key: cord-0962284-obu0ysan
authors: Balestrini, Simona; Koepp, Matthias J; Gandhi, Sonia; Rickman, Hannah M; Yen Shin, Gee; Houlihan, Catherine F; Anders-Cannon, Jonny; Silvennoinen, Katri; Xiao, Fenglai; Zagaglia, Sara; Hudgell, Kirsty; Ziomek, Mariusz; Haimes, Paul; Sampson, Adam; Parker, Annie; Helen Cross, J.; Pardington, Rosemarie; Nastouli, Eleni; Swanton, Charles; Sander, Josemir W; Sisodiya, Sanjay M
title: Clinical outcomes of COVID-19 in long-term care facilities for people with epilepsy
date: 2020-11-05
journal: Epilepsy Behav
DOI: 10.1016/j.yebeh.2020.107602
sha: 3579e5fee8382bc2f84b5c595e55b8d2f767f5ee
doc_id: 962284
cord_uid: obu0ysan

In this cohort study, we aim to compare outcomes from COVID-19 in people with severe epilepsy and other comorbidities living in long-term care facilities which all implemented early preventative measures, but different levels of surveillance. During 26-week observation period (16 March-19 September 2020), we included 404 residents (118 children), and 1643 caregivers. We compare strategies for infection prevention, control, and containment, and related outcomes, across four UK long-term care facilities. Strategies included early on-site enhancement of preventative and infection control measures, early identification and isolation of symptomatic cases, contact tracing, mass surveillance of asymptomatic cases and contacts. We measured infection rate among vulnerable people living in the facility and their caregivers, with asymptomatic and symptomatic cases, including fatality rate. We report 38 individuals (17 residents) who tested SARS-CoV-2-positive, with outbreaks amongst residents in two facilities. At Chalfont Centre for Epilepsy, 10/98 residents tested positive: two symptomatic (one died), eight asymptomatic on weekly enhanced surveillance; 2/275 caregivers tested positive: one symptomatic, one asymptomatic. At St Elizabeth’s, 7/146 residents tested positive: four symptomatic (one died), one positive during hospital admission for symptoms unrelated to COVID-19, two asymptomatic on one-off testing of all 146 residents; 106/601 symptomatic caregivers were tested, 13 positive. In addition, during two cycles of systematically testing all asymptomatic carers, four tested positive. At The Meath, 8/80 residents were symptomatic but none tested; 26/250 caregivers were tested, two positive. At Young Epilepsy, 8/80 children were tested, all negative; 22/517 caregivers were tested, one positive. Infection outbreaks in long-term care facilities for vulnerable people with epilepsy can be quickly contained, but only if asymptomatic individuals are identified through enhanced surveillance at resident and caregiver level. We observed a low rate of morbidity and mortality, which confirmed that preventative measures with isolation of suspected and confirmed COVID-19 residents can reduce resident-to-resident and resident-to-caregiver transmission. Children and young adults appear to have lower infection rates. Even in people with epilepsy and multiple co-morbidities, we observed a high percentage of asymptomatic people suggesting that epilepsy-related factors (anti-seizure medications and seizures) do not necessarily lead to poor outcomes.

positive. At Young Epilepsy, 8/80 children were tested, all negative; 22/517 caregivers were tested, one positive.

Infection outbreaks in long-term care facilities for vulnerable people with epilepsy can be quickly contained, but only if asymptomatic individuals are identified through enhanced surveillance at resident and caregiver level. We observed a low rate of morbidity and mortality, which confirmed that preventative measures with isolation of suspected and confirmed COVID-19 residents can reduce resident-to-resident and resident-to-caregiver transmission. Children and young adults appear to have lower infection rates. Even in people with epilepsy and multiple co-morbidities, we observed a high percentage of asymptomatic people suggesting that epilepsy-related factors (anti-seizure medications and seizures) do not necessarily lead to poor outcomes.

SARS-CoV-2; Vulnerable people; Surveillance; Prevention; Care Models. 

Novel coronavirus disease 2019 (COVID-19) associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has quickly spread around the world[1]. A range of typical symptoms is associated with COVID-19, including fever, cough, and dyspnoea [2] . but these may be absent in older age, and in those with multi-morbidity[3].

Long-term care facilities are high-risk settings for poor outcomes from respiratory disease outbreaks, including COVID-19, due to greater prevalence of risk factors, like age and chronic health conditions [4] [5] [6] .

Until recently, only people admitted to hospital were tested for COVID-19 in the United Kingdom (UK). Official figures for the number of deaths in the community do not provide a comprehensive account of what has happened in care-facilities [7] . These figures are likely to be underestimates due to the lack of testing.

Once COVID-19 is introduced into a care-facility, it has the potential to spread rapidly and widely, causing serious adverse outcomes among those in care and those providing it [8] [9] [10] .

Asymptomatic transmission of SARS-CoV-2 is considered the Achilles' heel for society fighting the COVID-19 pandemic [11] .

Here, we report the effect of early preventative measures and enhanced surveillance in a long-term care facility for people with epilepsy and multiple co-morbidities, and compare infection rates and outcomes with three other such facilities, which all adopted similar preventative measures, including attempts at shielding vulnerable and isolating symptomatic people, but did not have access to enhanced surveillance, and only very limited access to testing even symptomatic people.

This work was registered and independently approved by the Clinical Audit and Quality Improvement Subcommittee (Queen Square Division, UCLH University College London Hospitals Trust) as a service evaluation. This approval waives the need for approval by an ethics committee, in accordance with UK legislation and NHS operating procedures. Young Epilepsy (YE), south of London, supports children and young adults with epilepsy and other comorbidities. On this site, there is a school and a further education college, which continued to support some day-students, who were educated separately from boarders. The centre operates seven separate children's residential homes and a further 12 for young adults.

Before COVID-19 they housed 111 students. Some families, however, shielded their children at home, and during the identified period the centre supported 80 children and young adults (median age 20, range 8-25 years, 53 males), looked after by 517 caregivers.

In response to COVID-19, different sets of measures were implemented on a short timescale (starting in mid-March) to keep those in the facilities as safe as possible, given limited available resources. The measures fell into the categories of prevention and surveillance (Table 1) , and intervention.

At CCE, a program of systematic action was implemented for isolation and on-site testing for COVID-19 suspected residents. Individuals were suspected to have COVID-19 if they had a temperature >37.8°C, or a temperature rise of 1.5°C above their long-term average, and/or new persistent cough or shortness of breath. SWGC was repurposed as an isolation facility.

Any individual with suspected COVID-19 was admitted to SWGC (Figure 1 , yellow area).

Samples were obtained by nasopharyngeal and oropharyngeal swabs and tested at the Crick COVID-19 Consortium (CCC) by PCR for SARS-CoV-2 [12] . While waiting for the test results (up to 48 hours), individuals were cared for by dedicated and familiar caregivers in long shifts (i.e. 12 hours) to reduce staff contacts. Staff employed personal protective equipment (PPE) and measures recommended for caring for confirmed COVID-19 residents [13, 14] . Residents testing positive were transferred to a separate section of SWGC (Figure 1 , red area) for provision of the usual care and management, with additional vital signs monitoring using NEWS [15] . If the result of the first testing in a symptomatic resident was negative, a second test was performed after 24-48 hours. If the second testing was negative, other causes for raised temperature or other symptoms were re-considered (unless already indicated). De-isolation of negative residents took place only after 48 hours following the resolution of the symptoms. After three weeks of intensive shielding and pragmatic surveillance of all people living in the facility, a further management step became available.

This consisted of repeat enhanced surveillance of the remaining 97 of those in care, for early identification of positive residents in the asymptomatic phase [16] . Weekly rounds of enhanced surveillance testing of all those in care have been undertaken since 17 April 2020.

Naso-and oropharyngeal swabs were collected and tested as above [12] . Results were usually available within 12-48 hours and prompted isolation of identified positive asymptomatic residents in SWGC as described above (Figure 1 , red area). Tracing and testing of caregivers who had been in contact with those who had tested positive but were asymptomatic, was started within 12 hours of the original positive result. As a further preventative step, routine surveillance of all asymptomatic caregivers working on-site was commenced on 30 April 2020.

At STE, TM and YE, early preventative measures were implemented to different degrees, but no on-site testing was available initially, with individuals only tested when admitted to hospital. Individuals were isolated within their rooms whilst presenting with COVID-19 likesymptoms, and/or transferred to dedicated units upon return from hospital, if the diagnosis was confirmed. Testing for caregivers with symptoms became available at testing stations from mid-April 2020, and on-site testing for symptomatic individuals since early May. At STE, all 146 asymptomatic individuals were tested between 29 May and 05 June, and again once since then, with weekly testing of a random sample of 50 people, either residents or staff.

The authors confirm that the data supporting our findings are available from the corresponding author, upon reasonable request from bona-fide researchers.

We report the outcomes in 2047 people living and working in four different long-term carefacilities, home for 404 residents with an age range of 8-91 years.

Detailed demographic data for CCE are provided in Table 2. By 10 April 2020, two COVID-19 symptomatic residents were identified amongst the 98 individuals (2%) (Table 3, Figure 1 ).

The first (#1-1) tested positive on 03 April and was an individual in their 60s, living in a large nursing home consisting of two units with 9-10 people each. This person had severe epilepsy and multiple comorbidities, including dysphagia with percutaneous endoscopic gastrostomy (PEG) in situ. They became symptomatic on the evening of 02 April, with vomiting and subsequently pyrexia possibly related to aspiration, rapid and severe clinical deterioration with reduced oxygen saturation at ~70%, persistent high temperature not responsive to paracetamol, reduced conscious level (Glasgow Coma Scale <5). Transfer to hospital was promptly arranged and the person tested positive on 03 April; following further deterioration, death occurred six days after symptom onset.

The second (#1-2) was an individual in their 60s, with a genetic epilepsy and co-morbidities who lived in a large unit of 19 people with four self-contained flats each housing 4-5 people.

On 09 April, they became pyrexial (38.7°C) and were promptly isolated in a single room in SWGC, tested and confirmed positive. They remained clinically stable until day 3, when oxygen saturation dropped to ~85% leading to a transfer to our linked hospital facility (UCLH), given the risk of further deterioration. They tested positive again on days 7, 14 and 18, but remained clinically asymptomatic following admission, without pyrexia, and discharged back to CCE on day 40, after testing negative on two consecutive occasions.

Further details for these symptomatic individuals are provided in Table 3 .

As of 14 September, ten other individuals were promptly isolated due to the development of temperature above 37.8°C, with or without respiratory symptoms: all have repeatedly (minimum twice) tested negative and were discharged back to their residences and deisolated 48 hours after symptom resolution.

On 17 April 2020, CCE started regular weekly surveillance of residents. Of the remaining 96

people, seven were not tested in the first round as five declined and two had temporarily moved out. Of the 89 tested, four were positive (4.5%) and were immediately isolated.

On 22 April, in the second surveillance round, 95/96 were tested as only one declined Three who previously tested negative were now positive but remained asymptomatic throughout.

On 27 April, in the third surveillance round, all 96 people tested negative, including one of the asymptomatic individuals who had twice tested positive previously.

On 09 June, in the 9 th surveillance round, an 8th asymptomatic individual tested positive. Retesting on 11 and 13 June returned negative results. (see Table 4 ).

No furher positive individuals were identified in 13 further surveillance rounds, up to 14 September. June, titres for Nucleocapsid, receptor binding domain and full trimeric spike were raised, suggestive of an acute re-infection.

By 07 May 2020, three symptomatic individuals were identified amongst the 146 people living on-site (2%) ( Table 3 ).

The first (#2-1) was a young adult with epilepsy following encephalitis aged 2, dysphagia with PEG in situ and severe intellectual disability who lived in a unit with eight other people.

They were admitted to hospital on 05 March, with aspiration pneumonia following an episode of vomiting, tested then negative, and was discharged 09 March. Two weeks later, on the same day, and then tested positive. Ventilation became necessary. Death occurred 11 days after symptom onset.

The second (#2-2) was an individual in their 50s, with a genetic epilepsy who lived in the same unit as #3. On 09 April, this individual became symptomatic with fever, lethargy and cough for 1 week, after which they rapidly deteriorated with respiration rate >32 per minute and oxygen saturation <88%. They were promptly isolated and confirmed positive on 20

April, and remained in isolation until 05 May. One caregiver at the same unit showed symptoms on the same day as #2-2, and tested positive. Another caregiver was asymptomatic and tested positive on 08 May.

The third (#2-3) was an individual in their late 50s, with refractory epilepsy of unknown cause and moderate intellectual disability, who lived in a different unit to #2-1 and #2-2. The individual became symptomatic on 22 April, with mild fever and cough, but would not consent to isolation in room and so was moved to an unused area of another building.

Supplemental oxygen was used for the first few days as his oxygen saturation fell <90%, but, overall, symptoms remained mild. A positive result for COVID-19 testing was received on 01

May. The fourth (#2-4) was an individual in their early 20s, with a genetic epilepsy who was a boarder in college. The individual became symptomatic on 28 May, with mild fever. They were admitted to A&E with oxygen saturation <88% on 30 May, discharged that evening and transferred to isolation unit. A positive test result was received on 30 May; a re-swab on 03 June returned a negative result. One caregiver working in the college, but also in a hospital, was symptomatic and tested positive on 30 May.

Further details for these symptomatic individuals are provided in Table 3 .

Prior to 29 May, eight further resident were promptly isolated as they become symptomatic but only six were tested (testing was not available for the other two), and all were negative.

All eight individuals were discharged back to their residences and de-isolated 24-48 hours after symptom resolution.

A fifth (#2-5) individual tested positive on 07 May, during one of their frequent hospital admissions for recurrent urinary tract infections, but was considered asymptomatic for COVID-19 as malaise was attributed to the other health conditions, and was tested negative prior to discharge on 13 May. This individual in their late 40s lives in a different unit than the three symptomatic individuals tested positive. One caregiver from the same unit became symptomatic on 11 April and another on 08 May: both tested positive.

Between 29 May and 05 June 2020, all asymptomatic individuals living on-site were tested.

Of the 146 tested, one young adult living as a boarder attending college was found to be positive. This individual attended class together with the symptomatic boarder #2-4. One caregiver working in the college also become symptomatic a few days earlier and tested positive on 30 May. Since early June, a random sample of 50 residents or caregivers were tested weekly, so that all have been tested twice since June. One further asymptomatic individual tested positive and isolated.

From 06 April onwards, testing was available for symptomatic caregivers and those needing to self-isolate for 14 days if a household member had symptoms. Contact tracing was implemented from 02 May, with testing of all caregivers who had contact with positive individuals. Of the 601 workforce, 105 were tested once, 13 symptomatic caregivers tested positive. Enhanced surveillance was implemented at the end of May, with 50 random samples from caregivers, so that all staff members have tested twice. An additional four asymptomatic caregivers were found positive after introducing contact tracing and enhanced surveillance.

By 14 September 2020, eight symptomatic residents were identified amongst the 80 people living on-site (10%). There was no access to viral testing, but they were promptly isolated for at least 48 hours after complete resolution of the symptoms

There was no routine asymptomatic screening.

Up until 05 June, 26 of 250 staff were symptomatic, and have been tested, with two positive results.

By 14 September 2020, eight symptomatic individuals were identified amongst the 80 people living on-site (10%). All tested negative; seven were tested once, one individual twice for persistent COVID-like symptoms.

There was no routine asymptomatic screening at TM or YE.

There was no systematic testing, but at least 22 of 517 student-facing caregivers are known to have attended communal testing centres throughout this period. Only one agency nurse who had worked also at other facilities was severely ill and tested positive.

We report confirmed COVID-19 outbreaks in two out of four care facilities for people with epilepsy and additional co-morbidities. Less than 3% of individuals living in the two facilities showed COVID-19 related symptoms and tested positive. Enhanced surveillance, available at CCE, showed a high rate of asymptomatic SARS-CoV-2 infected individuals (8/10 testing positive; 80%). Our case fatality rate was high (CCE: 50%, or 10% corrected for asymptomatic; STE: 25%), but the total number of deaths, one at each of the two centres, was in line with the average death rate over similar observation periods over the last five years at each facility: there was no excess of deaths.

Our observations at CCE of a relatively low (10%) infection but high (80%) asymptomatic rates are similar to the report of initially heathy populations (3711 passengers on Diamond Princess cruise ship) with a fifth testing positive, and of those about half being asymptomatic [17] . Our higher asymptomatic rates might be explained by the difficulties of detecting mild or no symptoms in people with severe intellectual disability. Our rates are, however, dissimilar from those reported in another, similarly-sized long-term care facility with access to testing asymptomatic individuals: among 76 individuals, 48 (63%) tested positive initially with 27 (56%) asymptomatic at time of testing, but only three remained asymptomatic (6%) [4] . Their case fatality rate was also higher (26%), possibly due to a difference in population Infections of individuals living in the facilities and amongst caregivers were widespread across almost all care units at CCE (6/7) and STE (11/11) . Whilst the spread of infections was contained at CCE within 3 weeks, positive test results at STE were seen throughout the 26 weeks' observation period (see Figure 2 ). While symptom severity was similar between the two sites, we cassume that the difference in numbers of infected staff (3/275 at CCE vs 17/601 at STE, P<0.05) is likely due to enhanced surveillance available at CCE. There was no access to systematic testing at TM and YE.

Care facilities are highly vulnerable to COVID-19 outbreaks [9] [10] 18] , and it is crucial to identify effective strategies to prevent infection and to reduce impact. The approach reported here focused on two main strategies: (1) early on-site enhancement of preventative and infection control measures, (2) early identification and isolation of symptomatic individuals, with enhanced surveillance and isolation of asymptomatic people living and working at CCE as an additional measure. All centres were able to implement isolation of suspected and confirmed residents in empty or re-purposed units (see Figure 1 for CCE), avoiding hospital admission and allowing continuity of care by staff acquainted with the individuals. The use of PPE was enforced early during the pandemic, but to different degrees (see Table 1 ), mainly depending on open market sourcing rather than centralized procurement [19] . Similar early implementation of these measures in a care-facility in the US has been reported to be effective in minimizing viral spread [20] . Whilst this is reassuring, suggesting that PPE and good hand hygiene can effectively prevent transmission when in contact with confirmed positive individuals, caregivers themselves must have been pre-or asymptomatic earlier and so, unknowingly, infected colleagues and individuals under their care, as happened at CCE.

The initial spread of infection across the sites, very likely caused by healthcare workers from different care units sharing accommodation (see Figure 2) , questions the initial advice to healthcare workers of continuing to go to work despite household members self-isolating. Individuals in all centres had different degrees of intellectual disability, such that it was not possible to assess reliably for the presence of non-respiratory symptoms, which have been described involving various organs [3, 21] . For example, acute-onset anosmia may manifest either early in the disease process or in people with mild or no constitutional symptoms [22] .

Similarly, due to limited compliance, the false negative rate of testing can be expected to be higher in this population than the already quoted 20-30% [23] . Thus, enhanced surveillance through repeat testing of all 'asymptomatic' individuals is vital for case ascertainment in such settings, to identify covert transmitters and individuals at risk of rapid deterioration [24] [25] :

three of the seven asymptomatic SARS-CoV-2 positive individuals at CCE in round two tested negative during the first round of surveillance, and the first positive individual #2-1 from STE was initially tested negative on admission to hospital, but not when discharged.

According to UK public health guidance, a negative test was not required prior to discharge from hospital back to a care facility [26] . Such discharges may contribute to the risk of infection spreading within care-facilities. We also describe a case of re-infection among caregivers, a phenomenon which has been recently reported in the literature, although the mechanisms of immunity, or its loss, underlying re-infection have not been yet established [27] .

Not surprisingly, contact tracing at CCE proved difficult, not only for asymptomatic individuals testing positive without data on when the infection might have occurred, but also due to caregivers sharing accommodation (contacts of contacts, see Figure 2 ), large numbers of agency workers, in particular in CCE-Unit 2, and delay in obtaining test results (up to 5 days after testing). Testing of symptomatic caregivers at STE (13 positive out of 105 tested) and TM (2/26) returned similar numbers of positive tests in symptomatic people compared to the general UK population (as of 13 September 2020: 368,504 people/19,293,329 tests), with the official numbers not accounting for multiple tests in hospitals for the same individual (two negative tests prior to discharge). Together with a low rate of infected individuals, this is re-assuring as it suggests that early implementation of preventative and infection control measures in all four long-term care-facilities (see Table 1 ) can reduce the infection risk in high-risk environments [11] , be it for vulnerable individuals living in long-term care facilities or their caregivers, to a level similar to that observed in the general population. We also show, however, that these measures alone, without identification of asymptomatic people through enhanced surveillance, do not contain the spread of infection.

Despite the frailty and multiple co-morbidities of our population, the impact to date of SARS-CoV-2 in all the facilities has been limited. Children and young adults appear to have lower infection rates, although access to testing, even of symptomatic individuals, was limited in this age group. Enhanced surveillance, as at CCE, is required to determine the true infection rate in the younger age groups. Three of the confirmed positive individuals at CCE/STE and one of the suspected individuals at YE have an underlying genetic condition frequently observed in people with severe epilepsy, with mutation in the SCN1A gene, which is known to be associated with fever sensitivity and elevated risk of early mortality [28] Host genetic predictors of outcome in SARS-CoV-2 infections are yet to be established [29] . SARS-CoV-2 RNA mutations and additional molecular mechanisms may explain variability in clinical presentation [30-31].

We provide evidence of the need for enhanced surveillance for SARS-CoV-2 of asymptomatic people in high-risk environments. We recognize that CCE was fortunate to have extensive collaboration between basic science repurposed for high-throughput viral testing (the Francis Crick Institute), high-level virological and clinical input (from UCLH), and the ability to redeploy clinical academics (from UCL), to support dynamic and purposeful care teams. All centres benefit from close integration between health and social care with close reviews by epilepsy consultants from UCLH and/or GOSH. Such multidisciplinary input is not available to all care facilities, but the strategies outlined here may provide generally applicable guidance for other facilities facing similar challenges, in particular in preparation for a potential second wave of infection. We hope that such integration between science, healthcare and social care can also generate a new model for the care of the most vulnerable in society in the future. We must learn that there are better ways to be a civil society, to ensure that those living in care-facilities are not excluded from the expertise and interventions available for the wider population. 

This includes all symptomatic residents tested positive (red circle CCE 1-2; purple circle STE 1-4), asymptomatic tested positive (red outlined yellow circle CCE 3-10; purple outlined yellow circle STE 5-6), symptomatic caregiver (red outlined grey diamond CCE 1) who was asymptomatic when tested positive again during surveillance (red outlined yellow diamond CCE 1) after 8 negative tests; selected symptomatic staff at CCE (black outlined grey diamond CCE 2-7, self-isolating but not tested); symptomatic caregivers at STE tested positive (purple outlined grey diamond STE 1-13), and asymptomtic staff tested positive (red outlined yellow diamond CCE 1-2; purple outlined yellow diamond STE 14-16). Staff are presented in the unit where they regularly worked, arrows connect staff who are also household contacts at CCE. Timings represent date of symptom onset (symptomatic individuals), or date of self-isolation from work (staff members, who were not PCR tested), grey columns represent date of enhanced surveillance. 

Part of this work was carried out at the Francis Crick Institute, which receives core funding from Cancer Research UK (FC001169), the UK Medical Research Council (FC001169), and the Wellcome Trust (FC001169)

European Commission ITN (FP7-PloidyNet 607722), an ERC Advanced Grant (PROTEUS) from the European Research Council under the European Union's Horizon 2020 research and innovation programme (grant agreement No. 835297), and Chromavision from the European Union's Horizon 2020 research and innovation programme (grant agreement 665233). JW Sander receives research support from the Dr Marvin Weil Epilepsy Research Fund and the Christelijke Verenigingvoor de verpleging van Lijdersaan Epilepsie

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

Severe respiratory illness outbreak associated with human coronavirus NL63 in a long-term care facility

Epidemiology of COVID-19 in a Long-Term Care Facility in King County, Washington

COVID-19: Care home deaths in England and Wales double in four weeks

COVID-19: UK government is urged to publish daily care home deaths as it promises more testing

Asymptomatic Transmission, the Achilles' Heel of Current Strategies to Control COVID-19

coronavirus-infection-prevention-and-control

COVID-19-personal-protectiveequipment-use-for-aerosol-generating-procedures

Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19)

Public Health Responses to COVID-19 Outbreaks on Cruise Ships -Worldwide

The COVID-19 epidemic is posing entirely new problems for home cancer care services

Detection of SARS-CoV-2 Among Residents and Staff Members of an Independent and Assisted Living Community for Older Adults

Smell and taste dysfunction in patients with COVID-19

Clinical Performance of SARS-CoV-2 Molecular Testing

CT imaging and clinical course of asymptomatic cases with COVID-19 pneumonia at admission in Wuhan

Characteristics and outcomes of emergency interhospital transfers from subacute to acute care for clinical deterioration

Covid-19: Hong Kong scientists report first confirmed case of reinfection

Severe myoclonic epilepsy in infancy (Dravet syndrome

Epileptic Syndromes in Infancy, Childhood and Adolescence

Initial Review and Analysis of COVID-19 Host Genetics and Associated Phenotypes

The molecular biology of coronaviruses

We are grateful to all people living at the Chalfont Centre for Epilepsy, St Elisabeth, The