Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility.


Journal

The New England journal of medicine
ISSN: 1533-4406
Titre abrégé: N Engl J Med
Pays: United States
ID NLM: 0255562

Informations de publication

Date de publication:
28 05 2020
Historique:
pubmed: 25 4 2020
medline: 2 6 2020
entrez: 25 4 2020
Statut: ppublish

Résumé

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can spread rapidly within skilled nursing facilities. After identification of a case of Covid-19 in a skilled nursing facility, we assessed transmission and evaluated the adequacy of symptom-based screening to identify infections in residents. We conducted two serial point-prevalence surveys, 1 week apart, in which assenting residents of the facility underwent nasopharyngeal and oropharyngeal testing for SARS-CoV-2, including real-time reverse-transcriptase polymerase chain reaction (rRT-PCR), viral culture, and sequencing. Symptoms that had been present during the preceding 14 days were recorded. Asymptomatic residents who tested positive were reassessed 7 days later. Residents with SARS-CoV-2 infection were categorized as symptomatic with typical symptoms (fever, cough, or shortness of breath), symptomatic with only atypical symptoms, presymptomatic, or asymptomatic. Twenty-three days after the first positive test result in a resident at this skilled nursing facility, 57 of 89 residents (64%) tested positive for SARS-CoV-2. Among 76 residents who participated in point-prevalence surveys, 48 (63%) tested positive. Of these 48 residents, 27 (56%) were asymptomatic at the time of testing; 24 subsequently developed symptoms (median time to onset, 4 days). Samples from these 24 presymptomatic residents had a median rRT-PCR cycle threshold value of 23.1, and viable virus was recovered from 17 residents. As of April 3, of the 57 residents with SARS-CoV-2 infection, 11 had been hospitalized (3 in the intensive care unit) and 15 had died (mortality, 26%). Of the 34 residents whose specimens were sequenced, 27 (79%) had sequences that fit into two clusters with a difference of one nucleotide. Rapid and widespread transmission of SARS-CoV-2 was demonstrated in this skilled nursing facility. More than half of residents with positive test results were asymptomatic at the time of testing and most likely contributed to transmission. Infection-control strategies focused solely on symptomatic residents were not sufficient to prevent transmission after SARS-CoV-2 introduction into this facility.

Sections du résumé

BACKGROUND
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can spread rapidly within skilled nursing facilities. After identification of a case of Covid-19 in a skilled nursing facility, we assessed transmission and evaluated the adequacy of symptom-based screening to identify infections in residents.
METHODS
We conducted two serial point-prevalence surveys, 1 week apart, in which assenting residents of the facility underwent nasopharyngeal and oropharyngeal testing for SARS-CoV-2, including real-time reverse-transcriptase polymerase chain reaction (rRT-PCR), viral culture, and sequencing. Symptoms that had been present during the preceding 14 days were recorded. Asymptomatic residents who tested positive were reassessed 7 days later. Residents with SARS-CoV-2 infection were categorized as symptomatic with typical symptoms (fever, cough, or shortness of breath), symptomatic with only atypical symptoms, presymptomatic, or asymptomatic.
RESULTS
Twenty-three days after the first positive test result in a resident at this skilled nursing facility, 57 of 89 residents (64%) tested positive for SARS-CoV-2. Among 76 residents who participated in point-prevalence surveys, 48 (63%) tested positive. Of these 48 residents, 27 (56%) were asymptomatic at the time of testing; 24 subsequently developed symptoms (median time to onset, 4 days). Samples from these 24 presymptomatic residents had a median rRT-PCR cycle threshold value of 23.1, and viable virus was recovered from 17 residents. As of April 3, of the 57 residents with SARS-CoV-2 infection, 11 had been hospitalized (3 in the intensive care unit) and 15 had died (mortality, 26%). Of the 34 residents whose specimens were sequenced, 27 (79%) had sequences that fit into two clusters with a difference of one nucleotide.
CONCLUSIONS
Rapid and widespread transmission of SARS-CoV-2 was demonstrated in this skilled nursing facility. More than half of residents with positive test results were asymptomatic at the time of testing and most likely contributed to transmission. Infection-control strategies focused solely on symptomatic residents were not sufficient to prevent transmission after SARS-CoV-2 introduction into this facility.

Identifiants

pubmed: 32329971
doi: 10.1056/NEJMoa2008457
pmc: PMC7200056
doi:

Types de publication

Journal Article Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

IM

Pagination

2081-2090

Investigateurs

Atar Baer (A)
Leslie M Barnard (LM)
Eileen Benoliel (E)
Meaghan S Fagalde (MS)
Jessica Ferro (J)
Hal Garcia-Smith (H)
Elysia Gonzales (E)
Noel Hatley (N)
Grace Hatt (G)
Michaela Hope (M)
Melinda Huntington-Frazier (M)
Vance Kawakami (V)
Jennifer L Lenahan (JL)
Margaret D Lukoff (MD)
Emily B Maier (EB)
Shelly McKeirnan (S)
Jennifer L Morgan (JL)
Laura A Mummert (LA)
Sargis Pogosjans (S)
Leilani Schwarcz (L)
Daniel Smith (D)
Steven Stearns (S)
Kaitlyn J Sykes (KJ)
Holly Whitney (H)
Michelle Banks (M)
Arun Balajee (A)
Eric J Chow (EJ)
Barbara Cooper (B)
Dustin W Currie (DW)
Jessica Healy (J)
Michael Hughes (M)
Temet M McMichael (TM)
Leisha Nolen (L)
Christine Olson (C)
Agam K Rao (AK)
Kristine Schmit (K)
Noah G Schwartz (NG)
Farrell Tobolowsky (F)
Rachael Zacks (R)
Suzanne Zane (S)
Jing Zhang (J)
Krista Queen (K)
Clinton R Paden (CR)
Brett Whitaker (B)
Steve Lindstrom (S)
Denny Russell (D)
Brian Hiatt (B)
Jessica Gant (J)

Commentaires et corrections

Type : CommentIn
Type : CommentIn
Type : CommentIn
Type : CommentIn

Informations de copyright

Copyright © 2020 Massachusetts Medical Society.

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Auteurs

Melissa M Arons (MM)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Kelly M Hatfield (KM)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Sujan C Reddy (SC)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Anne Kimball (A)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Allison James (A)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Jesica R Jacobs (JR)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Joanne Taylor (J)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Kevin Spicer (K)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Ana C Bardossy (AC)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Lisa P Oakley (LP)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Sukarma Tanwar (S)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Jonathan W Dyal (JW)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Josh Harney (J)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Zeshan Chisty (Z)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Jeneita M Bell (JM)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Mark Methner (M)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Prabasaj Paul (P)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Christina M Carlson (CM)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Heather P McLaughlin (HP)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Natalie Thornburg (N)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Suxiang Tong (S)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Azaibi Tamin (A)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Ying Tao (Y)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Anna Uehara (A)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Jennifer Harcourt (J)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Shauna Clark (S)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Claire Brostrom-Smith (C)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Libby C Page (LC)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Meagan Kay (M)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

James Lewis (J)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Patty Montgomery (P)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Nimalie D Stone (ND)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Thomas A Clark (TA)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Margaret A Honein (MA)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

Jeffrey S Duchin (JS)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

John A Jernigan (JA)

From the Centers for Disease Control and Prevention COVID-19 Emergency Response (M.M.A., K.M.H., S.C.R., A.K., A.J., J.R.J., J.T., K.S., A.C.B., L.P.O., S. Tanwar, J.W.D., J. Harney, Z.C., J.M.B., M.M., P.P., C.M.C., H.P.M.L., N.T., S. Tong, A.T., Y.T., A.U., J. Harcourt, N.D.S., T.A.C., M.A.H., J.A.J.), and the Epidemic Intelligence Service (M.M.A., A.K., A.J., J.T., A.C.B., L.P.O., S. Tanwar, J.W.D.) and the Laboratory Leadership Service (J.R.J., C.M.C.), Centers for Disease Control and Prevention - all in Atlanta; and Public Health - Seattle & King County (S.C., C.B.-S., L.C.P., M.K., J.L., J.S.D.) and the University of Washington, Department of Medicine (J.S.D.), Seattle, the Washington State Public Health Laboratory, Shoreline (J.S.D.), and the Washington State Department of Health, Tumwater (P.M.) - all in Washington.

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