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| RESEARCH NOTE |
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| Year : 2021 | Volume
: 23
| Issue : 1 | Page : 34-37 |
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Containment of COVID-19 outbreaks in a non-COVID hospital – An experience
Kavita Raja1, EK Jyothi2, KP Dinoop2, Shiny Biju2
1 Department of Microbiology, Infection Control Unit, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2 Department of Microbiology and Hospital, Infection Control Unit, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| Date of Submission | 17-Apr-2021 |
| Date of Acceptance | 28-May-2021 |
| Date of Web Publication | 16-Sep-2021 |
Correspondence Address:
Dr. Kavita Raja
Department of Microbiology, SCTIMST, Trivandrum, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jacm.jacm_42_21
This brief communication describes the preventive measures taken to prevent the spread of COVID-19 in a non-COVID hospital and the outcome. In the initial stages of the pandemic, small clusters of cross-infection occurred within wards and intensive care units, but containment measures that are described reduced the cross-infection and spread inside the non-COVID hospital. However, reduction could also be due to the fall of infections in the community. Hence, the fact that reduction was due to these containment measures was proved by expressing the number as a percentage of the state positives, from 150 (0.13%) out of 111,891 positive in the state in September 2020 – 63 (0.04%) out of 157951 positive in the state in December 2020.
Keywords: Containment, COVID-19, non-COVID hospital, outbreak
How to cite this article:
Raja K, Jyothi E K, Dinoop K P, Biju S. Containment of COVID-19 outbreaks in a non-COVID hospital – An experience. J Acad Clin Microbiol 2021;23:34-7 |
| Introduction | |  |
The SARS CoV2 pandemic started in India when the first students from Wuhan landed in Delhi airport and were then isolated in their hometown of Thrissur. No spread occurred due to the prompt action of the health authorities. This was followed by travellers carrying the disease from outside India flying in and spreading among the community. In the first few months of lockdown, from April 2020 to the end of June 2020, the public health network in the state of Kerala efficiently tested and traced and isolated all positive cases and their contacts. When the lockdown was lifted and life slowly returned to normal, the outpatient departments (OPDs) of this super-speciality hospital with five departments, namely cardiology, cardiovascular and thoracic surgery with its paediatric unit, neurology, neurosurgery and imaging sciences with interventional radiology were soon filled to their capacity with patients. The infection control team (ICT) laid down strict protocols and guidelines to stop cross-infection within the hospital from community-acquired infection among staff and inpatients in the hospital.
In the period from March 01, 2020, to June 30, 2020, there was only one case of COVID-19 in a staff who returned from Spain, at the time when the pandemic had just started to spread in Spain, although he had a large number of high-risk contacts (since masks were not used by anybody at that time), not even one individual turned positive, probably because he came for duty wearing a mask, as per the instructions from the ICT.
Aim of this brief communication is to describe the containment measures taken before the pandemic started and the measures taken when small clusters of cross infection, developed within the hospital.
| Methods | | |
As part of pandemic preparedness, a new COVID ICT subcommittee chaired by the head of department of microbiology was constituted with a mid-level faculty from each clinical unit to coordinate the activities in the unit. The committee included the infection control nurse (ICN), assistant professor (AP) of microbiology and the nursing superintendent. The following activities were done by this ICT, before the next case of COVID-19 occurred:
- Developed a COVID infection control manual, using the protocols from WHO, CDC, MOHFW, GOI and Health Department of the state of Kerala
- Gave hands-on training to all healthcare workers (HCW) for donning and doffing PPE, proper use of masks, gloves, handwashing, ventilator care and biomedical waste management. Online webinars were also conducted on various topics related to COVID-19
- OPDs and reception areas were modified to suit the COVID protocol of social distancing and good cross-ventilation, more donning and doffing rooms were constructed in the existing areas and an isolation area was demarcated in each intensive care unit (ICU) and ward, in case an inpatient turned out to be positive for SARS CoV2
- Rounds of wards by ICN and AP, microbiology with corresponding ICT member. This was mainly to implement infection control measures described in the COVID infection control manual and also to look at the additional infrastructure put in place
- All patients who need admission for any procedure to be mandatorily tested by RTPCR for SARS CoV2.
The following protocol was followed to contain the spread of infection in a unit, by close coordination between ICN, AP, microbiology and the ICT member of the concerned unit with permission from the head of the department concerned.
After admission, if a patient develops symptoms, the patient is shifted to the COVID isolation area and nasal swab is sent for RTPCR for SARS CoV2. If positive, a detailed history is taken to find whether infected from outside or inside the hospital. If stable, the patient is shifted to Government Medical College, Trivandrum.
High-risk contacts of the patient (HCW), i.e. those who assisted in patient care, are tested by RTPCR for SARS CoV2 and sent for home quarantine for seven days. Being a hospital, healthcare workers are, if negative by repeat testing, allowed to join for duty. They are advised proper masking and self-monitoring for the next seven days. This prevents spread to co-workers and patients.
High-risk contacts of the patient (other patients) are also tested by RTPCR for SARS CoV2, shifted to isolation and closely monitored. If possible, such patients are discharged with advice to come after 14 days for re-admission. Testing is repeated on the eighth day. This prevents spread to newly admitted patients.
Low-risk contacts were advised proper masking, taking refreshments alone and close self-monitoring for symptoms.
All HCWs who were detected to be positive by RTPCR for SARS CoV2, either on surveillance or following symptoms, were questioned in detail to find the high-risk contacts and source of their infection. They were then asked to go for home quarantine for 14 days.
High-risk contacts of the HCW were defined as those who had close contact (within 1 m) for more than 15 min, while having refreshments, using the changing room or talking face to face without a mask. They were also asked to go for quarantine for seven days, followed by testing of nasopharyngeal swab by RTPCR on the eighth day.
A once-weekly surveillance of HCWs by RTPCR for SARS CoV2 was implemented with support from the members of ICT in each unit. In addition, an augmented surveillance by RTPCR for SARS CoV2 was instituted to include all HCWs in the ward when there was suspicion of an outbreak.
Biomedical waste (BMW) handling was not suspected as a cause since this is a respiratory virus and the hospital is a non-COVID hospital. Only contact and droplet precautions were used as preventive measures. The index cases got infected from the community, family and other patients. Secondary cases got infected by close contact without masks or inappropriate masking with other staff or patients who were index cases. This hospital follows the segregation of BMW as per guidelines of the Pollution Control Board.
These protocols were based on the standard operating procedure released by the National Cooperative Development Corporation.[1]
All the above data were entered into an EXCEL sheet for documentation and follow-up activities.
| Results | | |
The first inpatient to become positive by RTPCR was on July 14, 2020, in cardiology ICU. A total of 190 HCWs and 370 patients became positive up to December 2020. In September, there was a cluster of cases that developed inside the hospital due to cross-infection between the HCWs. Two more clusters occurred in October and November too, seen as peaks in the graph [Figure 1]. | Figure 1: Proportion of cases in SCTIMST, among positives of Kerala state
Click here to view |
The methods described above were implemented which reduced the incidence of infection among patients and HCWs here and thus reduced the percentage contribution of the hospital (staff and patients) to the state positives, from 150 out of 11,189 (0.13%) in September to 63 out of 157,951 (0.04%) by December[2] [Figure 1].
| Discussion | | |
This pandemic has affected the working of hospitals to a great degree. Each hospital has evolved its own strategies of prevention and control. HCWs and patients who become infected from the community were usually the index cases. The ICT moved into action when the first cluster developed in a surgical unit in September 2020 and the testing and quarantine measures described above were implemented. From then onwards, small clusters of cross-infection occurred within wards and ICUs, but the containment measures reduced the cross-infection and spread inside the non-COVID hospital. However, reduction could also be due to the fall of infections in the state. Hence, the fact that reduction was due to these containment measures was proved by expressing the number as a percentage of the state positives, which also showed a fall.
One common reason for spread among the HCWs was taking refreshments as a group and improper use of masks while taking duty at night. Another probable cause was a spread from one patient who was on ventilator and developed increased secretions, inside a non-COVID ward that was air-conditioned. Re-circulated air could have been a reason for cross-infection in that situation. Whole-genome sequencing is the only method to prove these hypotheses. A few articles that point to these factors are discussed below.
JAMA recently published in its viewpoint, a small review of papers related to hospital spread of COVID-19. On analysing several outbreaks, the key point was that community spread affects HCW and a HCW is more likely to get the infection from another staff rather than from patients. This led to a cluster of 55 cases starting from a break room in Baystate Medical Centre in Massachusetts in July 2020.[3] The author concludes that hospitals should provide airy well ventilated break rooms for its employees, stop shared rooms for patients and continue training in masking, staggering during mealtimes and statutory sick leave. These were the same measures that were implemented in our hospital also after the first cluster occurred. MMWR in its October 2020 weekly report has analysed the infection prevention activities of Minnesota Department of Health (MDH) since the first case was diagnosed in March 2020. This closely parallels our procedures when a staff member turns positive. To quote, “MDH staff members conducted 20-min telephone risk-assessment interviews with HCW who had unknown or higher-risk exposure. The interviews included questions addressing how the exposure occurred, what type of PPE (if any) was worn, and whether a PPE breach occurred; MDH staff members made recommendations regarding quarantine and symptom monitoring. HCWs who did not experience higher-risk exposure were asked to self-monitor for COVID-19–compatible signs or symptoms.”[4] They went on to find and prove that the risk of exposure without PPE was more among household contacts and long care facilities than in regular hospitals, hence the need to reinforce these measures in those facilities and in houses where a member turned positive. The importance of interventions to prevent SARS-CoV-2 exposures for HCW is highlighted by the finding that approximately one-third of high-risk exposures resulted from exposures to co-workers and to household or social contacts with COVID-19, and not through patient care. A study on genomic diversity of SARS CoV2 where the whole-genome sequencing was done in healthcare workers who were infected showed multiple introductions through community-acquired infections, and some local amplification related to specific social events in the community, rather than widespread within-hospital transmission.[5] In May 2020, the Indian Council of Medical Research reported that 1073 HCWs had been infected till date, accounting for 0.82% of the total cases in India,[6] while in this study, we found that only 0.13% were infected initially and this came down to 0.04% by December. In AIIMS, New Delhi, it was found that the COVID-19 infection rate at this tertiary care centre among the 50 quarantined HCWs was 6% (3 cases), though 76% of the quarantined had high-risk exposure. This exposure occurred mainly in non-COVID areas of the hospital. Out of the three positive cases, one had got infected from the community.[7]
| Conclusion | | |
This article describes the measures taken to prevent the spread of outbreaks of COVID within a non-COVID hospital and the outcome is shown by not a mere fall in numbers but showing how the proportion of cases contributed by the hospital also falls when compared to the total positives in the state of Kerala, as a result of the measures taken. COVID-19 outbreaks can occur within hospitals and when this occurs in a non-COVID hospital, adequate preparedness by training staff in proper use of PPE, regulating lunch breaks to reduce close contact, opening up windows for good air circulation and strict compliance to the use of masks helps in stopping the spread.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | |
| 2. | Information collected from Covid19, Health and Family Welfare Department, Government of Kerala. Available from: https://dashboard.kerala.gov in/. [Last accessed on 2021 Apr 17].  |
| 3. | Richterman A, Meyerowitz EA, Cevik M. Hospital-Acquired SARS-CoV-2 Infection: Lessons for Public Health. JAMA 2020;324:2155-6. |
| 4. | Fell A, Beaudoin A, D'Heilly P, Mumm E, Cole C, Tourdot L, et al. SARS-CoV-2 exposure and infection among health care personnel-Minnesota, March 6-July 11, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1605-10. |
| 5. | Sikkema RS, Pas SD, Nieuwenhuijse DF, O'Toole Á Verweij J, van der Linden A, et al. COVID-19 in health-care workers in three hospitals in the south of the Netherlands: A cross-sectional study. Lancet Infect Dis 2020;20:1273-80. |
| 6. | Chatterjee P, Anand T, Singh KJ, Rasaily R, Singh R, Das R, et al. Healthcare workers and SARS-CoV-2 infection in India: A case-control investigation in the time of COVID-19. Indian J Med Res 2020;151:459-67. [ PUBMED] [Full text] |
| 7. | Kumar SS, Kumar A, Kirtana J, Singh AK, Shankar SH, Khan MA, et al. Risk factors and outcome among COVID-19 exposed and quarantined healthcare workers: A study on the status of existing practices of standard precautions. Family Med Prim Care 2020;9:5355-9. |
[Figure 1]
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