key: cord-0798718-l0bbx2xs authors: Juhn, Young J.; Wi, Chung-Il; Ryu, Euijung; Sampathkumar, Priya; Takahashi, Paul Y.; Yao, Joseph D.; Binnicker, Matthew J.; Natoli, Traci L.; Evans, Tamara K.; King, Katherine S.; Volpe, Stephanie; Pirçon, Jean-Yves; Damaso, Silvia; Pignolo, Robert J. title: Adherence to Public Health Measures Mitigates Risk of COVID-19 Infection in Older Adults: A Community-based Study date: 2020-12-28 journal: Mayo Clin Proc DOI: 10.1016/j.mayocp.2020.12.016 sha: 793200288d78e7ff51e896544867bdb8d90d2b99 doc_id: 798718 cord_uid: l0bbx2xs Objective To assess the prevalence and characteristics of COVID-19 cases during the reopening period in older adults. Little is known about the prevalence of coronavirus disease 2019 (COVID-19) after the Stay-at-Home order was lifted in the United States, nor the actual effects of adherence to recommended public health measures (RPHM) on risk of COVID19. Patients and Methods This was a cross-sectional study nested in a parent prospective cohort study, which followed a population-based sample of 2,325 adults aged ≥50 years residing in Southeast Minnesota to assess the incidence of viral infections. Subjects were instructed to self-collect both nasal and oropharyngeal swabs which were tested by RT-PCR-based SARS-CoV-2 assay between May 8, 2020, and June, 30, 2020. We assessed the prevalence of COVID-19 cases and characteristics of study subjects. Results 1,505 eligible subjects participated in the study whose mean age was 68 years with 59% females, 3% racial/ethnic minorities, and 60% with high-risk conditions for influenza. The prevalence of other Coronaviridae (HCoV- 229E, -NL63, and -OC43) during the 2019-2020 flu season was 7%, and none tested positive for SARS-CoV-2. Almost all participants reported adhering to the RPHM (99% for social distancing, 96% for wearing mask in a public space, 98% for hand hygiene, and 96% for staying home mostly). 86% of participants resided in a single-family home. Conclusion We did not identify SARS-COV-2 infection in our study cohort. The combination of participants’ behavior in following the RPHM and their living environment may significantly mitigate the risk of COVID-19. The nationwide issuance of the Stay-at-Home policy significantly reduced the burden and transmission of COVID-19. For example, the orders were associated with a 30-49 percent reduction of cases and 60% reduction of COVID-19-related deaths during the first three weeks of issuance of the orders, 3 and this is true for the State of Minnesota. 4 As the states lifted the Stayat-Home Orders, resurgence of COVID-19 was observed at a national level. 5 In the State of Minnesota, the Stay-at-Home Order was enforced from March 27, 2020, to May 18, 2020. To date, no community-based population surveillance studies have assessed the prevalence of COVID-19 after the Stay-at-Home orders were lifted in a well-defined population in a mixed rural-urban setting of the United States. In addition, few studies assessed the influence of adherence to the recommended public health measures and social determinants of health (SDH) as factors characterizing COVID-19 cases and healthy individuals in the community. For example, a meta-analysis, which compiled 44 studies for SARS-CoV-2, SARS-CoV, or MERS-CoV primarily in health care settings, reported that adhering to the recommended public health measures including physical distancing, masks, and eye protection reduced the risk of transmission of COVID-19, SARS, or MERS. 6 However, none of these studies assessed such effects in the community. Also, while environmental conditions and SDH have been reported to be one of major risk factors for transmission of COVID-19 in the J o u r n a l P r e -p r o o f community, [7] [8] [9] [10] [11] little is known about the role of SDH on the risk of COVID-19 transmission in the community. Therefore, we assessed the prevalence of COVID-19 cases and characteristics of study subjects in a community-based sample of adults aged ≥50 years residing in Southeast Minnesota via community-based population surveillance during a period when restrictions for the Stay-at-Home order were being lifted. J o u r n a l P r e -p r o o f Study design and cohort: The study was designed as a cross-sectional study nested in a parent prospective cohort study, which enrolled a population-based sample of adults aged ≥50 years residing in SEMN and represents a stratified random sample by age, sex, race/ethnicity, and SES. Inclusion/exclusion criteria for the parent study can be found in the Supplementary Material. Subjects who agreed to participate in the present study were screened for COVID-19 symptoms J o u r n a l P r e -p r o o f and then were instructed to self-collect swabs (regardless of COVID-19 symptoms) of both the anterior nares and oropharynx (throat) using packaged testing kits distributed to consented participants between May 8, 2020, and June 30, 2020. Specimens were returned to the performing laboratory by a pre-arranged courier service within 24 hours for testing for SARS-CoV-2 by RT-PCR. The study aims were to assess the prevalence and characteristics of COVID- Instructions for self-collecting swabs of anterior nares and oropharynx: We developed instructions and workflow for self-collecting swabs of anterior nares and oropharynx (see Supplementary Material for details) as reported by others. [13] [14] [15] [16] Concordance rates for positive PCR test results for both influenza and RSV between swabs performed by research staff and selfswabs were 99% (95%CI: 94-100) in our parent study (n=98). Data analysis: We collated descriptive statistics summarizing characteristics of study subjects. Among those participating in this study, the proportion (prevalence) of subjects with confirmed COVID-19 by PCR and their characteristics were also evaluated. The funders for this investigator-initiated study had no influence on the study design, data collection, analysis, data interpretation, or writing of the report. Characteristics of study subjects: Characteristics of study subjects are summarized in Table 1 . Of the 2,325 adults who participated in the parent study, 1,508 participated in this present study and 3 subjects were excluded as 2 subjects did not have RT-PCR results for SARS-CoV-2 and 1 subject had missing survey data. There were no significant differences in demographic and clinical characteristics between those who participated and those that did not (data not shown). The mean (±SD) age of subjects was 68 years (± 9.6) and females were represented by 59%. While minority subjects 32 (2%) were under-represented in our study, 313 (21%) were rural residents, 566 (43%) were those with less than 4-year college education, 536 (38%) were those with SES below the median of our study population, 514 (35%) were current or former smokers, and 906 (60%) were those who had high-risk comorbidities for influenza (also for COVID-19). Exposure to SARS-CoV-2 among study subjects: Characteristics of exposure to COVID-19 cases at the time of testing for SARS-CoV-2 are summarized in Table 2 . Only 2% of study subjects reported being exposed to lab-confirmed COVID-19 cases at the time of testing and most exposures were outside the household (96%). 160 subjects (11%) reported to have at least one clinical symptom at the time of testing. About 9% of subjects were health care workers and 12% had traveled outside Minnesota. Most study subjects (86%) resided in a single family home whereas only 14% resided in multi-unit dwellings, mobile home communities or other group quarters. Tables 3 and 4 . As shown in Table 3 , based on self-reported public health measures for COVID-19, almost all study subjects followed the recommended public health measures (99% for social distancing, 96% for wearing mask in a public space, 98% for hand hygiene, and 96% for staying home as much as they can). Table 4 summarizes virology data based on specimens collected during the past flu season (October 2019 thru April 2020) when they had upper or lower respiratory symptoms. About 7% of subjects had infections by one or more seasonal coronaviruses (HCov NL63, HCov 229E, and HCov OC43) during the flu season (October thru April), 7% had influenza A or B. Influenza vaccination within 1 year before enrollment in the parent study and pneumococcal vaccination ever before enrollment in the parent study were 30% and 53%, respectively. concerned about systematic performance biases (from subject's specimen collection) leading to potential false negativity. However, during our study, concordance rates for both RSV and influenza between self-swab and swab by research staff were 99%. In addition, although it is not part of the current report, our ongoing work assessing the prevalence of COVID-during the flu season using the same processes and methods as the current study showed, indeed, a positive case suggesting our study findings are unlikely to be due to performance biases or errors leading to false negativity. Although our study participants over-represented the white race as a protective factor for COVID-19 raising a selection bias, it is unlikely to account for our study finding. For example, the prevalence of non-SARS-CoV-2 Coronavirus infections in our study cohort (7%, see Table 4 ) was higher than national average (4%) during the flu season. 17 The National Respiratory and for HCoV-HKU1. 17 Also, the prevalence of influenza in our study participants during COVID-19 pandemic was 7% while that of an older cohort during the pre-COVID-19 pandemic was 7% 18 . Our study subjects showed a high health care worker rate (9%), which may mean a potentially higher chance of contacting people including patients as essential workers, but also they might have had better personal protective equipment (PPE), of which the net effects are unknown but presumably higher for COVID. Our study results provide guidance to communities in terms of how to minimize the spread of COVID-19. First, as shown in Table 1 , our study cohort encompasses population features representing both reported protective (eg, predominant white race and higher proportion of females) and risk factors (eg, high frequency of high-risk comorbidities and older age) for COVID-19. Apart from these non-modifiable risk and protective factors, our study results showed almost all study subjects followed the recommended public health measures for COVID-19 as shown in Table 3 . The literature suggested only about 70-90% of people followed social distancing policy depending on age. [19] [20] [21] Given the reported evidence for preventing transmission of SARS-CoV-2, 11,22-24 this behavioral feature is likely to be a key mitigating factor protecting our study subjects from acquiring COVID-19, even though they were a high-risk population as reflected in influenza vaccination rate (lower than national average, 60% for those>65 years of age), 25 a history of smoking (national average of former smoking for adults, 21% in 2018), 26 socioeconomic background (almost 40% of subjects were below the median of HOUSES index of community population measuring SES), and rural residence (similar to national average, 19 .3%). 27 While the prevalence of exposure to lab-confirmed COVID-19 in the general population is not known, in our study only 2% were exposed to lab-confirmed cases, presumably due to almost all subjects following the recommendation of avoiding high-risk settings for exposures. Given the current unnecessary skepticism and controversies over current public health recommendations to preventing transmissibility of COVID-19, our study findings based on subjects who were protected from COVID-19 should provide guidance and reinforcement for following the recommended simple public health measures at the community, state, and national levels as shown in the recent reports. 6, 28 Second, as shown in Table 2 , 86% of our study subjects resided in single family housing units, which is higher than the national average single family homeownership rate (68% in J o u r n a l P r e -p r o o f 2020) 29 and could be another important factor mitigating the risk of COVID-19 as one of the important risk factors for COVID-19 is crowded residential units. 30, 31 This finding highlights the importance of at least one social determinant of health, such as housing or even arranging a temporary place for isolation or quarantine of affected family members for those living in crowded residential units (eg, apartments) beyond testing and tracing to mitigate the risk of COVID-19 transmissibility in the community. [8] [9] [10] Third, as shown in Table 4 , among our study subjects, 8% had seasonal coronavirus infections (HCoV 229E, NL63, and OC43), during the past flu season (October, 2019 thru April, 2020). Recent studies showed lymphocytes from 20-50% of unexposed individuals display significant reactivity to SARS-CoV-2 antigen peptide pools, [32] [33] [34] [35] and it is hypothesized, but not yet proven, that this might be due to immunity from cross reactivity to other coronaviruses and have implications for COVID-19 disease severity, herd immunity, and vaccine development. 36, 37 The role of non-SARS-CoV-2 Coronaviridae-associated pre-existing immune reactivity in the risk of COVID-19 needs to be determined in the future studies. 17 The main limitations of our study include no inclusion of a concurrent control or reference group and collection of specimens for SARS-CoV-2 testing by self-swab instead of collection by research staff (ie, possibility of false negativity for our study results). However, we believe the current single group analysis still provides valuable insight into the epidemiology of COVID-19 without including an arbitrary reference group. Community prevalence of COVID-19 in this setting is relatively low compared to national level (68 vs. 847 per 1,000,000 as of Jul 1 st 2020), so the results may not be generalizable to other study settings. Desirability bias through phone interview might have played a role in the high percentage of adhering to public health measures, although it is unlikely. In conclusion, while the prevalence of non-SARS-CoV-2 Coronavirus infections in our study cohort (7%) was higher than national average (4%) during the flu season, we did not observe subjects in this cohort testing positive for COVID-19. The combination of participants' behavior in following the recommended public health measures and a social determinant of health, such as access to a single family housing, may significantly mitigate the risk of COVID-19. The biological impact of the preceding infections with non-SARS-CoV-2 Coronaviridae and its associated pre-existing immune reactivity on the risk of COVID-19 remains to be determined. definition. If a COVID-19 close contact was endorsed, the type and timing of the contact was recorded. If there were no confirmed COVID-19 close contacts, subjects were asked about symptoms in other household members, if they were a health care provider with direct patient care or an essential worker with recent exposure to symptomatic co-workers, if they traveled outof-state within the last 14 days, if they had ever been recommended for self-quarantine, and if they had any of the following symptoms over the preceding 14 days: fever > 100.5 o F, subjective fever, cough, shortness of breath, sore throat, diarrhea, chills, myalgias, loss of smell, loss of taste, rhinorrhea, nausea or vomiting, abdominal pain, anorexia, headache, skin changes or rash, inflammation of testes (males), and other self-reported symptoms. Subjects were also asked about difficulties associated with regular daily activities, interactions with the health care system, practicing self-quarantine, social distancing, and universal precautions (eg, masking in public, hand hygiene), type of primary residence, current living situation (eg, number and ages of household members), as well as work status and type. In this parent study, we assessed infection with non-SARS-CoV-2 Coronaviridae (HCoV 229E, NL63, and OC43) at GlaxoSmithKline lab and influenza A and B at the Clinical Virology Lab at Mayo Clinic. We utilized baseline sociodemographic (age, sex, race/ethnicity, socioeconomic Spread of SARS-CoV-2 in the Icelandic Population Suppression of COVID-19 outbreak in the municipality of Vo, Italy. medRxiv The Effect of Stay-at-Home Orders on COVID-19 Cases and Fatalities in the United States Association of Stay-at-Home Orders With COVID-19 Hospitalizations in 4 States Coronavirus Disease 2019 (COVID-19) Cases in the US Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis Cities -try to predict superspreading hotspots for COVID-19 Racial Health Disparities and Covid-19 -Caution and Context Covid-19 and Health Equity -Time to Think Big Structural Racism, Social Risk Factors, and Covid-19 -A Dangerous Convergence for Black Americans Association Between Universal Masking in a Health Care System and SARS-CoV-2 Positivity Among Health Care Workers The epidemiology of gonorrhoea, chlamydial infection and syphilis in four African cities Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19) Comparison of Unsupervised Home Self-collected Midnasal Swabs With Clinician-Collected Nasopharyngeal Swabs for Detection of SARS-CoV-2 Infection Assessment of Sensitivity and Specificity of Patient-Collected Lower Nasal Specimens for Sudden Acute Respiratory Syndrome Coronavirus 2 Testing Swabs Collected by Patients or Health Care Workers for SARS-CoV-2 Testing Human coronavirus circulation in the United States Respiratory syncytial virus infection in elderly and high-risk adults Social Distancing during COVID-19 -Who, When Demographic Characteristics, Experiences, and Beliefs Associated with Hand Hygiene Among Adults During the COVID-19 Pandemic -United States What Protective Health Measures Are Americans Taking in Response to COVID-19? Results from the COVID Impact Survey Respiratory virus shedding in exhaled breath and efficacy of face masks Association of Stay-at-Home Orders With COVID-19 Hospitalizations in 4 States Universal Masking to Prevent SARS-CoV-2 Transmission-The Time Is Now Estimates of Influenza Vaccination Coverage among Adults-United States, 2017-18 Flu Season Smoking Cessation: A report of the Surgeon General New Census Data Show Differences Between Urban and Rural Populations: American Community Survey The effect of large-scale anti-contagion policies on the COVID-19 pandemic Bureau TUSC Associations Between Built Environment, Neighborhood Socioeconomic Status, and SARS-CoV-2 Infection Among Pregnant Women in New York City Associations Between Built Environment, Neighborhood Socioeconomic Status, and SARS-CoV-2 Infection Among Pregnant Women Targets of T Cell Responses to SARS-CoV-2 Coronavirus in Humans with COVID-19 Disease and Unexposed Individuals Phenotype of SARS-CoV-2-specific T-cells in COVID-19 patients with acute respiratory distress syndrome. medRxiv Presence of SARS-CoV-2 reactive T cells in COVID-19 patients and healthy donors. medRxiv Different pattern of pre-existing SARS-COV-2 specific T cell immunity in SARS-recovered and uninfected individuals Pre-existing immunity to SARS-CoV-2: the knowns and unknowns Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period Age 50 years or above at the time of consenting with a cap of 25% of subjects aged 50-59 years (to enroll a larger proportion of subjects≥60 years of age); (3) Having a primary care physician at Mayo Clinic and a history of primary care visits to Mayo Clinic; (4) Authorization to use medical records for research; and (5) Written consent to participate in the study. The exclusion criteria were: (1) No authorization for use of medical records for research but prior to enrollment and/or lack of availability for enrollment and swabbing within 5 days of symptoms; (4) Opting out for swab test and other study procedures; (5) Inability to ambulate or bedridden status Evidence of an ongoing systemic bacterial, fungal, or viral infection within 7 days prior to enrollment; and (8) Any reason in the opinion of the study PIs that someone would not be able to complete the requirements of the study for safety or other reasons Assessment of exposure to and symptoms of COVID-19 by a survey at the time of testing and Description of the telephone survey: We established detailed exposure and symptom screening algorithms based on the institutionally recommended guidelines derived from the CDC. COVID-related symptoms (eg, new fever, cough, and shortness of breath), history of travel, and close contact(s) with a person who had a laboratory All subjects who agreed to perform a self-swab for COVID-19 testing were screened by a survey and institutional algorithm for COVID-19, and if symptomatic Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19) Comparison of Unsupervised Home Self-collected Midnasal Swabs With Clinician-Collected Nasopharyngeal Swabs for Detection of SARS-CoV-2 Infection Assessment of Sensitivity and Specificity of Patient-Collected Lower Nasal Specimens for Sudden Acute Respiratory Syndrome Coronavirus 2 Testing Swabs Collected by Patients or Health Care Workers for SARS-CoV-2 Testing Equal Performance of Self-Collected and Health Care Worker-Collected Pharyngeal Swabs for Group A Streptococcus Testing by PCR Effectiveness of patient-collected swabs for influenza testing Development and initial testing of a new socioeconomic status measure based on housing data Socioeconomic Status, and Health Disparities in a Mixed Rural-Urban US Community-Olmsted County, Minnesota Socioeconomic Status, Race/Ethnicity, and Health Disparities in Children and Adolescents in a Mixed Rural-Urban Community-Olmsted County, Minnesota We developed instructions and workflow for self-collecting swabs of anterior nares and oropharynx. Detailed written and accompanying pictorial and video instructions for self-collection of swab specimens were provided to participants. Participants were instructed to place swab specimens in viral transport media (MicroTest™ M4RT® Multi-Microbe Media; Remel, Inc., Lenexa, KS) after self-collection prior to shipping. Helpful reminders to subjects included refrigeration of samples once collected and until courier pick-up, as well as review of logistics and confirmation of courier pick-up time. Self-collection of both nasal and oropharyngeal swabs at home has been suggested as an alternative to traditional nasopharyngeal swab by health care professionals for testing SARS-CoV-2, which is often difficult to perform due to contact restrictions imposed during the COVID-19 pandemic. 1-4 Therefore, at-home self-collection of both anterior nasal and oropharyngeal swabs from each participant to test for SARS-CoV-2 was implemented for this study. Concordance rates for positive PCR test results for both influenza and RSV between swabs performed by research staff and self-swabs was 99% (95%CI: 94-100) in our parent study (n=98). In addition, at Mayo Clinic, two independent studies were performed to determine the concordance between self-collected and health care professional-collected pharyngeal and nasal swabs. The results showed high concordance rates in streptococcal [95% (95% CI: 86-98)] and influenza [96% (95% CI: 90-98)] testing between patients and clinic staff. 5, 6 2. Study cohort: Our parent study cohort was composed of 2,325 subjects followed by primary care providers at Mayo Clinic, recruited as a community-based prospective cohort study of eligible adults ≥ 50 years old residing in southeast Minnesota. This cohort represents a stratified random sample by age, sex, race/ethnicity and SES of populations residing in Southeast Health care access was assessed by influenza vaccination and pneumococcal vaccination status.