Advertisement

Asymptomatic patients as a source of transmission of COVID-19 in homeless shelters

  • Massimo Ralli
    Correspondence
    Corresponding author at: Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00186, Rome, Italy.
    Affiliations
    Department of Sense Organs, Sapienza University of Rome, Italy

    Primary Care Services, Eleemosynaria Apostolica, Vatican City State
    Search for articles by this author
  • Aldo Morrone
    Affiliations
    Scientific Director, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
    Search for articles by this author
  • Andrea Arcangeli
    Affiliations
    Direzione di Sanità e Igiene, Vatican City State

    Department of Emergency, Anesthesiology and Resuscitation Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
    Search for articles by this author
  • Lucia Ercoli
    Affiliations
    Primary Care Services, Eleemosynaria Apostolica, Vatican City State

    Direzione di Sanità e Igiene, Vatican City State

    Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
    Search for articles by this author
Open AccessPublished:December 12, 2020DOI:https://doi.org/10.1016/j.ijid.2020.12.031

      Highlights

      • Asymptomatic COVID-19 cases represent the most common mean of contagion.
      • Asymptomatic COVID-19 cases may have the same infectivity as symptomatic infections.
      • Spread of COVID-19 in homeless shelters represents a serious public health threat.
      • Homeless persons are subject to more severe forms of COVID-19.
      • Prevention measures should be implemented in all homeless shelters.

      Abstract

      Objectives

      Asymptomatic carriers account for over a third of all Coronavirus Disease 19 (COVID-19) cases and are characterized by the absence of symptoms but the same infectivity as symptomatic infections. The high percentage of asymptomatic COVID-19 patients is significant in settings with specific vulnerabilities, such as homeless shelters, where the consequences of an outbreak may be dramatic. In this work, we briefly report our experience on residents and staff of homeless shelters in the City of Rome, Italy, with a particular focus on asymptomatic transmission, and compare it with the available evidence.

      Methods

      We performed routine Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) nasopharyngeal swab tests in all residents and staff of homeless shelters managed by the Eleemosynaria Apostolica of the Vatican City State in the city of Rome, Italy, in addition to daily symptom screening, body temperature monitoring, and application of other prevention measures.

      Results

      We evaluated 298 persons and identified twelve positive cases (4%). Most of the positive cases (75%) were asymptomatic, while only three patients reported symptoms that included fever, diarrhea, and cough.

      Conclusions

      Our data confirm the importance of early identification of asymptomatic carriers that could, in vulnerable conditions such as homeless shelters, spread the infection and cause outbreaks with severe consequences on individual and public health.

      Keywords

      As of November 29, 2020, the Coronavirus Disease 19 (COVID-19) pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has been characterized by more than 60 million cases worldwide, over 1.4 million deaths, and nearly 43 million persons discharged. Although the main symptoms of COVID-19 include fever, cough, respiratory difficulties, fatigue, and loss of smell and taste, up to severe complications such as interstitial pneumonia and acute respiratory distress syndrome, a large portion of cases are asymptomatic (
      • Kronbichler A.
      • Kresse D.
      • Yoon S.
      • Lee K.H.
      • Effenberger M.
      • Shin J.I.
      Asymptomatic patients as a source of COVID-19 infections: a systematic review and meta-analysis.
      ).
      Asymptomatic carriers account for about 40% of COVID-19 cases and are characterized by the absence of symptoms but the same infectivity as symptomatic infections (
      • Chen Y.
      • Wang A.H.
      • Yi B.
      • Ding K.Q.
      • Wang H.B.
      • Wang J.M.
      • et al.
      [Epidemiological characteristics of infection in COVID-19 close contacts in Ningbo city].
      ). Furthermore, asymptomatic cases can lead to significant subclinical lung abnormalities in a short time, suggesting that the absence of symptoms may not imply the absence of harm. In a recent review and meta-analysis published by
      • Kronbichler A.
      • Kresse D.
      • Yoon S.
      • Lee K.H.
      • Effenberger M.
      • Shin J.I.
      Asymptomatic patients as a source of COVID-19 infections: a systematic review and meta-analysis.
      ), the first systematic analysis of asymptomatic COVID-19 cases in the literature, the authors focused on the role of asymptomatic SARS-CoV-2 carriers in disease transmission. They concluded that they represent a significant portion of COVID-19 patients and their early identification is extremely important to prevent transmission. The authors also reported that more than half of the 506 asymptomatic patients from 34 studies included in their meta-analysis had lung alterations on computed tomography, mainly ground-glass opacities, although with normal laboratory findings in the majority of cases. A similar result was reported in a study on the outbreak of the Diamond Princess cruise ship in February 2020; in fact, 73% of the cases were asymptomatic or paucisymptomatic, and over half of them presented lung abnormalities at computed tomography (
      • Tabata S.
      • Imai K.
      • Kawano S.
      • Ikeda M.
      • Kodama T.
      • Miyoshi K.
      • et al.
      Clinical characteristics of COVID-19 in 104 people with SARS-CoV-2 infection on the Diamond Princess cruise ship: a retrospective analysis.
      ).
      The large number of asymptomatic patients is an extremely important characteristic of SARS-CoV-2 infection; however, it becomes even more important in settings with specific vulnerabilities, such as homeless shelters, where the consequences on individual and public health may be dramatic (
      • Karb R.
      • Samuels E.
      • Vanjani R.
      • Trimbur C.
      • Napoli A.
      Homeless shelter characteristics and prevalence of SARS-CoV-2.
      ). In homeless shelters characterized by the physical proximity of residents, elevated population density, a limited use of face masks, and often precarious hygienic conditions outside the shelter, the reported prevalence of COVID-19 is higher than the general population (
      • Karb R.
      • Samuels E.
      • Vanjani R.
      • Trimbur C.
      • Napoli A.
      Homeless shelter characteristics and prevalence of SARS-CoV-2.
      ). Also, homeless persons have more physical and mental comorbidities, usually undiagnosed and uncontrolled, that may worsen the disease's course. In these congregated living settings, asymptomatic cases represent the most common means of contagion, as reported by Baggett in Boston (
      • Baggett T.P.
      • Keyes H.
      • Sporn N.
      • Gaeta J.M.
      Prevalence of SARS-CoV-2 infection in residents of a large homeless shelter in Boston.
      ), Tobolowsky in Seattle and King County (
      • Tobolowsky F.A.
      • Gonzales E.
      • Self J.L.
      • Rao C.Y.
      • Keating R.
      • Marx G.E.
      • et al.
      COVID-19 outbreak among three affiliated homeless service sites—King County, Washington, 2020.
      ), and Imbert in San Francisco (
      • Imbert E.
      • Kinley P.M.
      • Scarborough A.
      • Cawley C.
      • Sankaran M.
      • Cox S.N.
      • et al.
      Coronavirus disease 2019 (COVID-19) outbreak in a San Francisco homeless shelter.
      ) (Table 1).
      Table 1Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) outbreaks in homeless shelters available in the scientific literature.
      AuthorLocationSARS-CoV-2 Positive (%)SymptomsAsymptomatic rate (%)
      • Baggett T.P.
      • Keyes H.
      • Sporn N.
      • Gaeta J.M.
      Prevalence of SARS-CoV-2 infection in residents of a large homeless shelter in Boston.
      Boston, USA36%Fever (0.7%), cough (7.5%), shortness of breath (1.4%)87.8%
      • Tobolowsky F.A.
      • Gonzales E.
      • Self J.L.
      • Rao C.Y.
      • Keating R.
      • Marx G.E.
      • et al.
      COVID-19 outbreak among three affiliated homeless service sites—King County, Washington, 2020.
      Seattle and King County, USA18.5%Not reportedNot reported
      • Imbert E.
      • Kinley P.M.
      • Scarborough A.
      • Cawley C.
      • Sankaran M.
      • Cox S.N.
      • et al.
      Coronavirus disease 2019 (COVID-19) outbreak in a San Francisco homeless shelter.
      )
      San Francisco, USA67%Fever, cough, shortness of breath, pain when breathing52.9%
      Our experience is consistent with these findings. Over the past months, we performed routine SARS-CoV-2 Real-Time Reverse-transcription Polymerase Chain Reaction (rRT-PCR) nasopharyngeal swab tests in all residents and staff of homeless shelters managed by the Eleemosynaria Apostolica of the Vatican City State in the city of Rome, Italy, in addition to daily symptom screening and body temperature monitoring. Tests were performed at admission and routinely afterward. Additional prevention measures were implemented, including mandatory use of face masks, daily health education programs, application of hygiene protocols, and adequate distancing. As of October 31, 2020, we evaluated 298 persons and identified twelve positive cases, with a prevalence of infection of 4%. Most of the positive cases (75%) were asymptomatic at the time of the testing and in the 14 days before, while only three patients had symptoms that included fever, diarrhea, and cough (Figure 1).
      Figure 1
      Figure 1Results of routine Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Real-Time Reverse transcription-polymerase Chain Reaction (rRT-PCR) nasopharyngeal swab tests in residents and staff of homeless shelters managed by the Eleemosynaria Apostolica of the Vatican City State in the city of Rome, Italy. The large pie chart represents the number of positive/negative cases; the small pie chart represents the number of symptomatic/asymptomatic positive cases.
      Our data, along with the evidence available in the literature, confirm the importance of early identification of asymptomatic carriers that could, in particularly vulnerable conditions such as homeless shelters, spread the infection and cause outbreaks with severe consequences (
      • Ralli M.
      • Cedola C.
      • Urbano S.
      • Morrone A.
      • Ercoli L.
      Homeless persons and migrants in precarious housing conditions and COVID-19 pandemic: peculiarities and prevention strategies.
      ). In fact, asymptomatic cases in these settings may rapidly spread COVID-19 among other residents and staff, leading to more severe forms of COVID-19 due to the higher number of comorbidities and precarious health conditions among homeless persons (
      • Tsai J.
      • Wilson M.
      COVID-19: a potential public health problem for homeless populations.
      ), as well as to closures of the shelters with resident relocation in alternative structures (
      • Bodkin C.
      • Mokashi V.
      • Beal K.
      • Wiwcharuk J.
      • Lennox R.
      • Guenter D.
      • et al.
      Pandemic planning in homeless shelters: a pilot study of a COVID-19 testing and support program to mitigate the risk of COVID-19 outbreaks in congregate settings.
      ).
      In conclusion, the role of asymptomatic carriers must always be considered, especially in vulnerable settings and congregate living conditions. Prevention measures including routine surveillance with molecular and nasopharyngeal antigen swabs and serological tests, in addition to other measures such as strict hygiene rules inside and outside the shelter, adequate distancing protocols, continuous symptom screening, and health education programs, should be implemented in all homeless shelters to intercept new clusters of infection and prevent outbreaks. Concurrently, temporary shelter closures may have severe effects on residents and public health, and alternative residential solutions should be carefully planned and made promptly available in case of outbreaks.

      Funding

      None declare.

      Conflict of interest

      The authors declare no conflicts of interest.

      Ethical approval

      Not applicable.

      Acknowledgments

      The authors wish to thank His Holiness Pope Francis for providing directions, structures, and equipment to make healthcare available for vulnerable populations through the Offices of Papal Charities (Eleemosynaria Apostolica), and Cardinal Konrad Krajewski, Apostolic Almoner, for the extraordinary efforts in the realization of this mission.

      References

        • Baggett T.P.
        • Keyes H.
        • Sporn N.
        • Gaeta J.M.
        Prevalence of SARS-CoV-2 infection in residents of a large homeless shelter in Boston.
        JAMA. 2020; 323: 2191-2192
        • Bodkin C.
        • Mokashi V.
        • Beal K.
        • Wiwcharuk J.
        • Lennox R.
        • Guenter D.
        • et al.
        Pandemic planning in homeless shelters: a pilot study of a COVID-19 testing and support program to mitigate the risk of COVID-19 outbreaks in congregate settings.
        Clin Infect Dis. 2020; (Online ahead of print)
        • Chen Y.
        • Wang A.H.
        • Yi B.
        • Ding K.Q.
        • Wang H.B.
        • Wang J.M.
        • et al.
        [Epidemiological characteristics of infection in COVID-19 close contacts in Ningbo city].
        Zhonghua Liu Xing Bing Xue Za Zhi. 2020; 41: 667-671
        • Imbert E.
        • Kinley P.M.
        • Scarborough A.
        • Cawley C.
        • Sankaran M.
        • Cox S.N.
        • et al.
        Coronavirus disease 2019 (COVID-19) outbreak in a San Francisco homeless shelter.
        Clin Infect Dis. 2020; (Online ahead of print)
        • Karb R.
        • Samuels E.
        • Vanjani R.
        • Trimbur C.
        • Napoli A.
        Homeless shelter characteristics and prevalence of SARS-CoV-2.
        West J Emerg Med. 2020; 21: 1048-1053
        • Kronbichler A.
        • Kresse D.
        • Yoon S.
        • Lee K.H.
        • Effenberger M.
        • Shin J.I.
        Asymptomatic patients as a source of COVID-19 infections: a systematic review and meta-analysis.
        Int J Infect Dis. 2020; 98: 180-186
        • Ralli M.
        • Cedola C.
        • Urbano S.
        • Morrone A.
        • Ercoli L.
        Homeless persons and migrants in precarious housing conditions and COVID-19 pandemic: peculiarities and prevention strategies.
        Eur Rev Med Pharmacol Sci. 2020; 24: 9765-9767
        • Tabata S.
        • Imai K.
        • Kawano S.
        • Ikeda M.
        • Kodama T.
        • Miyoshi K.
        • et al.
        Clinical characteristics of COVID-19 in 104 people with SARS-CoV-2 infection on the Diamond Princess cruise ship: a retrospective analysis.
        Lancet Infect Dis. 2020; 20: 1043-1050
        • Tobolowsky F.A.
        • Gonzales E.
        • Self J.L.
        • Rao C.Y.
        • Keating R.
        • Marx G.E.
        • et al.
        COVID-19 outbreak among three affiliated homeless service sites—King County, Washington, 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 523-526
        • Tsai J.
        • Wilson M.
        COVID-19: a potential public health problem for homeless populations.
        Lancet Public Health. 2020; 5: e186-e187