Temperature Screening for SARS-CoV-2 in Nursing Homes

Evidence From Two National Cohorts

Kevin W. McConeghy, PharmD, MS; Elizabeth White, APRN, PhD; Orestis A. Panagiotou, MD, PhD; Christopher Santostefano, RN, BSN; Christopher Halladay, ScM; Richard A. Feifer, MD MPH; Carolyn Blackman, MD; James L. Rudolph, MD; Vince Mor, PhD; Stefan Gravenstein, MD, MPH

Disclosures

J Am Geriatr Soc. 2020;68(12):2716-2720. 

In This Article

Abstract and Introduction

Abstract

Background/Objectives: Infection screening tools classically define fever as 38.0°C (100.4°F). Frail older adults may not mount the same febrile response to systemic infection as younger or healthier individuals. We evaluate temperature trends among nursing home (NH) residents undergoing diagnostic SARS-CoV-2 testing and describe the diagnostic accuracy of temperature measurements for predicting test-confirmed SARS-CoV-2 infection.

Design: Retrospective cohort study evaluating diagnostic accuracy of pre–SARS-CoV-2 testing temperature changes.

Setting: Two separate NH cohorts tested diagnostically (e.g., for symptoms) for SARS-CoV-2.

Participants: Veterans residing in Veterans Affairs (VA) managed NHs and residents in a private national chain of community NHs.

Measurements: For both cohorts, we determined the sensitivity, specificity, and Youden's index with different temperature cutoffs for SARS-CoV-2 polymerase chain reaction results.

Results: The VA cohort consisted of 1,301 residents in 134 facilities from March 1, 2020, to May 14, 2020, with 25% confirmed for SARS-CoV-2. The community cohort included 3,368 residents spread across 282 facilities from February 18, 2020, to June 9, 2020, and 42% were confirmed for SARS-CoV-2. The VA cohort was younger, less White, and mostly male. A temperature testing threshold of 37.2°C has better sensitivity for SARS-CoV-2, 76% and 34% in the VA and community NH, respectively, versus 38.0°C with 43% and 12% sensitivity, respectively.

Conclusion: A definition of 38.0°C for fever in NH screening tools should be lowered to improve predictive accuracy for SARS-CoV-2 infection. Stakeholders should carefully consider the impact of adopting lower testing thresholds on testing availability, cost, and burden on staff and residents. Temperatures alone have relatively low sensitivity/specificity, and we advocate any threshold be used as part of a screening tool, along with other signs and symptoms of infection.

Introduction

Nursing home (NH) residents with SARS-CoV-2 infection have the highest mortality rates from the COVID-19 global pandemic. NH residents account for an estimated 45% of all COVID-related deaths in the United States and make up only .6% of the total U.S. population.[1] Early identification of SARS-CoV-2 by symptomatic screening of staff and residents is critical. The Centers for Disease Control and Prevention (CDC) recommends temperature and symptom-based screening for COVID-19 on admission and at least daily for all residents.[2] Fever is a common symptom of SARS-CoV-2 infection, but definitions for febrile illness lack precision and are not widely accepted.[3–5] One definition of fever is a temperature above 100.0°F or possibly two above 99.0°F. Previous screening tools have used 38.0°C and higher.[6,7] However, frail older adults may be unable to mount the same temperature response to systemic infection as young healthy individuals. A so-called normal baseline temperature for NH residents is not well described nor is an age-specific definition of fever. A previous report by our research team highlighted the poor sensitivity of 38.0°C for identifying SARS-CoV-2 infection in a cohort of U.S. veterans undergoing facility-wide testing.[8] In this report we expand those findings with two separate NH populations: (1) a cohort of veterans residing in Veterans Affairs (VA) NHs, and (2) a cohort of community NH residents from a large private multistate nursing home chain. We describe the diagnostic accuracy of temperature cutoffs and hypothesized that the traditional cutoff of 38.0°C (100.4°F) has poor sensitivity for screening SARS-CoV-2 positive cases.

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