Discovery of COVID-19 cases and contact tracing in southern German nursing homes | BMC Infectious Diseases


Study population

Reutlingen County is a predominantly rural county located in the federal state of BW in southern Germany and has a population of 286,748. 1,985 of these residents live in one of the 37 nursing homes and are cared for by 2,510 staff members. One of the retirement homes accommodates residents of various ages with neurological conditions. 27% of residents and 17% of staff are men. Resident ages ranged from 26 to 106 (median 86) and staff (including volunteers) ranged from 16 to 84 (median 45). During the period of this study, nursing homes were not accepting new residents.

Testing strategies

Swab samples were taken from nursing homes by doctors employed by the PHDR. Laboratory sequencing of swabs was performed by polymerase chain reaction. The costs for the swab tests were covered by the German government and the health insurances of those tested. All positive SARS-COV-2 test results in Reutlingen County had to be reported to PHDR according to §7 of the German National Infection Protection Act – IfSG [11].

Phase 1: Screening of suspected cases (March 8 to April 5, 2020)

Knowing that the elderly are at particularly high risk of contracting a serious infection, the PHDR decided to extend its testing to residents and staff members of nursing homes. [2]. From March 8 to April 5, 2020, nursing home residents and healthcare workers with acute respiratory symptoms or fever or pneumonia were tested for SARS-CoV-2.

Phase 2: Screenings (from April 6 to 20, 2020)

Studies indicate that approximately 56% of potentially contagious geriatric cases of SARS-COV-2 are asymptomatic and pre-symptomatic, indicating that only testing symptomatic people (as recommended at the time) would miss many cases of those who could infect others [12, 13]. With the number of COVID-19 continuously increasing in the population and nursing homes, the PHDR took the drastic decision to screen all staff and residents of all nursing homes in Reutlingen county to break the wave of COVID-19. 19.

From April 6 to 20, 2020, all residents and staff at the 37 nursing homes in Reutlingen County were offered a SARS-CoV-2 swab test via mobile testing services. Non-nursing staff and volunteer workers were also included in this selection (along with nursing staff, they are classified as ‘staff’ in this article).

Phase 3: Contact tracing (April 21 to May 23, 2020)

From April 21 to May 23, symptomatic residents and staff members without positive test results were classified as suspected cases. In “hotspot nursing homes” where ≥ 40 confirmed cases had occurred, all residents and staff who had not yet tested positive were tested as soon as another person developed general symptoms related to COVID-19. In foci with

Collection of personal data

The PHDR collected the personal data of the test persons regarding age, gender, symptoms and name of the establishment, in accordance with the German Infection Protection Act – IfSG [11]. For individuals testing positive for SARS-CoV-2, pre-existing conditions were also recorded and the clinical course of infection was monitored daily in the form of a medical diary for 2 weeks after notification of test results .


Residents who tested positive and those who tested negative for SARS-CoV-2 were isolated into separate groups. Staff members with a positive test result had to self-isolate at home. Isolation usually ended 2 weeks after the test date. However, in facilities with ≥30 confirmed cases, isolation ended after 3 weeks. All residents and staff with a negative test result were monitored daily for symptoms for 2 weeks. If they subsequently developed symptoms related to COVID-19, they and their contacts were immediately reported to PHDR and tested for SARS-CoV-2. If someone tested positive, they were isolated as described above.

Follow-up and support via the PHDR

During all phases, PHDR maintained close contact with nursing homes, monitored the progress of their outbreaks, offered consultations, and ordered hygiene and prevention measures. All COVID-19 patients were monitored daily and PHDR was notified when symptoms worsened, patients were transferred to hospital, or died. Hygiene and quarantine measures of facilities with ≥ 10 confirmed cases have been inspected at least once by PHDR. Facilities with ≥ 40 cases were inspected weekly until hygiene standards were deemed satisfactory by PHDR.

During the COVID-19 pandemic, all facility staff were required to wear full PPE. Pandemic officers have been appointed in all facilities (including homes with no cases). They have implemented and monitored hygiene standards and procedures. Residents were not allowed to leave nursing homes or receive visitors except in an emergency, according to German laws at the time. [6]. Exceptional visitors were required to wear full PPE.

The SARS-CoV-2 positive and negative cohorts were cared for by staff members who had a negative test result. There was no exchange of nursing staff between these cohorts. Only in the event of a severe nursing shortage were asymptomatic staff members with a positive test result allowed to care for residents in the positive cohort, avoiding contact with people who did not have not tested positive for SARS-CoV-2. The PHDR has established contacts between nursing homes and the Red Cross to provide additional nursing staff in the event of an immediate shortage, and with the administrative office of the district of Reutlingen for the supply of additional PPE and disinfectants if necessary.


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