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Preventing COVID-19 Outbreaks in Long-Term Care Facilities Through Preemptive Testing of Residents and Staff Members – Fulton County, Georgia, March-May 2020

Our take —

This study compared two protocols for facility-wide SARS-CoV-2 testing at 28 long-term care facilities: 1) testing that occurred in response to reported cases; and 2) preventive testing of residents and staff before any reported cases. Preventive testing was associated with much lower prevalence of infection. This suggests that early testing may be effective in preventing severe outbreaks, though facilities may have differed in their underlying outbreak risks in ways that were not measured.

Study design


Study population and setting

This study compares the impact of preventive (i.e., before a known infection) versus responsive (i.e., after a known infection) testing in long-term care facilities in Fulton County, Georgia, USA from March through May, 2020. Early in the study period, limited testing supplies and staff meant testing of residents and staff was prioritized in long-term care facilities that had a known COVID-19 case. After April 29, additional resources meant that testing for staff and residents was available in long-term care facilities without a known infection. For facility-wide mass testing, nasopharyngeal swabs were used to test staff and residents, and additional cases were identified through symptom-based screening at the start of every shift for staff and at least daily for residents in the four weeks following mass testing at the facility. Symptom checks included measuring temperature and a questionnaire of COVID-19 symptoms. In total, 5,671 individuals (2,868 residents; 2,803 staff) were tested across 28 long-term care facilities (13 preventive, 15 responsive).

Summary of Main Findings

During mass testing across all facilities, 637 people (11.2%) including 484 residents (16.9%) and 153 staff (5.5%) tested positive, with an additional 348 (6.1%) cases detected during the follow-up period using symptom-based testing. Among responsive facilities (n=15), facility-wide mass testing showed a higher prevalence of COVID-19, with 28% of residents and 7.4% of staff members testing positive. In total, 42.4% of residents and 11.8% of staff tested positive in responsive facilities after including additional cases detected during the four-week follow-up period. In contrast, preventive facilities detected lower prevalence at both the initial facility-wide mass-testing (0.5% residents’ 1.0% staff) and overall (1.5% residents; 1.7% staff). This suggests that early detection was key in mitigating potential outbreaks.

Study Strengths

The study provides a practical approach to controlling COVID-19 outbreaks in the known high-risk setting of long-term care facilities, and presents data to support its effectiveness.


As acknowledged by the authors, preventive facilities may have been at lower risk of having a COVID-19 outbreak given that they did not report COVID-19 cases early on in the pandemic. The authors do not describe any potential differences between preventive and responsive facilities that may have contributed to the lower number of observed cases in preventive facilities, such as age distribution, staffing levels,and turnover of staff. Furthermore, during the study period, stay-at-home orders were mandated in Georgia (April 2), and the CDC issued guidance on infection, prevention and control (May 8). These developments may have contributed to reduced prevalence of cases in preventive facilities, as testing in these facilities occurred later relative to responsive facilities. Finally, case detection during the four-week follow-up period relied on facilities reporting any positive cases to the Fulton County Board of Health.

Value added

Long-term care facility residents are at greater risk of suffering adverse consequences from COVID-19. This study strongly suggests that preventive testing of residents and staff can mitigate the risks of large COVID-19 outbreaks.

This review was posted on: 2 October 2020