Publisher Copyright: © 2021Background shared accommodation may increase the risk of SARS-CoV-2 transmission. In April 2020, an increasing number of asylum seekers at a reception centre in Espoo, Finland presented with COVID-19 despite earlier implementation of preventive measures. We decided to screen the entire population of the centre for SARS-CoV-2. Methods we offered nasopharyngeal swab collection and SARS-CoV-2 real-time polymerase chain reaction (RT-PCR) analysis to the centre's clients. Symptoms were recorded at the time of diagnostic sample collection using electronic forms and followed up for two weeks through phone interviews and a review of medical records. Findings 260 clients were screened. Of them, 96 (37%) were found positive for SARS-CoV-2 and isolated. The high attack rate prompted the local public health authority to set the other clients in quarantine for 14 days to prevent further spread. Of the positive cases, 61 (64%) reported having had symptoms at the time of the screening or one week prior. Of the 35 initially asymptomatic individuals, 12 developed symptoms during follow-up, while 23 (or 18% of all screened SARS-CoV-2 positive clients) remained asymptomatic. No widespread transmission of COVID-19 was detected after the quarantine was lifted. Interpretation in this large COVID-19 outbreak, voluntary mass screening provided valuable information about its extent and helped guide the public health response. Comprehensive quarantine and isolation measures were likely instrumental in containing the outbreak. Funding Finnish Institution for Health and Welfare, Finnish Immigration Agency, City of EspooPeer reviewe

Dub, T.

Ekström, N.

Haveri, A.

Helve, O.

Hieta, P.

Hussein, I.

Ikonen, N.

Kontunen, K.

Melin, M.

Sane, J.

Snellman, O.

Sugulle, K.

Turunen, T.

English

Julkari

COVID-19 outbreak at a reception centre for asylum seekers in Espoo, Finland

Background shared accommodation may increase the risk of SARS-CoV-2 transmission. In April 2020, an increasing number of asylum seekers at a reception centre in Espoo, Finland presented with COVID-19 despite earlier implementation of preventive measures. We decided to screen the entire population of the centre for SARS-CoV-2. Methods we offered nasopharyngeal swab collection and SARS-CoV-2 real-time polymerase chain reaction (RT-PCR) analysis to the centre's clients. Symptoms were recorded at the time of diagnostic sample collection using electronic forms and followed up for two weeks through phone interviews and a review of medical records. Findings 260 clients were screened. Of them, 96 (37%) were found positive for SARS-CoV-2 and isolated. The high attack rate prompted the local public health authority to set the other clients in quarantine for 14 days to prevent further spread. Of the positive cases, 61 (64%) reported having had symptoms at the time of the screening or one week prior. Of the 35 initially asymptomatic individuals, 12 developed symptoms during follow-up, while 23 (or 18% of all screened SARS-CoV-2 positive clients) remained asymptomatic. No widespread transmission of COVID-19 was detected after the quarantine was lifted. Interpretation in this large COVID-19 outbreak, voluntary mass screening provided valuable information about its extent and helped guide the public health response. Comprehensive quarantine and isolation measures were likely instrumental in containing the outbreak. Funding Finnish Institution for Health and Welfare, Finnish Immigration Agency, City of EspooPeer reviewe

Helsingin yliopiston digitaalinen arkisto

https://helda.helsinki.fiCOVID-19 outbreak at a reception centre for asylum seekers inEspoo, FinlandTurunen, T.2021-01Turunen , T , Kontunen , K , Sugulle , K , Hieta , P , Snellman , O , Hussein , I , Dub , T ,Melin , M , Haveri , A , Ekström , N , Ikonen , N , Helve , O & Sane , J 2021 , ' COVID-19outbreak at a reception centre for asylum seekers in Espoo, Finland ' , Journal of Migrationand Health , vol. 3 , 100043 . https://doi.org/10.1016/j.jmh.2021.100043http://hdl.handle.net/10138/341455https://doi.org/10.1016/j.jmh.2021.100043cc_by_nc_ndpublishedVersionDownloaded from Helda, University of Helsinki institutional repository.This is an electronic reprint of the original article.This reprint may differ from the original in pagination and typographic detail.Please cite the original version.Journal of Migration and Health 3 (2021) 100043 Contents lists available at ScienceDirect Journal of Migration and Health journal homepage: www.elsevier.com/locate/jmh COVID-19 outbreak at a reception centre for asylum seekers in Espoo, Finland T. Turunen a , ∗ , K. Kontunen b , K. Sugulle, Investigation, Data Curation a , P. Hieta c , O. Snellman c , I. Hussein b , T. Dub b , M. Melin b , A. Haveri b , N. Ekström b , N. Ikonen b , O. Helve b , J. Sane, Conceptualization, Supervision, Writing - Review & Editing b a Infectious Disease Unit of Espoo Municipality, Finland b Finnish Institute for Health and Welfare, Finland c Finnish Immigration Service, Finland a r t i c l e i n f o Keywords: Migrant Refugee COVID-19 Reception centre Epidemiology Outbreak a b s t r a c t Background shared accommodation may increase the risk of SARS-CoV-2 transmission. In April 2020, an increas- ing number of asylum seekers at a reception centre in Espoo, Finland presented with COVID-19 despite earlier implementation of preventive measures. We decided to screen the entire population of the centre for SARS-CoV-2. Methods we offered nasopharyngeal swab collection and SARS-CoV-2 real-time polymerase chain reaction (RT- PCR) analysis to the centre’s clients. Symptoms were recorded at the time of diagnostic sample collection using electronic forms and followed up for two weeks through phone interviews and a review of medical records. Findings 260 clients were screened. Of them, 96 (37%) were found positive for SARS-CoV-2 and isolated. The high attack rate prompted the local public health authority to set the other clients in quarantine for 14 days to prevent further spread. Of the positive cases, 61 (64%) reported having had symptoms at the time of the screening or one week prior. Of the 35 initially asymptomatic individuals, 12 developed symptoms during follow-up, while 23 (or 18% of all screened SARS-CoV-2 positive clients) remained asymptomatic. No widespread transmission of COVID-19 was detected after the quarantine was lifted. Interpretation in this large COVID-19 outbreak, voluntary mass screening provided valuable information about its extent and helped guide the public health response. Comprehensive quarantine and isolation measures were likely instrumental in containing the outbreak. Funding Finnish Institution for Health and Welfare, Finnish Immigration Agency, City of Espoo IhRA2(Research in context Evidence before this study Outbreaks of COVID-19 have been described in nursing home, hospital and homeless shelter settings, among others. Factors such as crowded living conditions and asymptomatic and presymp- tomatic shedding of the virus have been suggested to precipitate the risk of outbreaks. Added value of this study We describe what is, to our knowledge, the first documented case of a large-scale outbreak and mass screening for COVID-19 in a reception centre setting. Implications of all the available evidence ∗ Corresponding author. E-mail address: topi.turunen@espoo.fi (T. Turunen).  l  ttps://doi.org/10.1016/j.jmh.2021.100043 eceived 26 November 2020; Received in revised form 7 December 2020; Accepted 7vailable online 16 April 2021 666-6235/© 2021 The Authors. Published by Elsevier Ltd. This is an open access ar http://creativecommons.org/licenses/by-nc-nd/4.0/ ) Responding to outbreaks of COVID-19 should be prompt and not restricted by residency status. Screening by RT-PCR is useful in establishing an overall picture of an assumed outbreak. Appro- priately targeted quarantine and isolation may help in containing local epidemics. Considering the ease with which SARS-CoV-2 ap- pears to spread once introduced in a reception centre, care should be taken in accommodation of the elderly and other risk groups for severe COVID-19 during the pandemic. ntroduction There were 7 683 asylum seekers in the reception system in Fin-and as of 27 April 2020. Finland’s system for providing health services April 2021 ticle under the CC BY-NC-ND license T. Turunen, K. Kontunen, K. Sugulle et al. Journal of Migration and Health 3 (2021) 100043 f  a  F  t  s  2 c  c  p  a  a  t 1  i  m  a  r  c o  t  c  p  c  I c  p  i  2  t  H  c  s d  r  w  w  w  CM o  2  s t  t  p  W  s  P  r  f w  f  t  n  t  d  r  u  t  a  e S  a  s  c  W  wR t  t  a  p  w d  i  1  q  t  p h  a  r  f  p  (  d  bD a  e  c  u w  v  c  v  e  h t  t  h  q  r  w  ( C  i  t  C  or asylum seekers is organised and funded by migration authoritiesnd partly separate from the general public health care. However, theinnish Communicable Diseases Act identifies the prevention and con-rol of infectious diseases as the responsibility of municipalities, irre-pective of the residency status of the people involved ( Tuomisto et al.,019 ; Anon 2021a ). Factors such as crowded living conditions may expose clients to in-reased risk of COVID-19 infection ( Anon 2021b ). Nihtisilta receptionentre in Espoo, Finland, is an asylum seeker reception centre with ca-acity of 499 clients and occupancy of 409 (as of April 2020). Addition-lly, some clients registered with the reception centre live in privateccommodation outside of the centre (350 as of April 2020). Many ofhe clients work outside the reception centre. The reception centre administration undertook a number of COVID-9 preparedness and prevention measures starting in March 2020. Thesencluded moving elderly or otherwise vulnerable individuals to accom-odation outside the centre, raising awareness on proper hand hygienend physical distancing, temporarily closing recreational spaces, andearranging meal services to take into account physical distancing prin-iples. Despite the implemented measures, in April, an increasing numberf clients were reporting symptoms compatible with SARS-CoV-2 infec-ion. Diagnostic PCR tests for SARS-CoV-2 were offered to symptomaticlients. Those tested positive were isolated within the reception centreremises and their contacts traced and quarantined in their rooms in ac-ordance with the Finnish Communicable Diseases Act ( Anon 2021a ).solation sections were established within the building. At first, cases seemed to be limited to one section of the centre. Onceases with no obvious epidemiological linkage were detected, the localublic health authorities recommended screening even asymptomaticndividuals in the section in question. However, towards the end of April020, an increasing number of cases appeared in other sections, leadinghe infectious disease unit, in coordination with the Finnish Institute forealth and Welfare and the Finnish Immigration Service, to screen alllients of the reception centre for COVID-19. By the time the screeningtarted, 29 symptomatic persons had tested positive for COVID-19. The aim of the universal screening was to perform case finding, toetermine the extent of the outbreak, and to inform future public healthesponse in receptions centres and similar environments. Furthermore,e aimed to study how symptoms developed over time in those whoere asymptomatic at the time of testing. Serology following infectionas assessed from a subgroup of those who tested positive for SARS-oV-2 and will be published separately after analysis of these data. ethods All reception centre clients living in the premises and not previ-usly diagnosed with COVID-19 were invited to take part in SARS-CoV- screening. The screening of clients took place at the reception centre;taff was advised to get tested at their occupational health care unit. Nasopharyngeal swab collection was organized at the reception cen-re on three days (28th and 29th April and 6th May 2020). The real-ime polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 waserformed in two laboratories, at the Finnish Institute for Health andelfare and at a designated clinical laboratory (in addition, prior tocreening, samples of symptomatic clients had been analysed by RT-CR at another clinical laboratory). At the time of sample collection,eception centre nurses filled in an electronic symptom screening formor the participants. For those who tested positive for SARS-CoV-2, a symptom follow-upas organized by reception centre staff by phone, using an electronicorm, with the intention to repeat the questionnaire every other day un-il two weeks from diagnostic sample collection. For the ones who didot participate in the symptom screening at the time of diagnosis, or par-icipated but did not report any symptoms, we collected complementaryata from the records of the Espoo municipality in order to capture all2 eported symptoms. These records were based on a minimum of twonstructured phone interviews: one at the time of diagnosis and oneowards the end of isolation. If the subject had reported symptoms inny of these interviews or the symptom screening, they were consid-red symptomatic. We compared the clinical and demographic characteristics betweenARS-CoV-2 positive and negative screening participants using T-testnd Fisher’s exact test. Specific ethics approval was not needed for thistudy as it was performed under the mandate of the Finnish Communi-able Diseases Act and the Act on the National Institute for Health andelfare ( Anon 2021a , 2021c ). Informed consent for sample collectionas obtained in writing. Role of the funding source: None esults Out of 409 clients living at the reception centre, 260 participated inhe screening by nasopharyngeal swab and 96 (37%) were found posi-ive for SARS-CoV-2 ( Table 1 ). Of the 260 participants, 257 were livingt the centre’s premises at the time of the screening; two were staying atrivate accommodation and for one, information on place of residenceas missing. In addition to the 29 previously diagnosed clients and the 96 casesetected through screening, 2 cases were diagnosed after the screen-ng. The total number of positive cases during the epidemic was thus27/409 (attack rate: 31%). All cases were relatively mild and none re-uired hospitalization because of the infection. In this report we presenthe characteristics of only those 96 PCR-positive and 164 PCR-negativearticipants who attended the mass screening. Of the positive cases identified in the screening, 61 (64%) reportedaving had symptoms at the time of the screening or one week priornd 35 (36%) reported none. Due to limited resources and difficulty ineaching clients, the number of follow-up interviews per client variedrom none to three. The data were supplemented with Espoo munici-ality’s records. Out of the 35 initially asymptomatic individuals, 12/3534%) went on to develop symptoms during the follow-up, meaning thaturing this outbreak, only 18% of the cases (23/127) appeared to haveeen completely asymptomatic. iscussion In total, 127 clients of the reception centre, representing one third ofll persons living in the premises, tested positive for SARS-CoV-2. Thextent of the outbreak demonstrates that once introduced in a receptionentre setting, SARS-CoV-2 can spread easily, likely facilitated by these of shared spaces. As cases were detected across the entire centre and the attack rateas high, the public health authority of the municipality assumed uni-ersal risk of exposure to COVID-19 within the centre and placed eachlient in the reception centre in quarantine for 14 days in order to pre-ent further spread. The staff was advised to wear personal protectivequipment at work and to avoid close contacts with others outside ofome and work settings. The evidence base and appropriateness of mass quarantines of en-ire facilities have been rightly questioned ( Anon 2021b ). However, inhe case of this exceptionally large and widespread outbreak, compre-ensive quarantine and isolation measures were likely instrumental inuelling transmission. It should be noted that after the quarantine pe-iod of 14 days, no more cases appeared apart from a single individualho fell ill with COVID-19 mere days after the quarantine was liftedconsistent with infection contracted during the quarantine). In this population of mostly working-age adults, presentation ofOVID-19 was largely mild and no one was hospitalized because of thenfection. The transfer of at-risk individuals to accommodation outsidehe centre prior to the epidemic may have helped prevent cases of severeOVID-19. Several asymptomatic cases were detected in the screening,T. Turunen, K. Kontunen, K. Sugulle et al. Journal of Migration and Health 3 (2021) 100043 Table 1 Characteristics of the participants in the COVID-19 screening study at a reception centre for asylum seekers in Espoo, Finland. SARS-CoV-2 PCR result Positive N = 96 Negative N = 164 p -value Age, years, mean (SD) 28,523 (6 • 7) 30,754 (8 • 4) 0.027 Male, N (%) 96 (100) 143 (87) < 0.001 Reported working outside of reception centre, N (%) 54 (56) 88 (54) 0.480 Reported smoking cigarettes, N (%) 27 (28) 44 (27) 0.288 Clinical Reported having symptoms at the time of diagnostic test or one week prior, N (%) 61 (64) 24 (15) < 0.001 Fever, N (%) 24 (25) 6 (4) < 0.001 Cough, N (%) 28 (29) 9 (6) < 0.001 Sore throat, N (%) 25 (26) 8 (5) < 0.001 Runny nose, N (%) 18 (19) 8 (5) < 0.001 Shortness of breath, N (%) 10 (10) 3 (2) 0.005 Loss of sense of smell/taste, N (%) 16 (17) 2 (1) < 0.001 diarrhea, N (%) 3 (3) 1 (1) 0.144 Abdominal pain, N (%) 10 (10) 2 (1) 0.001 Fatigue, N (%) 19 (20) 9 (5) 0.001 Body temperature at the time of diagnostic test, Celcius degrees, mean (SD) 36 • 3 (0 • 8) [ N = 92] 36 • 2 (0 • 7) [ N = 156] 0.150 No symptoms reported at the time of diagnostic test or one week prior, N (%) 35 (36) 132 (80) Information on symptoms missing, N (%) 0 (0) 8 (5) a  t  o  b  b  2  t w  s  F  v  m  o l  c  a  t  t  l  l  a  g  rDC I  v  v  I  a  y  O  SA p  f  c  s  t  wRT    AA    A  K   E   A  W   nd some of them remained asymptomatic for the whole duration ofhe outbreak. The impact of asymptomatic or presymptomatic clientsn the dissemination of the virus is difficult to quantify but some contri-ution seems plausible. Asymptomatic or presymptomatic carriage haseen described earlier in the context of nursing home ( Kimball et al.,020 ; Escobar et al., 2020 ), homeless shelter ( Anon 2021d ) and hospi-al ( Wang et al., 2020 ) outbreaks. The study comes with other limitations. The coverage of screeningas suboptimal as participation was voluntary and many clients maytill have had work commitments at the time the screening commenced.urthermore, scarcity of symptom follow-up data affects the externalalidity of the results; although medical records were used to comple-ent the results of the interviews, the possibility of some missing datan symptoms cannot be ruled out. In conclusion, we describe a large outbreak of COVID-19 in an asy-um seekers’ reception centre where approximately a third of the clientsontracted the virus. Mass screening is valuable in establishing an over-ll picture in the case of an assumed outbreak and in detecting asymp-omatic and presymptomatic carriers of the virus. Quarantine and isola-ion, when appropriately targeted and enacted in accordance with localaw, can be useful in containing an outbreak. Outbreaks among asy-um seekers and refugees should be responded to as promptly as withny other population and taking into account the elderly and other riskroups for severe illness. Prevention of infectious diseases should not beestricted by residency status. eclaration of Competing Interest The authors declare no competing interests. RediT authorship contribution statement T. Turunen: Investigation, Writing - original draft. K. Kontunen:nvestigation, Formal analysis, Writing - original draft. K. Sugulle: In-estigation, Data curation. P. Hieta: Investigation. O. Snellman: Super-ision, Writing - review & editing. I. Hussein: Investigation. T. Dub:3 nvestigation, Writing - original draft. M. Melin: Supervision, Formalnalysis, Writing - original draft. A. Haveri: Investigation, Formal anal-sis. N. Ekström: Formal analysis. N. Ikonen: Writing - original draft.. Helve: Conceptualization, Investigation. J. Sane: Conceptualization,upervision, Writing - review & editing. cknowledgments We would like to thank the clients of the reception centre for theirarticipation and cooperation, Mari Saari, Essi Virtanen and Elina Sirenrom the Luona company managing the reception centre, as well as re-eption centre staff for their collaboration and valuable inputs to thetudy, Medical Centre Aava for their contribution to the sample collec-ion and analysis, and laboratory personnel at THL for their valuableork. eferences uomisto, K., Tiittala, P., Keskimäki, I., Helve, O., 2019. Refugee crisis in Finland: chal-lenges to safeguarding the right to health for asylum seekers. Health Policy 123 (9),825–832. doi: 10.1016/j.healthpol.2019.07.014 , Epub 2019 Jul 20. PMID: 31399260 .non, 2021a. Communicable Diseases Act 1227/2016. Anon https://www.finlex.fi/fi/laki/ajantasa/2016/20161227 . non, 2021b. Guidance on Infection Prevention and Control of Coronavirus Disease(COVID-19) in Migrant and Refugee Reception and Detention Centres in theEU/EEA and the United Kingdom 15 June 2020. Anon https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-guidance-refugee-asylum-seekers-migrants- EU.pdf . non, 2021c. Act on the National Institute for Health and Welfare 668/2008. Anonhttps://www.finlex.fi/fi/laki/ajantasa/2008/20080668 . imball, A., Hatfield, K.M., Arons, M., et al., 2020. Asymptomatic and presymptomaticSARS-CoV-2 infections in residents of a long-term care skilled nursing facility - KingCountry, Washington, March 2020. MMWR Morb. Mortal. Wkly. Rep. 69 (13), 377–381. doi: 10.15585/mmwr.mm6913e1 , Published 2020 Apr 3 . scobar, D.J., Lanzi, M., Saberi, P., et al., 2020. Mitigation of a COVID-19 outbreak in anursing home through serial testing of residents and staff. [published online ahead ofprint, 2020 Jul 20]. Clin. Infect. Dis. doi: 10.1093/cid/ciaa1021 , ciaa1021 . non, 2021d. COVID-19 Outbreak at a Large Homeless Shelter in Boston: Implications forUniversal Testing medRxiv preprint doi doi: 10.1101/2020.04.12.20059618 . ang, X., Zhou, Q., He, Y., et al., 2020. Nosocomial outbreak of COVID-19 pneumonia inWuhan, China. Eur. Respir. J. 55 (6), 2000544. doi: 10.1183/13993003.00544-2020 ,Published 2020 Jun 4 . 

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COVID-19 outbreak at a reception centre for asylum seekers in Espoo, Finland

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