,28,29 A limitation of all these studies is that they lacked a control group, impeding assessment of excess mortality. In this sense, our results add important evidence regarding the profound dangers of COVID-19 in LTCFs, as illustrated by the 7-fold higher mortality.…”