key: cord-271146-levsbye2 authors: almuabbadi, basel; mhawish, huda; marasigan, bobby; alcazar, alva; alfrdan, zahraa; nasim, nasir; alharthy, abdulrahman; memish, ziad a.; karakitsos, dimitrios title: novel transportation capsule technology could reduce the exposure risk to sars-cov-2 infection among healthcare workers: a feasibility study date: 2020-07-22 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.352 sha: doc_id: 271146 cord_uid: levsbye2 nan icu. all data were collected and retrospectively analyzed. of these 190 transported patients, 100 patients had been intubated and 90 patients were on oxygen-supportive therapies. also, 109 hcws were employed for the transportation of covid-19 patients: 39 physicians, 20 respiratory physiotherapists, 20 icu nurses, and 30 paramedics (fig. 1) . apart from utilizing the capsule, all hcws used personal protective equipment according to the world health organization recommendations. 5 none of the 109 hcws became infected. moreover, all awake (ie, nonintubated) patients reported a high level of comfort during transportation. full treatment of icu patients via access ports, which facilitated emergency procedures (eg, intubation and insertion of central lines) has been possible. in conclusion, the insulated patient capsule has proven to be an efficient technology for the transportation of covid-19 patients. the capsule has shown good compatibility with ventilator circuits and full treatment of icu patients as well as ambulance stretchers. most importantly, none of our hcws was infected in the transportation process. large prospective studies are required to confirm or refute the present findings. strong associations and moderate predictive value of early symptoms for sars-cov-2 test positivity among healthcare workers, the netherlands covid-19: protecting health-care workers escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (covid-19) due to sars-cov-2 in hong kong covid-19 and the risk to healthcare workers: a case report epiguard-medical isolation and transportation systems covid-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health interim guidance acknowledgments. none.financial support. no financial support was provided relevant to this article.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-273675-0oiq44gl authors: wu, di; lu, jianyun; liu, qun; ma, xiaowei; he, weiyun title: to alert coinfection of covid-19 and dengue virus in developing countries in the dengue-endemic area date: 2020-05-04 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.187 sha: doc_id: 273675 cord_uid: 0oiq44gl coronavirus disease 2019 (covid-19) is a new outbreak infectious disease caused by sars-cov-2, which was originated from wuhan in china and has now spread to the whole world. at the meantime, dengue was endemic in the southeast asia and south america, and a part of the patients shared the same symptoms, so, we write this paper to alert the clinicians to distinguish these two diseases. to the editor-the sars-cov-2 outbreak has raised serious concerns worldwide. the world health organization (who) has raised the risk of spread to very high level, and as of march 30, 2020, a total of 634,835 cases had been reported, including 29,891 deaths. 1 gabriel yan et al 2 reported 2 cases of covid-19 patients coinfected with dengue fever in singapore. the cases shared similar diagnoses and disease courses. they both first tested negative for dengue using a rapid test, then they were discharged and returned to the hospital for persistent fever and were then diagnosed with dengue fever and sars-cov-2 coinfection. joob et al 3 also reported a patient coinfected with sars-cov-2 and dengue virus in thailand. this patient first presented with a with petechiae skin rash and was diagnosed with dengue fever. however, the patient further presented with respiratory symptoms and was rediagnosed with covid-19 infection. these 3 cases raise concern that patients with fever can be infected with both sars-cov-2 and dengue at the same time in dengue-endemic areas such as singapore, thailand, and malaysia in southeast asia and brazil in south america. according to a recent study of 1,099 patients conducted by guan et al, 4 87.9% of covid-19 patients present with fever, 67.7% present with cough, and 13.7% present with headache. some patients present only with fever when infected with sars-cov-2. in another study of 1,792 patients, 100% of dengue fever patients presented with fever and 25.7% presented with headache. 5 thus, covid-19 patients can present the same clinical signs as dengue patients. furthermore, the singapore cases were misdiagnosed and later confirmed with covid-19, 2 which shows that the misdiagnosis of the patients with atypical symptoms (as listed above) is possible. therefore, measures should be taken to distinguish patients with fever and headache from dengue fever and covid-19, and these atypical symptoms should trigger alerts, especially in developing countries with a high incidence of dengue fever, as in southeast asia and south american. we strongly recommend that rapid, sensitive, and accessible tests include a polymerase chain reaction (pcr) test of nasopharynx swabs and anal swabs. furthermore, dengue ns1, igm, and igg tests should be used to distinguish those with atypical symptoms in the developing countries facing the coming dengue endemic. covid-19) situation report -69. world health organization covert covid-19 and false-positive dengue serology in singapore covid-19 can present with a rash and be mistaken for dengue clinical characteristics of coronavirus disease 2019 in china a survey of clinical and laboratory characteristics of dengue fever epidemic from financial support. this work was supported by the national natural science conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-279639-9vd3ew41 authors: cronin, sean; piacquadio, megan; brendel, katelyn; goldberg, aden; goldberg, marco; white, chase; jaspan, david; goldberg, jay title: re: universal sars-cov-2 testing on admission to the labor and delivery unit: low prevalence among asymptomatic obstetric patients date: 2020-07-30 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.382 sha: doc_id: 279639 cord_uid: 9vd3ew41 nan to the editor-in their recent publication, goldfarb et al 1 reported a low prevalence of coronavirus disease 2019 (covid-19), 1.5%, among asymptomatic pregnant women in boston presenting for admission to labor and delivery between april 18, 2020, and may 5, 2020. noting that their rate was substantially lower than that reported in new york city, the authors theorized that it might be due to their patients (1) being tested >30 days after physical distancing orders were in place; (2) the population density of boston being less than new york city; and (3) new york women underreporting symptoms due to new york hospitals banning support people from labor and delivery. 1 studying similar universal screening in pregnant women presenting to labor and delivery at einstein medical center philadelphia during the same time frame as the boston study, we found that 9.6% of 114 consecutive asymptomatic women tested positive for severe acute respiratory coronavirus virus 2 (sars-cov-2). none of those 11 sars-cov-2-positive pregnant women had any covid-19-related symptoms. the much higher rate of asymptomatic covid-19 infections that we found (9.6% vs 1.5%) cannot be explained by the 3 theories proposed by goldfarb et al. our philadelphia covid-19 testing data are from the same period as the boston study, when physical distancing orders were also in place. although boston does have fewer people per square mile (13,841) than new york city (27,000), philadelphia has an even lower population density (11,854 people per square mile). on march 28, 2020, prior to the boston study's time frame (and ours), governor andrew cuomo announced an executive order that new york hospitals were required to allow 1 person to accompany a patient throughout their labor and delivery. this was issued several days after 2 major new york city hospital systems banned support people from labor and delivery rooms because of the coronavirus pandemic in effort to protect patients, babies, and labor and delivery healthcare providers. 2 based upon our findings, as well as others 3 , the very low rate of asymptomatic pregnant women infected with sars-cov-2 in the boston study may be an outlier during the early stages of the pandemic, with a more accurate infection rate being much higher. the higher rate of asymptomatic pregnant women infected with sars-cov-2, who may still infect healthcare providers and others, demonstrates the importance of universal testing of pregnant women admitted to labor and delivery, as well as precautions such as mask wearing and hand washing. universal sars-cov-2 testing on admission to the labor and delivery unit: low prevalence among asymptomatic obstetric patients universal screening for sarscov-2 in women admitted for delivery screening all pregnant women admitted to labor and delivery for the virus responsible for covid-19 acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. author for correspondence: jay goldberg, e-mail: jaygoldbergmd@yahoo.com key: cord-257994-i6hut28h authors: nogee, daniel; tomassoni, anthony j. title: covid-19 and the n95 respirator shortage: closing the gap date: 2020-04-13 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.124 sha: doc_id: 257994 cord_uid: i6hut28h due to extreme shortages of personal protective equipment caused by the covid-19 pandemic, many healthcare workers will be forced to recycle protective masks intended for disposal after a single use. we propose investigating the use of ultraviolet germicidal irradiation to sterilize masks of sars-cov-2 for safer reuse. the covid-19 pandemic has created an unprecedented demand for disposable particulate filtering facepiece respirators (ffrs) typified by n95 respirators in widespread use. the centers for disease control and prevention has published guidelines for optimizing supply to extend stocks through limiting use, reuse at the patient and provider levels, and alternative personal protective equipment recommendations. 1 however, these strategies may increase risk of infection in healthcare workers due to ffr contamination with sars-cov-2, further straining the overburdened healthcare system through the temporary or permanent loss of frontline physicians, nurses, and other healthcare professionals. several viral decontamination strategies have been explored to improve the safety of disposable ffr reuse without compromising protective filtration capacity and structural integrity. testing of several variants of n95 masks included in the strategic national stockpile demonstrated that they should withstand sterilization by means of exposure to ultraviolet germicidal irradiation (uvgi), ethylene oxide, or vaporized hydrogen peroxide while maintaining appropriate protective function. 2 uvgi has also demonstrated efficacy at significantly reducing influenza virus contamination from droplets and aerosols applied to n95 ffrs, 3 even with mucin or sebum soiling. 4 although no studies have yet examined uvgi effectiveness at destroying sars-cov-2, it demonstrated efficacy at destroying the original sars-cov in viral culture media. 5 a wide variety of uvgi facilities, including uvgi rooms and movable cabinets, are currently employed for sterilization of laboratory equipment, protective eyewear, manicure tools, microbiological materials, and more. based on the light source employed, such devices can be calibrated via radiometry to deliver a measured amount of ultraviolet radiation per unit surface area (joules per square centimeter) for a period sufficient to decontaminate ffrs. with appropriate instruction and oversight, smaller uvgi units may even be suitable for small facilities or point-of-care use. single-user use of an assigned individual mask may eliminate the need to consider eradication of non-sars-cov-2 pathogens introduced to the mask by the user. this approach could also increase trust and confidence in the ffr reuse program because each user will know how their mask has been cared for and how many decontamination cycles it has been subjected to. although further work will be needed to determine dosages of uvgi to effectively sterilize sars-cov-2 contaminated ffrs, uvgi provides a potential avenue for greatly extending the limited ffr supply in the face of the ongoing covid-19 pandemic in a simple, cost-effective, and rapidly deployable manner. hospitals and healthcare facilities should consider immediate implementation of collection programs for used ffrs in anticipation of near-future sterilization and reuse programs. strategies for optimizing the supply of n95 respirators evaluation of five decontamination methods for filtering facepiece respirators a pandemic influenza preparedness study: use of energetic methods to decontaminate filtering facepiece respirators contaminated with h1n1 aerosols and droplets ultraviolet germicidal irradiation of influenza-contaminated n95 filtering facepiece respirators inactivation of the coronavirus that induces severe acute respiratory syndrome, sars-cov acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-261985-ezzcgy6z authors: musa, saif a.; sivaramakrishnan, anand; paget, stephanie; el-mugamar, husam title: covid-19: defining an invisible enemy within healthcare and the community date: 2020-06-08 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.283 sha: doc_id: 261985 cord_uid: ezzcgy6z nan to the editor-the rapid dissemination of severe respiratory coronavirus virus 2 (sars-cov-2) throughout the globe has been declared a pandemic. a lack of national and internationally agreed case definitions for healthcare-associated coronavirus disease 2019 (covid-19) has led to inconsistencies in describing epidemiology, which limit comparisons. 1,2 a median incubation period of 5 (range, 1-14) days has been accepted in covid-19 guidance. 3 adapting established case definitions from other infectious diseases, such as clostridium difficile infection (cdi), may help overcome variability. 4 all cases with a positive nasopharyngeal real-time polymerase chain reaction (pcr) assay would therefore be described as either healthcare associated (ha) or community associated (ca). hospital-onset healthcare-associated (hoha) covid-19 would define current hospitalized inpatients residing >14 days. hospitalonset possible healthcare-associated (hopha) cases, in those residing between 3 and 14 days in the hospital, in the absence of suspected covid-19 on admission. new cases diagnosed within 14 days of acute-care hospital discharge would be community-onset, healthcare-associated (coha) infection. community-associated (ca) cases would refer to those diagnosed within 2 days or suspected on admission (diagnosed >2 days after admission) and no acute-care hospitalization within the previous 14 days. this group can be further subdivided into those who are independent and self-caring from their own home (coca) or those requiring social care, that is, social-onset community-associated (soca). social care includes those requiring domiciliary care (including visiting home care, extra care housing and live in homecare), admissions from care homes, community rehabilitation, and mental healthcare institutions. we retrospectively applied these definitions to 631 adult covid-19-positive patients (aged >16 years) at our acute-care institution in north london from march 1, 2020, to april 15, 2020 inclusive. the study was registered with our local clinical governance committee. because all care was routine, in keeping with uk national guidance, ethical approval was not required. in total, hoha, hopha, and coha cases accounted for 80 of 631 (12.68%) of all positive cases (fig. 1) . the rates of hoha and hopha covid-19 cases per total number of hospital admissions during this period were 32 of 1,818 (1.76%) and 32 of 1,818 (1.76%), respectively. median diagnosis occurred 25 days (iqr, 21-43) after admission for hoha covid-19 and 9 days (iqr, 6-11) after admission for hopha covid-19, respectively. for coha, 16 of 631 patients (2.54%) presented a median of 8 days (iqr, 2-11) after hospital discharge. median diagnosis of ca cases occurred 1 day (iqr, 1-2) after testing. recent nhs england guidance recommends screening all emergency hospital admissions on admission followed by a single repeat, for those testing negative, between 5 and 7 days after admission. 5 our data demonstrate that healthcare-associated covid-19 has contributed an important number of cases patients during the height of a pandemic. sequential screening of non-covid-19 hospitalized patients beyond this, possibly on a weekly basis up to 14 days after hospital discharge, may prove beneficial in further reducing the threat posed by sars-cov-2. further validation of proposed definitions is required and according to the evolution of cdi definitions, amendments are likely. prevention of nosocomial covid-19: another challenge of the pandemic fast nosocomial spread of sars-cov2 in a french geriatric unit lyon study group on covid-19 infection covid-19: infection prevention and control guidance clostridium difficile infection objectives for nhs organisations in 2019/20 and guidance on the intention to review financial sanctions and sampling rates from 2020/21 improvement. national health service england and national health improvement website operating framework for urgent and planned services in hospital settings during covid-19. national health service england and national health improvement website algorithm describing covid 19 cases presenting at our institution from financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-303680-lva35prk authors: chopra, teena; sobel, jack title: detroit under siege, the enemy within: the impact of the covid-19 collision date: 2020-04-21 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.154 sha: doc_id: 303680 cord_uid: lva35prk nan to the editor-our detroit is burning. it is not a blaze that is scorching the city we love, but an invisible enemy that has the city under siege. as covid-19 spreads its tentacles deeper into the lives of our people, we scramble to fight this new inferno in a community that is still recovering from an unfortunate past. one of the shrinking cities of the united states, detroit has faced urban decay due to a multitude of socioeconomic factors. a dramatic decline in population, loss of industrial and working-class jobs, and vanishing businesses have all hit our city hard in the last several decades. although younger people moved out of the city, most of the 700,000 stayed behind. the remaining population is disproportionately elderly lacks resources and transportation, and is heavily dependent on state help. 1,2 today, 36% of detroiters live in poverty-1 in 3 people in the city that is home to motown and the world's original automotive manufacturing center. with the city's bankruptcy in 2018 came the disintegration of a failing healthcare system, and in fiscal recovery, the critical public health framework and its safety net have not followed. with a median income of $26,000, far below the us average, we have struggled with socioeconomic and healthcare disparities. nowhere are the social determinants of health as glaring and impactful as in detroit. the high rates of unemployment and medically uninsured, in addition to reliance on a dramatically reduced auto industry for jobs, all underpin the current invasion by the covid-19 pandemic. the lockdown poses a huge barrier for daily wage earners; it is an enormous complicating factor in this dire situation. in the past decade, private investors and companies have begun to resurrect detroit by pumping new life and confidence into the economy. as their efforts began to catalyze progress, little did they know that a lethal enemy would strike down this regrowth like a tsunami. as covid-19 ravages our city, our people are hit hard. a population with an overburdened healthcare system that is underserved socially, fiscally, and educationally is ill equipped to tackle this deadly adversary. with cases doubling daily and mortality dramatically escalating, we have become the next epicenter in the united states. the growth of the infection rate and the total cumulative numbers of cases in detroit are high, with a curve steeper than that of new york due to the dangerous combination of inadequate resources and higher rates of comorbid conditions like hypertension, diabetes, and obesity. to top it off, testing has been massively inadequate. our vulnerability puts us in a very unfortunate situation. sars-cov-2 has revealed the previously unrecognized susceptibility of a vulnerable community unaware of its precarious situation. with the aggressive efforts of medical personnel and our amazing nurses and hospital staff, we will continue to combat this steep curve. covid-19 will, regrettably, take a massive toll in detroit. poverty, inadequate healthcare, higher rate of macro and microvascular disease, and an inherent mistrust of the medical community make our beloved city a perfect storm for this pandemic. at highest risk are the elderly, especially those in nursing homes. we continue to rely on appeals for social distancing and watching out for the elderly, the herculean efforts of our healthcare providers, and the generosity of philanthropists. detroit is a community built on care. we count on the spirit of our people-their resilience, courage, and ability to rise up in the face of adversity. we start each day with a renewed vigor to fight the microbial opponent and aggressive efforts to safeguard the health of our people. in the face of this perfect storm, we pray and hope that no matter what, we will ultimately contain this contagion. can we count on the grit of this great city to bounce back yet again when the world reboots after this pandemic passes? the measurement of neighborhood socioeconomic characteristics and black and white residential segregation in metropolitan detroit: implications for the study of social disparities in health city of opportunity". detroit and the great migration acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-285406-mlpqvshk authors: van praet, jens t.; claeys, bram; coene, ann-sofie; floré, katelijne; reynders, marijke title: prevention of nosocomial covid-19: another challenge of the pandemic date: 2020-04-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.166 sha: doc_id: 285406 cord_uid: mlpqvshk nan to the editor-coronavirus disease 2019 (covid-19) is an illness caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), a recently emerged novel virus that is currently spreading globally. 1 its clinical presentation varies from mild, sometimes unrecognized, respiratory symptoms to overwhelming pneumonia and multiple-organ failure leading to death. the virus is probably mainly transmitted via respiratory droplets and can survive on surfaces for several days. the incubation period varies between 4 and 14 days, and patients can be contagious before the onset of symptoms. 2 the duration of infectivity is uncertain, with one study reporting that 90% of mild cases had a negative real-time polymerase chain reaction (pcr) test by day 10. 3 on march 13, 2020, the first outpatient with covid-19 was admitted to our hospital, a 1,182-bed acute-and tertiary-care hospital in belgium consisting of 3 separate campuses. in week 13 (march 16-22), we observed that 4 patients who had been hospitalized for other reasons presented with covid-19 (table 1) . covid-19 was diagnosed based on a positive real-time pcr test from a nasopharyngeal swab and/or the presence of typical radiographic abnormalities on a computed tomography (ct) scan of the lungs. because the hospitalization duration of these patients clearly exceeded the minimal incubation period, these infections were considered nosocomially acquired, transmitted by healthcare workers or external visitors. we implemented several measures to prevent further cases of nosocomial transmission. first, from the beginning of week 12, we screened all healthcare personnel with direct patient contact for cases of low-grade fever (>37.4°c) and acute developing or worsening respiratory symptoms and tested possible cases using nasopharyngeal swabs and real-time pcr. positive screening resulted in removal from the work floor for 14 days. furthermore, we cancelled all elective consultations and procedures, and we prohibited visits to the hospital with restrictive exceptions for intensive care, pediatric wards, and obstetric wards, as required by government regulations from march 13 (end of week 12). from this day forward, all healthcare workers were obligated to wear surgical masks as personal protective equipment during patient contact, regardless of their own symptoms. additionally, we created physically separated wards for patients with or without covid-19. the number of admissions of outpatients with covid-19 increased from 5 in week 12 to 22 in week 13, 49 in week 14 and 42 in week 15, illustrating the increasing incidence of covid-19 during the beginning of the epidemic in belgium. in these same weeks, the screening positivity rates of symptomatic healthcare workers in our hospital were 8.6% (6 out of 70), 31% (17 out of 54), 39% (16 out of 41) and 28% (16 out of 57), respectively and the numbers of patients diagnosed with probable nosocomial covid-19 were 0, 4, 4, and 23, respectively. we defined probable nosocomial covid-19 as a diagnosis made beyond 4 days of hospitalization and the absence of clinical suspicion of covid-19 upon admission. of 31 probable nosocomial covid-19 infections, 22 (71%) were observed at geriatric wards. our data indicate that nosocomially acquired covid-19 can be observed at the start of a local epidemic and represents another challenge of the pandemic. despite diverse and strictly followed preventive measures, we observed increasing numbers of new cases in our hospital during the first weeks of the epidemic, especially in geriatric wards. further studies are required to identify the optimal preventive approach, which will probably include the regular screening of all asymptomatic healthcare personnel working at wards with high rates of nosocomial transmission. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia viral load of sars-cov-2 in clinical samples viral dynamics in mild and severe cases of covid-19 financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-313246-2gtiqrnj authors: hazra, aniruddha; collison, maggie; pisano, jennifer; kumar, madan; oehler, cassandra; ridgway, jessica p. title: coinfections with sars-cov-2 and other respiratory pathogens date: 2020-07-03 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.322 sha: doc_id: 313246 cord_uid: 2gtiqrnj nan in march 2020, our laboratory (university of chicago medicine) began in-house real-time reverse transcriptase-polymerase chain reaction (rt-pcr) testing for sars-cov-2 from nasopharyngeal (np) swabs (roche cobas sars-cov-2 rt-pcr assay, xpert xpress sars-cov-2 test). notably, no cross reactivity with non-sars-cov2 coronaviruses has been observed with these assays because primer design is specific to the sars-cov-2 genome. 3 the same specimen can be tested via rt-pcr for a respiratory panel (rp) of other common pathogens, including adenovirus, coronavirus 229e/hku1/nl63/oc43, human metapneumovirus, influenza a/b, parainfluenza 1-4, respiratory syncytial virus, mycoplasma pneumoniae, chlamydophila pneumoniae, bordetella pertussis, and rhinovirus/enterovirus (biofire filmarray respiratory panel 2). this report examines patients with influenza-like illness symptoms who were simultaneously tested for sars-cov-2 and the above panel from march 12, 2020, through april 15, 2020. we stratified the specimens by sars-cov-2 positivity and compared those that tested positive for a rp pathogen in each group with the χ 2 test and the fisher exact test. we also calculated the median age in each subgroup and compared them using a 2-sample t test with equal variances. all statistical testing used a p < .05 level of statistical significance. we used stata version 15 software (statacorp, college station, tx) for all analyses. during the observed period, 2,535 specimens were simultaneously tested for sars-cov-2 and rp pathogens on 2,458 symptomatic patients. the overwhelming majority of tests (1,214 of 2,535, 47.9%) were collected in the emergency department or from inpatients (1,042 of 2,535, 40.1%). overall, 459 (18.1%) were positive for sars-cov-2 and 364 (14.4%) were positive for at least 1 rp pathogen. the most common rp pathogens found were rhinovirusenterovirus (7.1%), influenza a (2.1%), coronavirus nl63 (2.1%), and human metapneumovirus (2.0%). of the specimens positive for sars-cov-2, 15 (3.3%) were also positive for at least 1 rp pathogen (table 1) . patients coinfected with sars-cov-2 and a rp pathogen (median, 39 years) were significantly younger than those with only sars-cov-2 infection (median, 58 years; 95% confidence interval [ci], 2.2-20.7; p = .02). these coinfections were most common with rhinovirusenterovirus (8 of 15, 53%). of those negative for sars-cov-2, 349 (16.8%) were positive for at least 1 rp pathogen and 33 (1.8%) were positive for 2 or more rp pathogens. detection of any rp pathogen was significantly lower in specimens positive for sars-cov-2; coronavirus nl63, human metapneumovirus, influenza a, respiratory syncytial virus, and rhinovirus/enterovirus occurred significantly less frequently in specimens positive for sars-cov-2. our results suggest that infection with other respiratory pathogens is uncommon among patients with covid-19. notably, the median age of coinfected patients was nearly 20 years younger than those only infected with sars-cov-2. this observation is consistent with established literature that community-acquired viral coinfections are more common in younger populations. 4 the difference in coinfection frequency from recently published reports may be partially explained by seasonal and geographic variability in respiratory pathogens. during the study period, the illinois department of public health noted a decline in influenza tests positivity from 14.9% to 1.6% between the weeks ending march 14, 2020, and april 11, 2020, respectively. 5 as rates of infection due to influenza and other seasonal respiratory pathogens continue to decline into summer, coinfections among patients with covid-19 are expected to decrease as well. notably, differences in clinical presentation and any concurrent microbiologic data were not investigated in this brief report; further analysis of these variables may offer clarity on which patients are at highest risk for coinfection. in the setting of limited sars-cov-2 testing and concerns for low sensitivity of sars-cov-2 rt-pcr, many hospitals utilize rp results to determine the likelihood of covid-19 among puis. although further evaluation of different institutional and regional experiences is needed to improve testing algorithms, our results support this use of rps to risk stratify symptomatic puis where widespread sars-cov-2 testing may still not be available. note. sars-cov-2, severe acute respiratory syndrome coronavirus. a statistical significance determined by both χ 2 and fisher exact tests; χ 2 p values listed. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study rates of coinfection between sars-cov-2 and other respiratory pathogens interpreting diagnostic tests for sars-cov-2 viral pneumonia illinois department of public health website acknowledgments.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-278130-x83kl052 authors: wander, pandora l.; orlov, marika; merel, susan e.; enquobahrie, daniel a. title: risk factors for severe covid-19 illness in healthcare workers: too many unknowns date: 2020-04-27 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.178 sha: doc_id: 278130 cord_uid: x83kl052 nan to the editor-we were very interested to read the recent letter by zhou et al, "protecting chinese healthcare workers while combating the 2019 novel coronavirus." 1 we agree that everything possible should be done to protect healthcare workers (hcws) from developing covid-19. we agree with the recommendations of zhou et al including the importance of increasing production of personal protection equipment (ppe), training hcws in proper use, and maintaining a high clinical suspicion for covid-19 even in patients without respiratory symptoms. in addition, we call for more research into the risk factors leading to severe illness among hcws, defined as covid-19 requiring hospitalization or admission to the intensive care unit. 2 research in this area is sorely lacking, limiting implementation of evidence-based practices. despite being younger and healthier than the general population with covid-19, hcws have similar rates of severe illness. in china, the proportion of hcws with severe illness decreased from 45% in early january 2020 to 9% after february 1, 3 likely reflecting more consistent adoption of appropriate infection-control practices, including the use of ppe. however, severe illness among hcws continues to be reported, suggesting that the use of currently approved infection control processes do not entirely prevent severe covid-19 among hcws. to explore risk factors for severe covid-19 in hcws, we performed structured searches using a twitter analytics tool (tweet archivist, seattle, wa) to identify news stories reported before march 16, 2020, about hcws with severe covid-19related illness (n = 6 cases) ( table 1 ). in most of these articles, neither high-risk host factors nor a clear high-inoculum exposure was evident, but in a few reports, potential exposure to inocula containing a high viral load was reported, including potential exposures to virus in stool. in 10% of cases, gastrointestinal symptoms precede fever or respiratory symptoms by 1-2 days. 4 furthermore, 60% of samples from the toilet, sink and door handles of an individual with sars-cov-2 were positive for viral rna, even though the individual reported respiratory symptoms but not diarrhea. 5 for hcws, contact with surfaces and/or patients with these symptoms could represent opportunities for high-inoculum exposure. during the sars epidemic, sars-cov rna was detected in stool in greater quantities than any other site, 6 leading the world health organization to conclude that, "diarrhoea could still remain important for infectivity, regardless of its cause." although sars-cov-2 rna is readily found in stool, 7 whether replicating virus is present is less clear. however, ace2 receptors, which are used by the virus to infect cells, are present in the gi tract, 7 making it plausible that the gi tract is an active site of viral replication. we therefore postulate that exposure to virus from high-viral load sites such as stool should be formally evaluated as an ongoing risk factor for severe covid-19related illness in hcws. to facilitate research in this area and to ensure adequate power, we suggest that deidentified information about hcw cases be shared in national data repositories so that these and other risk factors can be assessed and the workforce can be adequately protected. in the meantime, institutions, if not already doing so, should screen for diarrheal symptoms. protecting chinese healthcare workers while combating the 2019 novel coronavirus characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72,314 cases from the chinese center for disease control and prevention novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient viral shedding patterns of coronavirus in patients with probable severe acute respiratory syndrome what should gastroenterologists and patients know about covid-19? two women fell sick from the coronavirus, one survived chinese doctor, silenced after warning of outbreak, dies from coronavirus evergreenhealth doctor tests positive for coronavirus, in critical condition american college of emergency physicians website colleagues mourn italian 'hero' physician killed by covid-19 acknowledgments. none.financial support. no financial support was provided relevant to this article.conflicts of interest. tweet archivist is owned by dr. wander's family. all authors report no conflicts of interest relevant to this article. key: cord-273477-ifhgbm2e authors: lee, joon kee; jeong, hye won title: wearing face masks regardless of symptoms is crucial for preventing the spread of covid-19 in hospitals date: 2020-05-06 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.202 sha: doc_id: 273477 cord_uid: ifhgbm2e nan to the editor-as of april 16, 2020, the number of confirmed cases of pandemic coronavirus disease 2019 (covid-19) has reached 1,991,512, with 130,885 associated deaths. 1 although the numbers of confirmed cases and deaths continue to increase steeply through person-to-person transmission, asymptomatic or presymptomatic covid-19 infections mean that mitigating community spread by isolating patients has limitations. 2, 3 preventing outbreaks in healthcare centers is crucial because the demand for healthcare services is high, and mixing infected persons with those who are immunocompromised and/or elderly is almost unavoidable in these settings. the centers for disease control and prevention (cdc) of the united states and the korean centers for diseases control and prevention (kcdc) have provided guidelines for infection control measures at healthcare facilities. 4, 5 in addition to the use of personal protective equipment by healthcare workers (hcws), ensuring that all visiting patients and guardians wear face masks and adhere to strict hand hygiene protocols is crucial. here, we share our experience in preventing the spread of sars-cov-2 within a hospital through strict monitoring at the hospital entrance by ensuring that all visitors wear face masks and practice strict hand hygiene. in south korea, the first covid-19 patient was diagnosed on january 20, 2020. since then, chungbuk national university hospital (cbnuh), an 810-bed referral hospital in cheongju with 2,300 employees and 3,000 outpatient visits per day, has undertaken hospital entrance control measures. these measures include reducing the number of unnecessary access points, checking the body temperatures of visitors using a thermal camera, and ensuring that all visitors and employees adhere to hand hygiene protocols and wear face masks, regardless of symptoms. the number of gates to the hospital was reduced from 5 to 2 during the day and to 1 at night. on march 26, 2020, a point when almost 50% of covid-19 cases in south korea were imported from foreign countries, the regional public health office notified us that a 60-year-old female covid-19 patient had visited cbnuh the day before. the kcdc requested an in-hospital epidemiologic investigation of all close contacts because they needed to quarantine them for at least 14 days. we started contact investigations using a photo of the patient and closed-circuit television recordings of the hospital entrance area. we identified the patient trying to enter the hospital. the alarm of the thermal camera was activated because the patient had a fever. to confirm the fever, a contactless thermometer was used by the hospital guard to check her body temperature, which was 38.3°c. the patient was guided to the covid-19 screening clinic in a separate area of the emergency department. nevertheless, the patient tried to re-enter the hospital through another gate. similarly, the thermal camera was activated, and officials returned her to the covid-19 screening clinic. the patient and all personnel who encountered her were wearing face masks. we identified 3 persons who had come into close contact with the patient: 2 hospital security guards who were wearing face masks, and 1 hospitalized patient who passed by within 2 meters and was not wearing a face mask. even though the contact was brief, those who had close contact with this patient self-monitored with delegated supervision for 14 days, 6 and none became ill with covid-19. although face masks cannot completely prevent covid-19, patients spread the virus through coughing, 7 and face masks may reduce the number and travel distance of respiratory droplets. 8 to prevent hospital spread of covid-19, hospital entrance control, wearing of face masks, and strict hand hygiene protocols appear to be effective. wearing eye shields protects hcws in case of an accidental encounter with patients not wearing face masks. 4, 5 individual preparedness in accord with major guidelines is crucial in preventing the spread of sars-cov-2 in healthcare centers. covid-19) situation report -87. world health organization website a familial cluster of infection associated with the 2019 novel coronavirus indicating potential personto-person transmission during the incubation period presumed asymptomatic carrier transmission of covid-19 interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings interim us guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease 2019 (covid-19) effectiveness of surgical and cotton masks in blocking sars-cov-2: a controlled comparison in 4 patients rational use of face masks in the covid-19 pandemic acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-271360-2s6h4u8p authors: gon, giorgia; dancer, stephanie; dreibelbis, robert; graham, wendy j.; kilpatrick, claire title: reducing hand recontamination of healthcare workers during covid-19 date: 2020-04-06 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.111 sha: doc_id: 271360 cord_uid: 2s6h4u8p nan to the editor-worldwide, the response to the covid-19 pandemic requires hand hygiene compliance by everyone, as highlighted in the who #safehands campaign and numerous documents. hand hygiene is particularly critical for frontline healthcare workers (hcws) who are overstretched and for whom this key routine task must be easy to complete and effective. 1 however, a neglected aspect of hand hygiene, even in the absence of a global pandemic, is the risk of touching surfaces or objects that could recontaminate hands after hand rubbing or washing, whether gloves are worn or not. infection prevention is key during this pandemic, and reducing hand recontamination is important to ensuring patient and hcw safety at all times. avoiding recontamination is implicit in the who hand hygiene guidelines for health facilities. 2 failure to comply with hand hygiene can result from not washing or rubbing hands at the right time or from subsequent hand or glove recontamination. in a recent study in tanzania during which 781 hand hygiene indications were observed, approximately half of the times when birth attendants rubbed or washed their hands, they then recontaminated their hands on potentially unclean surfaces before performing an aseptic procedure. 3 similar findings come from obstetric wards in nigeria and ghana. 4, 5 recontamination is not only a problem in low-income settings. a us study demonstrated microbiological recontamination of hands at the point of care despite high levels of self-reported hand hygiene compliance. 6 reports from the united kingdom and australia show that hcws touch privacy curtains between hand hygiene and touching a patient. 7 the tanzanian study also suggested that hand rubbing or washing and glove recontamination are underpinned by different behavioral determinants. 8 without targeting these 2 behaviors separately, hand hygiene initiatives during this pandemic may be undermined. hcws are able to prioritize patient needs when providing routine care. however, the covid-19 pandemic has introduced significant uncertainty into the care environment and thus workflow, including timing of necessary procedures, anticipating and managing patient volumes, and rapidly evolving guidelines on patient management. during this crisis, hand hygiene, along with other infection control activities, may be compromised, not because it is not a priority but rather because staff may be too busy or uncertain on how to implement hand hygiene in this outbreak setting. in their ethnography of infection prevention in australia, hor et al 9 state that understanding the "boundaries of what is clean" is not straightforward in hospital departments and that hcws have different perceptions over whether certain surfaces could potentially lead to cross transmission. recontamination may be an indication that staff fail to understand the definition of the who hand hygiene recommendations or how those apply in rapidly changing healthcare settings. 3 an understanding of surfaces that are safe to touch depend upon assumptions about appropriate cleaning of surfaces, cleaning frequencies, established methods, and sufficient trained cleaning staff. in spite of amazing efforts from all staff, including environmental cleaning staff, standards are not always optimal in the united kingdom, as in many other countries. 10 surface contamination played a plausible role in sars, mers, and pandemic influenza transmission in healthcare settings. emerging evidence suggests that the virus responsible for the current pandemic (sars-cov-2) can survive on common surfaces for days, but viral demographics and characteristics have yet to be sufficiently studied. 11 recontamination of hands is a consequence and a source of poor surface cleanliness (fig. 1, steps 5 and 7) . we call for greater attention to the risk from hand recontamination and the opportunity for its prevention through empowering hcws and strengthening cleaning of the care environment. for those managing covid-19 cases, these actions will improve their own and coworkers' safety as well as that of all patients and visitors. like so much in the covid-19 response, behavior change plays a key part. behavior change needs to be tailored and targeted. following michie's principles for behavior change during the covid-19 pandemic, 1 we recommend the following: fig. 1) , in relation to hand hygiene, especially before a clean or aseptic procedure. 2. social norms: managers and their colleagues should lead by example by demonstrating appropriate hand hygiene including avoiding recontamination. hand hygiene protocols should be followed by everyone involved in patient care. 3. emotion: the importance of recontamination in patient and hcw safety needs to be clearly emphasized. 4. replace the behavior to stop the habit: "keep hands off unsafe surfaces" rather than "do not touch unsafe surfaces." 5. make it easy: create a user-friendly environment that facilitates hand hygiene and reduces opportunities for recontamination. the environment needs to account for the workflow for patient management, allowing for minimal opportunities to recontamination when collecting equipment or moving between patients. the environment should also include appropriate cues to remind and trigger hand hygiene, such as strategic placement of handrub dispensers. slowing down the covid-19 outbreak: changing behaviour by understanding it who guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care hand washing, glove use, and avoiding recontamination before aseptic procedures at birth: a multicenter time-andmotion study conducted in zanzibar hygiene during childbirth: an observational study to understand infection risk in healthcare facilities in kogi and ebonyi states, nigeria obstetric infection control in a developing country hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission antimicrobial resistance & infection control website behavioural determinants of hand washing and glove recontamination before aseptic procedures at birth: a timeand-motion study and survey in zanzibar labour wards beyond hand hygiene: a qualitative study of the everyday work of preventing cross-contamination on hospital wards measuring the effect of enhanced cleaning in a uk hospital: a prospective cross-over study aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 key: cord-268935-4obwu75u authors: lepak, alexander j.; shirley, daniel k.; buys, ashley; stevens, linda; safdar, nasia title: implementation of infection control measures to prevent healthcare-associated transmission of severe acute respiratory coronavirus virus 2 (sars-cov-2) date: 2020-10-12 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.1262 sha: doc_id: 268935 cord_uid: 4obwu75u care of sars-cov-2-positive patients in healthcare institutions is challenging because of potential risk of transmission to other vulnerable patients. we describe infection control measures which were associated with no instances of hospital transmission. adoption of the infection control bundle described may be helpful to prevent sars-cov-2 spread within healthcare institutions. (eua)-approved rt-pcr testing methods. patients who were tested as outpatients, those tested in the emergency room or urgent care clinics, and those tested within the first 24 hours of an admission were excluded. notably, repeated inpatient testing of individuals was, in general, directed toward those undergoing procedures, those in whom signs or symptoms suggested possible covid-19, those with acute changes in status requiring intensive care unit (icu) or intermediate (imc) care, and/or based on provider judgment. in total, 720 patients were tested >24 hours after admission to an inpatient unit, and the total number of inpatient sars-cov-2 tests was 1,007. the median age was 59 years (iqr, 40-69) and 52% were male. the reason for testing was skewed toward asymptomatic screening preceding procedures (71%). this finding was expected because repeat preprocedural testing was directed to be done within 48 hours prior to any aerosol-generating procedure. of 1,007 inpatient tests, 59 tests (5.9%) were positive and 58 were known to be positive prior to inpatient testing (eg, positive prior to admission or as part of admission work-up). thus, only 1 patient (0.1%) tested positive during an inpatient stay in which that patient was not known to have a history of a positive test. over the study period, we had a sizeable covid-19 inpatient population (112 inpatients with 1160 inpatient days) and a large at-risk pool of inpatients without covid-19 (37,096 inpatient days). for the single positive inpatient without a prior history of sars-cov-2, chart review revealed that this adult patient lived in a community setting, had mild symptoms (sinus congestion, eye pain, and cough) that started 10 days prior to admission, and was self-isolating at home. the patient presented with a myocardial infarction before universal admission testing was instituted, and the prior mild respiratory symptoms were not noted. on hospital day 4, the patient tested positive as part of pre-procedure screening. we believe that infection was present from community exposure prior to admission; therefore, we did not find any laboratory-confirmed cases suggestive of possible nosocomially acquired sars-cov-2 infection despite a substantial inpatient population with and without covid-19. it has been suggested that false-negative results may occur, but negative-to-positive conversion has rarely occurred at our institution (<1%). 10 we were able to achieve these results without routine, serial testing of asymptomatic healthcare workers (hcws), and we had a low threshold for testing hcws with symptoms with a 1% rate of infection in our hcws. our study has several limitations. first, this was a retrospective observational study. second, because testing was limited to inpatient setting, we were not able to ascertain symptom onset after discharge, which may have resulted in testing elsewhere. however, we examined all positive ambulatory tests and did not find any positive results in patients within 7 days of discharge from our hospital. finally, we were unable to examine the relative effect of each individual infection control measure. our study has a number of strengths. as the single positive case we found demonstrates, it can be difficult to identify all potential positive patients by history taking alone. thus, we strongly believe that universal testing of patients admitted to the hospital should be performed. this testing should be followed by targeted testing based on daily, protocol-driven screening questions to determine whether any symptoms have changed that suggest possible covid-19. these first 2 measures aim to rapidly identify patients that should be placed in transmission-based isolation and to help prevent inadvertent spread. however, additional measures are obviously necessary to prevent nosocomial spread from known sars-cov-2-positive patients who may need complex medical care including intensive care, multiple-specialty care, invasive procedures or surgery, and intrahospital transport. these measures include meticulous infection control measures described here. in conclusion, using iterative implementation of infection control measures we were able to care for numerous covid-19-infected and -uninfected patients without any cases of nosocomial spread. why did outbreaks of severe acute respiratory syndrome occur in some hospital wards but not in others? covid-19-new insights on a rapidly changing epidemic high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2 a conceptual discussion about r0 of sars-cov-2 in healthcare settings presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility presumed asymptomatic carrier transmission of covid-19 transmission potential of asymptomatic and paucisymptomatic severe acute respiratory syndrome coronavirus 2 infections: a 3-family cluster study in china molecular and serological investigation of 2019-ncov infected patients: implication of multiple shedding routes virological assessment of hospitalized patients with covid-2019 utility of repeat nasopharyngeal sars-cov-2 rt-pcr testing and refinement of diagnostic stewardship strategies at a tertiary care academic center in a low prevalence area of the united states acknowledgments. the content of this articles is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health.financial support. this research was supported by the national institute of allergy and infectious diseases of the national institutes of health office of the director (grant no. dp2ai144244). all authors report no conflicts of interest in relation to this study. key: cord-273500-u8m59f17 authors: slade, david h.; sinha, michael s. title: return to work during coronavirus disease 2019 (covid-19): temperature screening is no panacea date: 2020-09-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.1225 sha: doc_id: 273500 cord_uid: u8m59f17 nan to the editor-in the midst of the current pandemic, employee screening is a critical component of reopening businesses, but cost is an important consideration. 1 screening involves a designated individual asking symptom-related questions and performing a temperature check of employees as they enter the premises. some state governors have issued executive orders requiring temperature checks, and many large businesses have implemented automated systems for checking temperature, including amazon and emirates airlines. the centers for disease control and prevention (cdc) recommends that employers implement symptom and temperature screening. 2 the centers for medicare and medicaid services (cms) also requires this screening and will be auditing healthcare facilities to ensure compliance. failing to comply would place hospitals at risk of losing medicare funding and incurring major financial losses. temperature screening for coronavirus disease 2019 (covid-19) is thought to have little down side, but in practice it does little to prevent the spread of the virus. the cost of paying staff and the oversight required to implement and monitor such a program diverts valuable resources away from more effective measures. temperature screening can be performed in several ways: (1) home screening using commercial thermometers; (2) in person temperature measurement with noncontact infrared thermometers; and (3) automated noncontact thermal imaging cameras. home screening is the most cost-effective option, but in practice employees cannot be relied upon to consistently and accurately measure and self report temperature. for in-person screening, noncontact infrared thermometers can be used at employee entrances, but the close contact required for measurement places both parties at risk of covid-19 transmission. measurements are frequently inaccurate due to inaccurate positioning of the thermometer relative to the examinee, and the cost of paying an hourly employee to perform screening is high and not feasible for after-hours access. at first glance, temperature screening seems highly appealing, in that it offers objective data for monitoring employees. yet when implemented at scale, the cost of temperature screening can quickly escalate to millions of dollars. to reduce costs associated with hiring employees for screening, thermal imaging cameras may appeal to some as a one-time investment with low cost of maintenance. an employee stands within 1-2 m (3-6 feet) of the device, aligns their face with the camera, and the temperature is registered from either the forehead or tear duct. tear duct measurement is preferred, as it measures temperature from a single artery. 3 thermal imaging cameras provide comparable accuracy to oral temperature readings, but only when routinely calibrated and adjusted to control for individual and environmental factors. the accuracy of such devices can be affected by the presence of facial hair, wigs, eyeglasses, masks, hats, the employee's height, use of a wheelchair, and other external sources of temperature variation, such as a hot beverage. for those entering from a cold environment, facial skin must reacclimate to ambient temperature, 3 which may contribute to crowding at the entrance. moreover, the screening area where thermal imaging cameras are placed must be maintained at relatively consistent ambient temperature and humidity; this may be difficult to achieve in entrances to facilities, particularly in extreme weather conditions. finally, these devices still require paying employees to monitor them. numerous reports have shown that temperature screening rarely identifies elevated temperatures. 4 for example, at loyola university medical center, where one of us is employed, from the time temperature screening was implemented on may 1 through july 31, several thousand screens have been performed, with zero positive temperature readings. there may be good explanations for this. first, an employee with a subjective fever is more likely to stay home. in practice, given the limitations discussed above, device readings are frequently inaccurate and may miss some low-grade temperatures. fever is transient and follows a diurnal pattern, making a one-time morning spot check of temperature a poor means of monitoring for fever. antipyretic agents such as acetaminophen could mask the presence of a fever. fever is also not present in every patient with covid-19, and by definition, is not present in an asymptomatic individual. finally, fever is nonspecific for covid-19, so elevated temperatures captured by screening could be due to other illnesses such as seasonal influenza. recently, the value of temperature screening has been called into question. dr anthony fauci described temperature checks as "notoriously inaccurate," 5 and the administrator of the transportation security administration (tsa) similarly cast doubt upon their reliability. 6 we recommend abandoning the use of temperature checks for employee screening. on-site temperature screening is a high-cost, low-yield tool for preventing the spread of covid-19. it will fail to catch most covid-19 cases, and the expenditure required to support on-site screening may require other budgetary restrictions, such as the furloughing or layoff of employees. symptom screening alone-combined with strict adherence to universal precautions like masking and eye protection-is a superior strategy to prevent spread of covid-19 in the workplace. a daily questionnaire is a low-cost measure that can identify symptomatic employees, increase awareness, and promote adherence to infection prevention guidelines. policymakers should follow the evidence, moving away from temperature screening mandates in favor of practices that are better tailored to mitigate risk of covid-19 transmission while at work. challenges of "return to work" in an ongoing pandemic sars-cov-2 testing strategy: considerations for non-healthcare workplaces expert advice for selecting thermal imaging technology. avi systems website covid-19 temperature checks might do more harm than good. popular science website fauci says coronavirus temperature checks 'notoriously inaccurate tsa casts doubts on effectiveness of passenger temperature checks at airports. cnbc website key: cord-305437-e1hcsnr7 authors: tang, xiujuan; zhao, shi; he, daihai; yang, lin; wang, maggie h.; li, yuan; mei, shujiang; zou, xuan title: positive rt-pcr tests among discharged covid-19 patients in shenzhen, china date: 2020-04-16 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.134 sha: doc_id: 305437 cord_uid: e1hcsnr7 among all 209 discharged coronavirus 2019 patients in shenzhen china between january 23 and february 21, 2020, there are 9 (4.3%) patients showed rt-pcr positive in throat swabs, 13 (6.2%) patients showed rt-pcr positive in anal swabs, and 22 (10.5%) positive in either type. the time between discharge and positive rt-pcr tests is 4.7 days on average. these numbers shed light on the viral dynamics of covid-19. to the editor-according to the current guideline of the national health commission of china, discharge of inpatients with the coronavirus 2019 (covid-19) infection in china have to fulfill 2 recovery criteria: (1) symptoms disappear and computed tomography (ct) images become normal and (2) test negative for 2 consecutive times in reverse transcriptase-polymerase chain reaction (rt-pcr) tests for sars-cov-2. 1 however, lan et al 1 recently reported 4 cases who were tested positive for sars-cov-2 at 5 days after discharge, suggesting positive status among discharged patients. 2 to date, the prevalence and associated risk factors remain unclear. we investigated all 209 patients with laboratory-confirmed sars-cov-2 infection who were discharged from the designated hospital in shenzhen, china, between january 23 and february 21, 2020. demographic data, laboratory profile, clinical data, and ct images were collected from these patients' electronic medical records. throat swabs and anal swabs were collected from all patients for rt-pcr tests according to the following scenarios: (1) on february 18, 2020, for those discharged before february 12, 2019; (2) on february 19, 2020 for those discharged between february 13 and 19, 2019; (3) on days 7 and 14 after discharge thereafter. this study was approved by the shenzhen center for disease control and prevention review board and the need for informed consent was waived. all data used in this work are available upon request and approval of shenzhen center for disease control and prevention. we compared the settings in the study by lan et al 2 with those in this study (appendix table s1 online). logistic regression models were adopted to explore the factors associated with the rt-pcr test results. odds ratios (ors) were calculated for the probability of positive test in throat swabs, or anal swabs, or either, and the rest were considered negative in each of the 3 scenarios. the results are as follows: • scenario 1: 9 positive rt-pcr test results from throat swabs normally, only scenario 3 should be considered, but we included scenario 1 to be consistent with lan et al. 2 among all 209 discharged patients, 9 (4.3%) tested positive in throat swabs only, 13 patients (6.2%) tested positive in anal swabs only, and 22 (10.5%) tested positive in either. together, 10.5% of discharged patients showed virus shredding around an average of 4.7 days after discharge (range, 2-13 days). under scenario 3, the logistic regression models revealed that a high risk of positive test was significantly associated with older age (or, 0.95; 95% confidence interval [ci], 0.93−0.98), diarrhea during hospital stage (or, 10.44; 95% ci, 1.60−68.16). the "during disease" stage was the other significant factor, with an adjusted and 9.59 (95% ci, 2.02−45.62) under scenarios 2 and 3, respectively. expectoration during the disease stage is also a significant factor, with an adjusted or of 4.00 (95% ci, 1.24−12.88) but only under scenario 3 (table 1) . although the prevalence of virus was substantial (10.5%), no infection was discovered among close contacts. discharged covid-19 patients in shenzhen are required to be self-isolated for an additional 14 days after discharge to prevent the possible transmission due to the positive test post discharge. although live sars-cov-2 virus has been found in stool samples in some cases, 3 the role of fecal-oral transmission remains unclear. among 209 patients, 10 (4.8%) had diarrhea, and this ratio is slightly higher than the 3.8% rate based on 1,099 patients nationwide, 4 and 2 of 10 patients (20%) with diarrhea showed positive tests post discharge with positive anal swabs. we report that 15.7% of patients <50 years old showed positive tests, while 2.4% of patients >50 years old showed positive tests from anal swabs. the delay between discharge and rt-pcr result date was negatively associated among positive cases of throat swabs, with an adjusted or of 0.36 (95% ci, 0.18 −0.72). this finding implies that the risk of positive tests gradually vanishes over time. our study was limited by the lack of treatment information. further and large-scale study on this phenomenon is warranted. nevertheless, this study sheds lights on the viral dynamics of covid-19. yantian cdc, longhua cdc, guangming cdc, pingshan cdc, dapeng cdc, shenzhen samii medical center and shenzhen hezheng hospital, all in shenzhen, china, for offering 14-day isolation services for the discharged patients. we thank the third people's hospital of shenzhen for the admission and treatment for the relapse patients. the funding agencies had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. note. rt-pcr, reverse transcriptase-polymerase chain reaction; or, odds ratio; iqr, interquartile range. a the or is adjusted by the age, sex, sampling delay, disease severity and the backgrounds of the healthcare staff who delivered the treatment. diagnosis and treatment of the novel coronavirus (2019-ncov) pneumonia in china positive rt-pcr test results in patients recovered from covid-19 report of the who-china joint mission on coronavirus disease clinical characteristics of coronavirus disease 2019 in china acknowledgments. we thank the luohu center for disease control (cdc), futian cdc, baoan cdc, nanshan cdc, longgang cdc, polytechnic university collaborative research project. all other authors declared no competing interests related to this article. key: cord-327574-24t10fs4 authors: fakih, mohamad g.; sturm, lisa k.; fakih, rand r. title: overcoming covid-19: addressing the perception of risk and transitioning protective behaviors to habits date: 2020-06-09 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.284 sha: doc_id: 327574 cord_uid: 24t10fs4 nan to the editor-we started this year facing an incredible challenge that defied many assumptions regarding pathogens. the coronavirus disease 2019 (covid-19) has spread from china across borders and oceans to become a pandemic. our unfamiliarity with the nature of the disease, from asymptomatic infection to presymptomatic contagiousness, to its efficiency of transmission and the varied nonspecific clinical presentations, made containment of its early spread difficult. the risk of contracting covid-19 infection depends on the prevalence within a community, the efficiency of viral transmission, and the behavior of the susceptible host. some regions within the united states have been disproportionately affected, 1 but the uncertainty related to the risk for exposure and severity of outcome, combined with the desire to return to our normal lives for economic and mental health reasons, has led to varied practices across the nation. social distancing (shelter in place or stay at home) imposed by states, curtailed the outbreak in many of our communities. in the absence of a treatment or a vaccine that delivers protection, along with greater herd immunity, effective management of this disease is contingent to a large extent on the protective behaviors adopted by the population at large. for decades, we have struggled with hardwiring the compliance with hand hygiene before and after caring for patients, although many providers acknowledge that poor compliance leads to transmission of multidrug-resistant organisms and patient harm. 2 we also accept contracting a cold or influenza as an unavoidable, expected event. we marginally altered our behavior even when a seasonal influenza vaccine was not a good match. the contrast between our approach to covid-19 and previous epidemics and pandemics is our perception of risk. the mortality of covid-19 patients is thought to be up to 10 times that of influenza, creating the urgency to intervene. 3, 4 on the other hand, other threats to society, such as climate change are uncommonly perceived as an emergency, hence the action may not be pressing. our reaction to covid-19 threat has been based on our variable interpretation of such risk. the approach to curbing further transmission of covid-19 within communities focuses on the institution of measures (1) to detect and isolate those infected, (2) to practice point source control, (3) to reduce environmental contamination, and (4) to optimize engineering controls. symptoms and epidemiologic risk (eg, travel, known exposure) screening has been widely used to identify suspected cases as a prequel to molecular testing and identifying active infection. testing, however, is not failure proof and may risk providing a false sense of security. recent data on rapid polymerase chain reaction testing reported potentially inaccurate results. 5 on the other hand, instituting behaviors such as selfisolation for 10-14 days prior to a surgery, eliminates the risk of a patient being actively infected at the time of the procedure. environmental cleaning reduces the chance for persons to contact contaminated surfaces, and engineering control through deploying spatial separation and reducing crowding will lessen the chances of exposure to the pathogen. to achieve long-lasting benefits that help reduce covid-19 and other future infectious outbreaks, we will need to learn and adopt precautionary actions. one of the main predictors of people's engagement in protective behavior is risk perception. [6] [7] [8] people are more likely to comply with the recommended precautionary behaviors if they think that they are susceptible to contracting the disease (ie, perceived vulnerability) and if that illness is deemed to lead to severe health consequences (ie, perceived severity). 7, 9 however, according to the protection motivation theory, 7 risk perception is an imperative but insufficient precursor for the adoption of protective behaviors. 6 in times of stress, people also assess their ability to cope with the threat (ie, coping appraisal). thus, the motivation to engage in protective behavior is heightened with the belief that the recommended protective measures would lead to successful outcomes (ie, response efficacy) and when there is confidence in one's ability to perform healthy behaviors (ie, self-efficacy; for example, "i am able to constantly perform hand hygiene and mask."). 7 in addition, risk perception and self-efficacy beliefs are greatly influenced by the sources of information to which individuals are exposed (eg, media, friends, governmental health agencies). information deemed questionable or coming from a noncredible source may negatively influence one's motivation to adopt protective behavior. 6 behavioral change requires understanding the risk we are facing, learning through effective means how to mitigate the risk, and sustaining protective behaviors to become effortless habits. 10 we suggest moving our population to adopt healthy behavior as the primary venue to minimize exposure to pathogens transmitted through droplets or contact. this includes regular hand hygiene, no hand shaking or sharing objects, following respiratory etiquette, and avoiding exposure to those that are sick. in addition, we need to continue public education on how to perform hand hygiene, how to mitigate the risk of fomite transmission, and how to use cloth face coverings correctly. the messages are then culturally accepted and espoused by the community so the actions become part of our regular activities. in addition, structural changes within the community and public settings may be required to establish an environment that is favorable to the concepts of minimizing ongoing risk. finally, similar to enjoying our coffee every morning as part of our daily routine, we will need to experience the satisfaction and reward of performing these safe behaviors as an anchored habit. covid 19): cases, data, and surveillance interventions to improve hand hygiene compliance in patient care estimating the infection fatality rate among symptomatic covid-19 cases in the united states cardiovascular disease, drug therapy, and mortality in covid-19 covid-19) update: fda informs public about possible accuracy concerns with abbott id now point-of-care test. us federal drug administration website risk perceptions and behaviour: towards pandemic control of emerging infectious diseases: international research on risk perception in the control of emerging infectious diseases protection motivation and self-efficacy: a revised theory of fear appeals and attitude change perceived threat, risk perception, and efficacy beliefs related to sars and other (emerging) infectious diseases: results of an international survey meta-analysis of the relationship between risk perception and health behavior: the example of vaccination social psychology in action: evidence-based interventions from theory to practice acknowledgments. none.financial support. no financial support was provided relevant to this article.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-275765-58iul47s authors: yao, wenlong; wang, xueren; liu, tianzhu title: critical role of wuhan cabin hospitals in controlling the local covid-19 pandemic date: 2020-04-22 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.167 sha: doc_id: 275765 cord_uid: 58iul47s nan to the editor-covid-19 is quickly spreading all over the world. the total number of confirmed cases has exceeded 1.6 million in just 2 months. 1 patients with a variety of respiratory symptoms have flooded into hospitals in a relative short time, posing an enormous challenge to every healthcare system. wuhan was the first center of the pandemic, and it had the highest number of cases in china. but the pandemic in wuhan was controlled by 2 months of lockdown beginning january 23, 2020, and newly detected cases of covid-19 have now decreased to zero. among a series of preventive approaches, 2 cabin hospitals played a critical role in isolating mild and asymptomatic cases. here, we evaluate the role of cabin hospitals in controlling the covid-19 pandemic by retrospectively analyzing the correlation between available beds in cabin hospitals and epidemic data. we obtained the data regarding total daily beds available in cabin hospitals from the official website of the wuhan municipal government, and we extracted daily numbers of newly diagnosed cases, newly cured cases, and new deaths, and we calculated the overall recovery rate and mortality from covid-19 in wuhan from the official website of the national health commission of the people's republic of china. covid-19 cases were diagnosed according to history, symptoms, chest ct, and nucleic acid test. 3 from february 12 to february 14, a clinical diagnosis of covid-19 was applied to make sure that every patient received immediate treatment in wuhan. therefore, the number of cases diagnosed in these 3 days dramatically increased, and we was excluded these data from our analysis. we used spss version 19.0 software (ibm, armonk, ny) for the statistical analysis. a pearson correlation analysis was performed by correlating cabin beds with all epidemic data. p < .05 was considered a significant difference. the official government website reported a total of 28 designated hospitals with 8,254 beds for covid-19 patients in wuhan before february 4, 2020. the utilization ratio of beds was as high as 99.1%. on february 4, 2020, the first cabin hospital in hongshan stadium opened with 1,000 beds. by february 26, 2020, a total of 17 cabin hospitals with 35,499 beds had been set up in wuhan; overall these cabin hospitals received~12,000 mild cases of covid-19. the final utilization ratio of cabin beds was 33.8%. all epidemiological data and their fluctuating trends with the increase in cabin beds are shown in figure 1 . by statistical analysis, the number of newly diagnosed cases showed a highly negative correlation with the availability of cabin beds (r = −0.833; p < .0001). we detected a highly negative correlation between the number of new death cases and the number of cabin beds (r = −0.859; p < .0001). the overall recovery rate was positive correlated with cabin beds (r = 0.961; p < .0001). in addition, we detected a significantly decrease of severe cases in the hospital with the increase of cabin beds (r = −0.977; p < .0001). the approaches for prevention and control of covid-19 can vary from city to city. however, the principle of controlling contagious diseases is to isolate the source of infection, to cut off transmission, and to protect vulnerable populations. 4 although both covid-19 and sars are respiratory diseases caused by coronavirus, covid-19 differs from sars 5 in that many mild and asymptomatic cases of covid-19 also have transmissibility, and these cases are often missed and not isolated. therefore, the management of mild or asymptomatic covid-19 cases is equally important as the treatment of severe cases. our analysis showed that, with the increase of available beds by cabin hospitals, the newly diagnosed cases and severe cases decreased. thus, the cabin hospitals played an important role in controlling the covid-19 pandemic. they effectively prevented family infection or community spread. early treatment of mild cases can prevent covid-19 cases from deteriorating. cabin hospitals were mainly responsible for the treatment of mildly ill patients. all admitted patients were diagnosed by a positive nucleic acid test, concern regarding cross infection was alleviated. in these temporary hospitals, patients were also cared for by professional medical staff. when a case became severe, the patient was transferred to a designated infectious hospital immediately. food, accommodation, medication, and examination were paid by the government. these incentives greatly increased the motivation of mildly ill patients to be admitted to cabin hospitals, which reduced social mobility and the risk of community infection. at the same time, timely medical treatment also improved prognoses, avoiding exacerbation of the disease. 6 in addition, initiation of cabin hospitals reduced the workload of designated infectious hospitals, so the limited public medical resources could be used to treat severe patients and thus reduce the death rate. according to xu et al, 7 the cost of cabin hospitals was low enough that the government could support the roll out on a large enough scale to ensure rapid sequester of cases. short-term training should be employed to equip cabin hospital staff with self-protection and medical care. psychological counseling for patients and medical staff should be provided to alleviate anxiety and panic. we also advocate communication and entertainment activity between patients. online visits for comprehensive mental consultation were also available. a cabin hospital is like a large community clinic. home quarantine and community isolation play an important role in the treatment of mild cases, but there is a risk of neglecting some cases, which could lead to community transmission, and a percentage of patients become severely ill. in wuhan, cabin hospitals connected traditional community clinics and hospitals to achieve early diagnosis, timely treatment, and effective isolation of covid-19 patients. in conclusion, these cabin hospitals were an important part of effectively controlling the covid-19 pandemic in wuhan. supplementary material. to view supplementary material for this article, please visit https://doi.org/10.1017/ice.2020.167 covid-2019) situation reports. world health organization website association of public health interventions with the epidemiology of the covid-19 outbreak in wuhan clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study viral shedding patterns of coronavirus in patients with probable severe acute respiratory syndrome can we contain the covid-19 outbreak with the same measures as for sars? viral dynamics in mild and severe cases of covid-19. the lancet infectious diseases establishing and managing a temporary coronavirus disease 2019 specialty hospital in wuhan, china the relationships between total beds of cabin hospitals and epidemic data of covid-19 in wuhan. data were obtained from national health commission of china and people's government of wuhan to acknowledgments. none.financial support. no financial support was provided relevant to this article.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-281194-yafwcway authors: amir-behghadami, mehrdad; janati, ali; gholizadeh, masoumeh title: battle with covid-19 in iran: what lessons can be learned from the implementation of response strategies so far? date: 2020-05-13 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.231 sha: doc_id: 281194 cord_uid: yafwcway nan to the editor-the novel coronavirus disease (covid-19), with human-to-human transmission and severe human infection, has been escalating rapidly since late december 2019. 1 disease symptoms can range from mild flu-like cases to severe cases with life-threatening pneumonia. 2, 3 the global condition is evolving dynamically, and on january 30, 2020, the world health organization (who) announced that covid-19 is a "public-health emergency of international concern." during the coronavirus pandemic, the authorities of the iranian ministry of health and medical education (mohme) reported the first cases of coronavirus on february 19, 2020 in qom. 4 as of march 6, 2020, according to mohme, 27,017 cases of covid-19 have been identified in the country, 2,077 of whom have died and 9,625 of whom have recovered so far. following the widespread outbreak of sars-cov-2 in china, the mohme launched a campaign in early february 2020 including monitoring and examining all incoming travelers from china and quarantine of iranian students residing in china. currently, no licensed vaccine for specific antiviral prevention and treatment is available for covid-19. 5 therefore, the most effective measures are to eliminate the source of infection, to cut off the transmission route and to protect the susceptible. 6 prevention and control became the most urgent task in iran during the early days of the sudden outbreak of the sars-cov-2 virus. 7, 8 in this regard, the government has invested large amounts of human capital and material resources. regarding the origin of the infection, people who are in close contact with patients may become new patients or new sources of infection. for this reason, the first action after the media provided public education on covid-19 disease was to establish a corona national antivirus headquarters chaired by the president of iran and headed by the mohme. with the establishment of the headquarters, many actions were taken, such as canceling public events and friday prayers; closing schools, universities, shopping centers and bazaars, as well as holy shrines; and banning festival celebrations. economic measures were also taken to assist families and businesses. with the intersectoral collaboration, the headquarters is trying to control the outbreak of sars-cov-2. the ministry of roads and urban development initiated the necessary steps for public transport, and the ministry of industry, mine, and trade will build the required medical equipment. on march 13, 2020, the revolutionary guard announced a plan to clear streets, shops, and public places in iran. in addition, 1,000 fixed and mobile diagnostic clinics will be set up, and the military will work alongside medical providers as well as in the production of face masks and gloves, and army beds will be made available to patients. the administrative and employment affairs organization has allowed telecommuting of government employee and academic organizations. academic organizations have also launched learning management systems. the government created a mobile software application and a website to battle the covid-19 epidemic. 9 the covid-19 self-assessment and electronic screening system was launched by mohme on march 4, 2020 (salamat.gov.ir). when residents log into this system, they provide information such as national code, date of birth, and phone number, and they answer some questions about covid-19 symptoms and their physical condition. after answering these questions, if a person is suspected of having a coronavirus, follow-up is provided through healthcare centers affiliated with the mohme. the chart map shows proportion of the target population screened for covid-19 by province (fig. 1) . people suspected of having covid-19 receive a text message about their health status. if they do not recover physically after 3 days, they are referred to a hospital. also, their homes will be disinfected, and other family members will be isolated if needed. the plan has been implemented, and thus far, with the allocation of >17,000 health houses and >9,000 comprehensive health centers in urban, suburban, and rural areas throughout the country. organized epidemic response work has been carried out at these mobilization centers and bases. the social-law enforcement committee of the coronavirus battle national headquarters at the iranian interior ministry began implementing the social distancing plan in march; it will continue through april 2020, and it will be extended by the committee if necessary. according to the plan, intercity trips will be banned and only locals will be allowed to enter cities and towns. also, any sites that might draw large clusters of people, including schools, universities, shopping centers, parks, swimming pools, tourist sites, promenades, etc, will be closed. holding any official or unofficial celebration that can draw crowds will also be forbidden during this period. maximum restrictions will also be carried out regarding transport by aircraft, trains, and buses. there has been a significant effort to treat covid-19 patients. 10 on march 26, 2020, iran launched plasma therapy for coronainfected patients. 11 the blood plasma of people who have recovered from covid-19 infection will be donated to patients to boost their immune systems. based on the concept of passive immunity, this new method will help improve the condition of patients. in the fight against sars-cov-2, it is crucial that countries around the world take steps to prevent transmission and save human lives. the iranian authorities are implementing their policies and plans with the help of intersectoral collaboration and public participation. however, they should continue to develop new policies and programs to prevent and control the spread of sars-cov-2 until a vaccine or medication is available. a novel coronavirus from patients with pneumonia in china clinical features of patients infected with 2019 novel coronavirus in wuhan, china electronic screening through community engagement: a national strategic plan to find covid-19 patients and reduce clinical intervention delays understanding the 2019-novel coronavirus (2019-ncov) and coronavirus disease (covid-19) based on available evidence available evidencea narrative review an update on the 2019-ncov outbreak the role of electronic health during the covid-19 crisis: a systematic review of literature covid-19 daily epidemiology journal iranian ministry of health and medical education website the importance of designing and implementing a participatory surveillance system: an approach to early detection and prevention of novel coronavirus (2019-ncov) iranian national covid-19 electronic screening system: experience to share considerations relating to social distancing measures in response to covid-19-second update. european centre for disease prevention and control website iran to produce medicine for covid-19 by plasma-derived therapy acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-275420-zkxyxiv5 authors: crabtree, scott j.; cohen, stuart h. title: the role of multidisciplinary infection prevention teams in identifying community transmission of sars-cov-2 in the united states date: 2020-07-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.360 sha: doc_id: 275420 cord_uid: zkxyxiv5 this case study highlights the role of a multidisciplinary infection prevention team in the identification of the first community-transmitted sars-cov-2 case at a large, tertiary referral center in the united states. by rounding on the hospital units such teams can serve vital infection prevention, antibiotic stewardship, and disease surveillance functions. to the editor-the first case cluster of what would be later called coronavirus disease 2019 (covid-19) was reported in wuhan, china, on december 31, 2019. 1 by january 20, 2020, the first imported case in the united states was identified in a returning traveler. 2 the first community-transmitted case of covid-19 was not identified in the united states until february 26, 2020, at the university of california davis medical center (ucdmc) in sacramento, california, in a patient without known travel to china or contacts with a known patient with covid-19. prior to this, the centers for disease control and prevention (cdc) guidance had recommended sars-cov-2 testing only in these patient populations. through the coordinated efforts of ucd's multidisciplinary infection prevention (ip) program, the patient was identified as a possible covid-19 case and obtained sars-cov-2 testing. on february 15, 2020, the case patient presented to a local community hospital with complaints of a flu-like illness. she decompensated shortly after her admission, requiring intubation, vasopressors, and progressively greater ventilatory support. arrangements were therefore made to have her transferred to ucdmc for the possible initiation of extracorporeal membrane oxygenation for acute respiratory distress syndrome. she arrived at ucdmc on hospital day 5 (hd5). on hd7, ucdmc's ip team conducted its weekly rounds in the medical intensive care unit. the ip team is a multidisciplinary team of an infectious diseases (id)-trained physician, an id-trained pharmacist, an ip nurse, and a unit nurse champion (table 1) . this team rounds daily in a different icu with a recurring weekly schedule for individual units. during rounds, each patient is reviewed through the electronic medical record and via discussion with the bedside nurse to evaluate for possible infection prevention and antimicrobial stewardship interventions. efforts are focused on reducing unnecessary lines and devices, ensuring appropriate use of isolation precautions, and improving antibiotic utilization. recommendations are given directly to the bedside nurse when applicable or are later directed to the primary physician. at times, patients with complicated, presumed infectious processes are also referred to the infectious diseases consultation service for further evaluation. rounds typically require an hour daily, depending on the complexity of the patient population and the size of the unit. these teams have been active at ucdmc since the beginning of 2018 and are considered an important arm of ucdmc's ip program. at this point, the patient remained intermittently febrile but stable on the ventilator with an improving pao 2 /fio 2 and minimal respiratory secretions. laboratory testing was remarkable, with a white blood cell count of 8.0 cells/mm 3 (2.5% lymphocytes), sodium of 126 mmol/l, and worsening creatinine of 1.89 mg/dl. computed tomography images of the chest showed confluent consolidative and ground glass opacities in the right upper and (to lesser extent) middle lobes. testing for common respiratory pathogens was negative. she had been in good health prior to her illness, with no significant travel or exposure histories. the patient's case was discussed with her bedside nurse, who confirmed that sars-cov-2 was considered by her primary team, but given the absence of exposures, testing for this agent was not pursued. we then made the decision for the bedside nurse to further clarify patient's occupational, travel, and potential exposure histories with her family, with plans for the ip team to reassess later that morning. the patient's bedside nurse subsequently reported that the patient worked in the service industry and had had direct and close interaction with multiple individuals on a daily basis. one of these individuals had returned from china a few weeks prior and was briefly detained by customs upon arrival. no further details of this encounter were available. the community in which she worked was located southwest of sacramento near a local air force base, where a number of diplomatic evacuees had been in recent quarantine. we then elected to review her case with the director of hospital epidemiology and infection control, and we collectively decided that, despite the absence of clear exposure risks, given her clinical picture and its unknown cause, testing for sars-cov-2 would be requested through the county public health officer. this request was first denied due to the patient's not meeting the cdc's criteria for a person under investigation (pui), but 2 days later (on hd9) was granted by the cdc. on hd13, nasopharyngeal rt-pcr results returned positive for sars-cov-2. due to ongoing critical illness, the id consultation service made a request to the food and drug administration for compassionate-use remdesivir, which was granted that same day. the first dose was administered on hd14. on hd19, the patient was extubated, and on hd31 she was discharged home. antimicrobial stewardship "handshake" rounds, involving the regular in-person interaction between stewardship teams and frontline providers, were first rolled out at children's hospital colorado in 2013, with good results. 3 such rounds have been associated with sustained improvements in antibiotic utilization, 4 high critical-care physician satisfaction, 5 and improved and timely id consultation. 6 similar ip-focused multidisciplinary teams have been shown to reduce the rate of catheter-associated urinary tract infections and central-line-associated bloodstream infections. 7 however, given that this strategy is only a recent development, further research is needed to better appreciate its impact and to optimize this practice. this case highlights an additional and critical surveillance role that a multidisciplinary ip team can provide, especially in times of emerging infectious disease. due to the identification of this case, the cdc reviewed and later revised its pui case definition, with widespread impact on the management of the covid-19 epidemic within the united states. 8 undiagnosed pneumonia-china (hubei) first case pf 2-19 novel coronavirus in the united states intervention and acceptance rates support handshake-stewardship strategy sustainability of handshake stewardship: extending a hand is effective years later attitudes and perceptions amongst critical care physicians towards handshake antimicrobial stewardship rounds a handshake from antimicrobial stewardship opens doors for infectious disease consultation the effect of interdisciplinary team rounds on urinary catheter and central venous catheter days and rates of infection a community transmitted case of severe acute respiratory distress syndrome due to sars cov2 in the united states acknowledgments. we would like to thank janet peterson, felicidad loomis, and shavinderpal sanga for their roles in the care of this patient and their contribution to the multidisciplinary ip team.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-255652-3n2dxljj authors: challener, douglas w.; challener, gregory j.; gow-lee, vanessa j.; fida, madiha; shah, aditya s.; o’horo, john c. title: screening for covid-19: patient factors predicting positive pcr test date: 2020-05-19 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.249 sha: doc_id: 255652 cord_uid: 3n2dxljj to inform the efficient allocation of testing resources, we evaluated the characteristics of those tested for covid-19 to determine predictors of a positive test. recent travel and exposure to a confirmed case were both highly predictive of positive testing. symptom-based screening strategies alone may be inadequate to control the ongoing pandemic. sars-cov-2, the novel coronavirus causing covid-19, was isolated in patients from wuhan, china, in december 2019 and sparked a global pandemic in early 2020. 1, 2 symptom-based and exposure-based screening was recommended by the us centers for disease control (cdc) in late february 2020 as the virus began to spread throughout the united states. unfortunately, current evidence suggests that symptom-based screening programs are likely to miss a large proportion of infected cases. [3] [4] [5] the containment of an infectious disease of large public health consequence relies on case identification, contact tracing, and isolation. at mayo clinic in rochester, minnesota, we developed a polymerase chain reaction (pcr) assay 6 for sars-cov-2 and deployed a drive-through specimen collection site on march 12, 2020, that was modelled after similar interventions in south korea and washington state. 7 to inform efficient allocation of limited testing resources, we sought to identify patient characteristics most predictive of a positive test. at the mayo clinic in rochester, minnesota, we began screening patients for covid-19 on a large scale on march 12, 2020, after minnesota's first case was reported on march 10, 2020. patients who were screened were given a standardized questionnaire by a nurse prior to testing. this questionnaire included questions about patient symptoms such as fever (subjective or objective), cough, shortness of breath, and medical comorbidities. the patients were also asked about recent travel as well as exposure to laboratoryconfirmed cases of covid-19. we examined the medical records of patients with the first 48 positive tests and a selection of 98 patients with negative tests. the covid-19-negative patients were selected in a random fashion by matching age (±5 years), sex, collection date, and testing location (minnesota, wisconsin, or arizona) with the positive patients. each positive patient had at least a single negative control. all patients were screened between march 12 and march 26, 2020. the chart of each patient was then manually abstracted by a physician to identify patient characteristics, symptoms, and potential exposures identified by the nurse triage line as reasons to recommend screening prior to each individual's test date. travel to a major metropolitan area was also recorded. study data were collected and managed using redcap electronic data capture tools hosted at the mayo clinic. 7, 8 descriptive statistics, t tests, and logistic regression analysis were performed using jmp version 14 software (sas institute, cary, nc). our institutional review board approved this study. the average age in the cohort was~46 years, with slightly more men than women (table 1 ). due to the matching strategy for negative controls, there was no statistically significant difference between the 2 groups. patients with both negative and positive tests had high rates of fever and cough, which likely led to the initial decision to screen them. overall, the cohort had few medical comorbidities. the largest differentiating factors between the patients with positive and negative tests were exposures. patients with positive tests were significantly more likely to have travelled to a major metropolitan area within the preceding 2 weeks or to have come into contact with a person with laboratory-confirmed covid-19. in a multivariable logistic regression model predicting a positive test adjusted for these 2 factors, close contact with a confirmed case increased the odds of a positive test by 17 times (95% ci, 4.6-88.4), and recent travel increased the odds of a positive test by 4.7 times (95% ci, 1.9-12.7). the selection of patients for sars-cov-2 screening remains challenging. many factors influence the decisions on which patients to screen, including testing resources, test characteristics (sensitivity and specificity), and local disease prevalence. the challenge in determining the appropriate patients to screen has been apparent; the cdc has revised its guidance several times. this study investigates the results of testing ambulatory patients in a relatively low prevalence area in early march 2020 and suggests that exposure to the disease is more predictive of a positive test than any examined symptom. this retrospective analysis of the initial phase of our screening for covid-19 had several strengths. a rigorous physician review of each medical record helped ensure accurate capture of patient information. additionally, the short study period helped limit any major local factors that could have affected the results, such as changing screening guidelines or increasing community prevalence. furthermore, all the tests were collected, transported, and analyzed within the same internal institutional laboratory process. this study also had several limitations. first, this was a retrospective analysis; thus, it may have suffered from selection bias affecting the participants. to help avert this bias, our negative controls were matched for sex, age, date, and state of collection. in addition, very few asymptomatic patients were screened during this time, making it difficult to assess the predictive value of fever or cough. moreover, at the time of this study, local disease prevalence was relatively low, thereby limiting the applicability of the findings to higher prevalence areas. although testing for covid-19 remains supply constrained, strategies are needed to best utilize testing resources. identifying patient factors that are strongly associated with positive results may help to identify those patients best suited for testing. in this analysis, exposure to confirmed sars-cov-2 and recent travel were both significantly more predictive of a positive test than the presence of any symptoms. in the effort to contain the pandemic, there may be a role for testing patients with these risk factors regardless of symptom presence. note. covid-19, novel coronavirus 2019; sd, standard deviation; copd, chronic obstructive pulmonary disease; ild, interstitial lung disease. clinical features of patients infected with 2019 novel coronavirus in wuhan, china guide to understanding the 2019 novel coronavirus estimated effectiveness of symptom and risk screening to prevent the spread of covid-19 spread of sars-cov-2 in the icelandic population estimation of the asymptomatic ratio of novel coronavirus (2019-ncov) infections among passengers on evacuation flights evaluation of saline, phosphate buffered saline and minimum essential medium as potential alternatives to viral transport media for sars-cov-2 testing drive through testing: a unique, efficient method of collecting large volume of specimens during the sars-cov-2 (covid-19) pandemic research electronic data capture (redcap) -a metadata-driven methodology and workflow process for providing translational research informatics support acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-255458-81ugj38k authors: doll, michelle e.; pryor, rachel; mackey, dorothy; doern, christopher d.; bryson, alexandra; bailey, pamela; cooper, kaila; godbout, emily; stevens, michael p.; bearman, gonzalo title: utility of retesting for diagnosis of sars-cov-2/covid-19 in hospitalized patients: impact of the interval between tests date: 2020-05-11 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.224 sha: doc_id: 255458 cord_uid: 81ugj38k nan molecular testing of nasopharyngeal specimens for sars-cov-2 are highly specific and sensitive. 1, 2 however, sars-cov-2 viral shedding within the respiratory specimens of individual patients may not be dependable or consistent throughout the course of illness. [2] [3] [4] [5] the range of clinical presentations of covid-19 present a diagnostic dilemma; reports of false positives 6 add to uncertainty. retesting of patients is increasingly requested in the setting of ongoing concern for covid-19 after an initial negative test. which patients should be prioritized for retesting and at what time interval are currently unclear. all patients admitted to a tertiary medical center with clinical concern for covid-19 were referred to a team of infectious disease physicians for case review and testing approval. retesting requests were largely driven by primary team concerns for false-negative initial test results. to avoid patients going off and back on isolation, an early interval retesting protocol was developed in which patients were held on isolation and retested 24 hours after the first result if they were categorized with high probability for covid-19. infectious disease physicians designated each patient with high or low probability based on the following clinical criteria consistent with reported literature 7 : (1) exposure to sars-cov-2; (2) symptoms of covid-19, including hypoxia, respiratory or gastrointestinal symptoms, or fever; (3) leukopenia; (4) chest imaging; (5) lack of other explanatory diagnosis. patients labeled with high probability who tested negative were held on isolation another 24 hours for retesting. longer-interval retesting outside this protocol continued concurrently; providers could request retesting any time during the hospitalization. if approval was granted, these patients were reisolated for possible covid-19 pending the repeat testing. nasopharyngeal specimens were collected by nurses who had received online training in specimen collection. on march 26, 2020, a patient tested negative on admission to our institution, but subsequently a previously collected outpatient test was positive. the resulting concerns about proper specimen collection were addressed by requiring nurses to do in-person retraining in a "train-the-trainer" model. testing was performed using an in-house rt-pcr test developed from the centers for disease control and prevention (cdc) primers. overall, 70 inpatients with initially negative sars-cov-2 testing underwent repeat testing for ongoing clinical concerns between march 2 and april 4, 2020. one patient converted to a positive test; the interval between tests for this individual was 6 days. all other patients remained negative on repeat testing. early interval retesting of patients with a high pretest probability for sars-cov-2 as part of a formal protocol was performed from march 31, 2020, through april 7, 2020. during this period, 38 patients were deemed "high probability" by infectious diseases physicians using the standard criteria. of the 38 patients with high pretest probability for covid-19, 19 tested positive and 19 tested negative. the 19 "high probability" but negative rt-pcr patients were then re-tested within 24 hours and all remained negative. this protocol was abandoned after april 7, 2020, given a lack of observed clinical utility. overall, repeat testing was performed within 24 hours for 28 of 70 patients with no discordant results observed. intervals between testing and result outcomes are shown in figure 1 . the patient who tested positive 6 days after a negative result was deemed "low probability" when re-evaluated for that repeat test. decisions to isolate and test inpatients for covid-19 are balanced between concerns for overtesting or overuse of scarce ppe and undertesting with cross-transmission risks. provider distrust of test results further complicates testing considerations. reports of serial patient testing indicate that the quantity of virus is highest in the first week after symptom onset, with a potential to decrease as patients recover. 3, 4 however, cases of high probability symptomatic patients with false-negative testing early in the course of illness have been reported. 5 reported 3 patients presenting with respiratory illness in the setting of known exposures to sars-cov-2 who initially tested negative. interval computed tomography (ct) scans over the next 1-2 days revealed findings concerning for viral pneumonia. patients were retested, and the results were positive at an interval of 1-3 days. 6 in a larger cohort, 258 patients were retested, and 15 converted from initially negative to positive results. 5 the mean interval between these tests was 5.1 days (sd, 1.5 days; range, 4-8 days). 5 differences in testing platforms and specimen types should be taken into consideration; the cdc recommends nasopharyngeal samples as the preferred specimen type. 8 experience with repeat testing using samples obtained by nasopharyngeal sampling is lacking at present. our data suggest that short-interval testing is low yield. assuming that specimen collection is appropriate, the presence or absence of virus in the nasopharynx or other sites is not expected to change dramatically within 24 hours. our patient with discordant results in the course of symptomatic illness had testing performed at an interval of 6 days, suggesting that changes in viral shedding may have occurred over that time period. overall, our experience inspires confidence in the accuracy of the test. however, false negatives can occur for a variety of reasons. a better understanding of host factors associated with false negatives and/or decreased viral shedding while symptomatic is urgently needed to inform testing, retesting, and patient isolation protocols. testing strategies incorporating samples from multiple sites, or other combinations of multiple test types, 9 may become standard practice as validation continues. in the meantime, covid-19 diagnostic uncertainty remains problematic for infection control and occupational health efforts. one patient had discordant results on repeat testing, becoming positive for sars-cov-2. all tests were performed using reverse-transcriptase polymerase chain reaction (rt-pcr) testing on nasopharyngeal swab upper respiratory specimens. comparative performance of sars-cov-2 detection assays using seven different primer/probe sets and one assay kit the laboratory diagnosis of covid-19 infection: current issues and challenges temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sars-cov-2: an observational cohort study virological assessment of hospitalized patients with covid-2019 correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1,014 cases computed tomographic imaging of 3 patients with coronavirus disease 2019 with negative virus real-time reversetranscriptase polymerase chain reaction test epidemiologic and clinical predictors of covid-19 interim guidelines for collecting, handling, and testing clinical specimens for persons for coronavirus disease 2019 (covid-19) profiling early humoral response to diagnose novel coronavirus disease (covid-19) acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-265309-1su480xi authors: bagdasarian, natasha; mathews, ian; ng, alexander j. y.; liu, eugene h.; sin, clara; mahadevan, malcolm; fisher, dale a. title: a safe and efficient, naturally ventilated structure for covid-19 surge capacity in singapore date: 2020-06-24 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.309 sha: doc_id: 265309 cord_uid: 1su480xi nan to the editor-the need for airborne infectious isolation (aii) surge capacity is a problem for hospitals globally, 1, 2 and this problem has been highlighted during the covid-19 pandemic. 3 alternatives to aii rooms have been proposed for surge periods. airborne isolation units can be quickly converted to cohort patients with the same illness, typically requiring negative pressure relative to adjacent areas and adequate ventilation without recirculation to other areas. 2, 4 mobile containment units have been used in conflict zones 5 and in outbreak response settings 6,7 including the current pandemic. many countries still face spiraling numbers of cases, while others are attempting to return to normalcy after a period of lockdown; some of these countries may experience a second wave even larger than the first. here, we describe the design and function of a low-cost, naturally ventilated temporary structure to increase emd capacity during the covid-19 response in singapore. national university hospital (nuh) is a 1,200-bed tertiarycare academic hospital in singapore, with an emergency medicine department (emd) that sees more than 110,000 patients per year. with the emergence of covid-19, containment strategies were implemented nationally, requiring isolation of large numbers of patients and placing an extraordinary demand on the existing healthcare infrastructure. a multidisciplinary taskforce was assembled to plan for surge capacity, with the intent to create an "emd extension," a temporary outdoor facility to manage patients with suspected covid-19 and relieve the pressure on the existing emd isolation facilities. we designed an a-shaped structure with open-air sides and a canvas roof, a perimeter fence for privacy, and ceiling fans to maximize air flow. the structure measured 31 m × 16.5 m, with a height of 5 m at its highest point (fig. 1 ). this temporary structure was built on an existing empty flat concrete platform, which was covered with vinyl flooring. the structure contained a resuscitation bay and a radiology cubicle with walls lined with lead shields; an adjacent air-conditioned cabin served as a rest area for staff. the structure has 20 patient cubicles (2 m × 2 m), constructed using aluminum framing and polyvinyl chloride (pvc) panels. the walls are 2.5 m high, with 3 fixed and 1 curtained side. the modular nature of the construction allowed for 5 additional cubicles to be added later. alcohol-based hand rub (abhr) dispensers were placed in patient cubicles, at healthcare worker (hcw) stations, at medication preparation station, and in the donning and doffing areas. hand hygiene sinks were installed and connected to the main water supply line, and portable toilets were connected to central sewage. we engaged a local tent contractor without specific expertise in medical or emergency response structures, although the designs were verified with an engineer. the structure was erected within 17 hours, followed by fire safety checks, temperature monitoring, rehearsals of patient movement and resuscitation drills, and a smoke test that demonstrated good air flow. the structure was fully operational within 6 days. staff working in the extension building wear long-sleeved gowns, n95 masks, gloves and eye protection at all times, changing gloves and performing hand hygiene between patients. donning and doffing areas for personal protective equipment (ppe) were designated near entry and exit points. between february 14, and may 12, 2020, the emd extension received 5,004 patients, while 9,374 patients were seen in the main emd isolation facility. in total, 710 confirmed covid-19 cases were managed in the nuh emd. no infection prevention and control (ipc) breaches or exposures were observed in the emd extension. no transmission of covid-19 to hcws or patients has been identified thus far at nuh. the maximum temperature in singapore remains 31-33°c year-round. with the use of portable cooler units and shade cover, the average internal temperature was maintained at 28.1°c, with 90% of staff stating they could wear required ppe for >1 hour without discomfort. this report demonstrates the potential for an adapted structure to provide rapid, safe and effective surge capacity for the triage, screening and management of covid-19 patients. this design successfully incorporated commonly sourced building materials, and natural ventilation, as a rapid solution for the screening and care of covid-19 patients. here, we utilized existing plumbing and water lines, but portable alternatives could be substituted. temperature control was managed effectively with portable coolers, and in colder climates portable heaters could be adapted. natural ventilation, while not commonly utilized in the west, remains a common design feature for hospital wards in other parts of the world. although aii rooms with 12 air changes per hour (ach) have become the gold standard for airborne diseases, natural ventilation may provide rates that exceed these requirements 8 and could represent a low-cost alternative. ach of up to 40 have been reported in naturally ventilated structures with high ceilings, 8 and such designs were historically used in the construction of tuberculosis wards. 9 in recently published guidelines on the design of severe acute respiratory infection (sari) treatment centers in limited-resource settings, natural ventilation is highlighted as one potential solution. 10 literature describing the use of natural ventilation combined with low-cost and low-tech materials for the safe management of covid-19 patients is scarce. this report, in conjunction with older studies recognizing the utility of natural ventilation, lends credence to the idea that low-cost, rapidly erected structures (ie, open-air tents, without hepa filtration units) may be a solution to managing the surge of covid-19 patients, particularly in low-income countries, or other areas with depleted medical capacity. at national university hospital for their assistance in creating the figure. we are grateful for the support of hospital leadership and operations teams in supporting the covid-19 response and the safety of our healthcare workers, as well as our colleagues in the emergency medicine department who are on the front lines. financial support. no financial support was provided relevant to this article. conflicts of interest. all authors report no competing interests. containment effectiveness of expedient patient isolation units implementing a negative-pressure isolation ward for a surge in airborne infectious patients proposed protocol to keep covid-19 out of hospitals environmental control measures for airborne infection isolation surge capacity planning in health care facilities for smallpox, sars or other infections. potentially transmitted via airborne droplet nuclei measures undertaken in the german armed forces field hospital deployed in kosovo to contain a potential outbreak of crimean-congo hemorrhagic fever preparing an academic medical center to manage patients infected with ebola: experiences of a university hospital development and use of mobile containment units for the evaluation and treatment of potential ebola virus disease patients in a united states hospital natural ventilation for infection control in health-care settings. geneva: world health organization natural ventilation for the prevention of airborne contagion severe acute respiratory infections treatment centre: practical manual to set up and manage a sari treatment centre and sari screening facility in healthcare facilities. world health organization website key: cord-252149-0n58lec6 authors: wang, jiancong; lee, yew fong; liu, fangfei; zhou, mouqing title: to relax restrictions: are communities ready to deal with repeated epidemic waves of covid-19? date: 2020-05-11 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.228 sha: doc_id: 252149 cord_uid: 0n58lec6 nan to the editor-with strict lockdown and movement restriction measures, in europe the incidence of newly confirmed covid-19 cases has slowed down and the epidemiological curve has flattened. 1 however, the world health organization (who) has warned that the peak of the pandemic has not yet passed. 2 however, some countries are considering relaxing restrictions because they have to weigh ethical issues and social and economic crises against another potential covid-19 wave. 3, 4 when and how to relax the restrictions have become items of strong debate between health politicians and other stakeholders. according to the who's covid-19 daily situation report and a recent study, 5,6 community spread and clusters have predominantly contributed to most sars-cov-2 transmission. therefore, the question facing policy makers remains: if restrictions are relaxed, will we be ready to deal with a repeated epidemic wave(s) in our community? in china, resumption of works and production, reopening shops and restaurants, and even relaxation of travel restrictions have restored hope for virus-ravaged economies around the world. 7 the national health commission of the people's republic of china strengthened and implemented various measures and/or policies in the face of another potential epidemic wave. here, we summarize the key elements of infection prevention and control (ipc) measures implemented in china. first, border control included screening and testing for covid-19. imported cases from abroad, especially international travelers, pose a potential threat to the community if they are not properly screened at the borders. 8 according to data retrieved on the april 18, 9 of every 16 newly confirmed cases (56%) were identified as imported cases. 9 various measures (eg, travel history declaration, health epidemiological survey, temperature measurement, and rapid screening at airports) were conducted to efficiently detect suspected cases. all travelers were required to undergo a 14-day quarantine period at dedicated hotels, including sars-cov-2 testing by swab. 10 detected cases were directly referred to dedicated covid-19 hospitals, which minimized the risk to close contacts and the spread of disease in the community. second, informative technology and the health declaration mobile telephone software application (ie, app) 11 played a significant role in assessing the health status of residents. information gathered was categorized and visualized using colored barcodes, which included each individual's national identification number and address, temperature results (if available), 14-day travel history declaration, and contact history with suspected or confirmed covid-19 patients. a green barcode indicated that a person was at low risk of having covid-19 and/or transmitting sars-cov-2 and had been given approval for a "health permit" that allowed to access workplaces, shops, and restaurants (supplementary material fig. 1 online) . a red barcode indicated that a person was at high risk of having covid-19 and/or transmitting sars-cov-2 and that he or she would be contacted by the local health authorities for mandatory quarantine measures (by law) and medical observation. third, china implemented 'closed-off' management of residential communities. 12 only community residents were permitted enter or exit their residential areas, and no visitors were allowed. temperature measurement was mandatory upon entry, and mask wearing was compulsory upon exiting a residential area. even though mask use is still being debated in some countries, asia, austria, germany, and the czech republic have demonstrated positive effects of using masks in reducing further spread of sars-cov-2 in the community. 13 fourth, community and public healthcare services were reinforced and supported. in guangzhou, sun yat-sen memorial hospital launched online consultation services by a dedicated professional covid-19 team via the "internet community hospital" platform. 14 this online service provided timely and accessible healthcare services and information to residents in the community, thus avoiding hospital visits. furthermore, the mental health of workers was also supported and monitored. in recent survey, 31.7% of respondents reported having fear when work resumed, and 28.6% of respondents reported having anxiety when work resumed. 15 local universities made mental health hotlines available to provide assistance, psychological consultation services, and even social support. for those with severe illness, psychological intervention by a specialist was recommended to minimize the impact of covid-19 across the community. last but not least, the establishment of public health centers has been suggested to undertake in communities in first-and secondclass cities. their function includes providing medical supplies, as well as storage and distribution of medical products for emergency use (ie, masks, and disinfectants), not only for healthcare workers but also for local residents. we learned the lesson of a rapid increase in the demand for the medical products during early outbreak, and these facilities will quickly meet the medical needs of the community as well as reduce the risk of community spread of the virus. in the latest press conference, who reiterated that although some countries have planned to relax restrictions due to socioeconomic concerns, the covid-19 pandemic is not over in any country. ending the covid-19 pandemic requires continued efforts by individuals, communities, and governments to suppress and control this deadly virus. finally, the who not only welcomes the accelerated advancement and implementation of sars-cov-2 antibody testing, which will help map infections in the community population; but will also provide technical, scientific, and financial support for sero-epidemiological investigations worldwide. supplementary material. to view supplementary material for this article, please visit https://doi.org/10.1017/ice.2020.228 coronavirus covid-19 global cases by johns hopkins csse website world 'certainly not seeing peak' of covid-19 yet, says who. france 24 news website covid-19: too little, too late? several european countries relax coronavirus restrictions. deutsche welle news website world health organization website sars-cov-2 in wastewater: potential health risk, but also data source work resumption in china raises hope for virus-hit european economies epidemiological characteristics of imported cases of covid-19 from outside china in early stage national health commission of the people's republic of china website flow chart of arrival of beijing capital international airport how to access to "health barcode" platform grid-based community workers power up china's grassroots coronavirus fight coronavirus: why you now have to wear a mask in austrian shops epidemiological characteristics of covid-19 and its countermeasures in guangzhou knowledge, behavior and psychological response of new coronavirus pneumonia: a web-based cross-sectional survey acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-259396-vmc2q1bi authors: periyasamy, petrick; ng, b. h.; ali, umi k.; rashid, zetti z.; kori, najma title: aerosolized sars-cov-2 transmission risk: surgical or n95 masks? date: 2020-09-15 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.465 sha: doc_id: 259396 cord_uid: vmc2q1bi based on available evidence, the covid-19 virus is thought to spread through close contact and droplet transmission. however, some have debated that it could be airborne. airborne transmission occurs when particles of less than 0.5 μm within droplets spread through exhaled air via a process called aerosolisation. these particles can remain in the air for long periods and can disseminate over distances further than 1 meter. in the context of covid-19, airborne particles can occur during certain aerosolised-generating-procedures (agp). who underlines the use of n95 respirators or equivalent as part of personal protective equipment (ppe) for healthcare workers (hcw) managing covid-19 positive patients when aerosolised-generating-procedures (agp) are being conducted.this retrospective observational study describes the result of covid-19 reverse transcriptase polymerase chain reaction (rt-pcr) in health care workers (hcw) wearing different form of personal protective equipment (ppe) who had had close contact with a confirmed covid-19 patient during performing such procedures. all hcws were quarantined for 14 days after the exposure. covid-19 rt-pcr nasopharyngeal swabs were performed at different intervals. little is known about the effectiveness of different types of personal protective equipment (ppe) for preventing sars-cov-2 in hcws. we describe the clinical outcome of hcws exposed to sudden acute respiratory infection patient before the diagnosis of covid-19 was known. to the editor-based on available evidence, coronavirus disease 2019 (covid-19) is thought to spread through close contact and droplet transmission. however, some have debated that it could be airborne. airborne transmission occurs when particles of <0.5 μm within droplets spread through exhaled air via a process called aerosolization. these particles can remain in the air for long periods and can disseminate over distances >1 m. in the context of covid-19, airborne particles can occur during certain aerosolgenerating procedures (agps). the world health organization (who) underlines the use of n95 respirators or equivalent as part of personal protective equipment (ppe) for healthcare workers (hcws) managing covid-19-positive patients when agps are being conducted. this retrospective observational study describes the result of reverse-transcriptase polymerase chain reaction (rt-pcr) testing for severe acute respiratory coronavirus virus 2 (sars-cov-2) in hcws wearing different form of ppe who had close contact with a confirmed covid-19 patient during performing agps. all hcws were quarantined for 14 days after the exposure. sars-cov-2 rt-pcr nasopharyngeal swabs were performed at different intervals. little is known about the effectiveness of different types of ppe for preventing covid-19 in hcws. we describe the clinical outcome of hcws exposed to sudden acute respiratory infection patient before the diagnosis of covid-19 was known. a 70-year-old man with known ischemic heart disease and dyslipidemia presented with severe headaches and cough for 1 week. he had a recent history of travelling to russia in december 2019 and jakarta in early february 2020. on presentation, no screening for sars-cov-2 was performed as russia and jakarta have not been flagged as epidemiological links to covid-19 by the malaysian ministry of health. in the emergency department, he was tachypneic with respiratory rate of 28 breaths per minute, oxygen saturation of 86% in room air and requiring oxygen supplement of 40% via venturi mask. his condition worsened, requiring noninvasive mechanical ventilation (niv); niv failed and he was intubated. while awaiting transfer to the intensive care unit, manual ventilation via bag-valve-mask was performed. his chest radiography showed bilateral ground-glass opacities, mainly in the lower lobes. in view of sudden acute respiratory infection, nasopharyngeal (np) swabs were sent for sars-cov-2 real-time reverse-transcriptase polymerase chain reaction (rt-pcr) testing. overall, 25 hcws were exposed to agps by this severe pneumonia patient who later tested positive for sars-cov-2. these procedures included nebulizer therapy, endotracheal intubation, invasive ventilation, and tracheal suctioning. the mean time of exposure was 34.4 minutes (range, 15-180 minutes). all 25 at-risk hcws were placed on home quarantine for 14 days. they were monitored for cough, sore throat, headaches, myalgia and dyspnea. all hcws with different levels of ppe and exposure times finally tested negative for sars-cov-2. covid-19 is a very contagious disease that poses an occupational health risk to hcws. sars-cov-2 transmission is believed to occur mainly through respiratory droplets. current guidelines recommend the use of n95 masks and goggles during agps when attending to covid-19 patients because the virus may become airborne under certain conditions. respiratory ppe is particularly important to reduce the risk of respiratory infection in hcws. a variety of ppe that provides different degrees of respiratory protection: medical face masks, respiratory protection equipment, goggles, and face shield. the size of the virus particle, the distance it can travel, and how deeply the virus can penetrate the host's respiratory tract are determinants of required ppe. medical masks have a fluid-resistant outer layer designed to prevent a stream of liquid entering the mouth. medical masks are able to filter large particles but are not certified to protect users from airborne infections. data concerning how well medical masks work against sars-cov-2 are lacking. the n95 is a type of respirator able to filter out both large and small airborne particles. factors that may affect the efficacy of n95 masks includes whether the hcw is trained in wearing n95 respirator and whether a fittest was conducted. in one study comparing fit-testing with no fittesting, there was no difference in respiratory infection risk between the 2 groups. 1 the previous study claimed that there was insufficient evidence regarding the superiority of n95 masks over medical masks in protecting hcws from transmissible acute respiratory infections in clinical settings. 2 a study from singapore reported on 41 hcws exposed to an unknown covid-19 patient during an agp for >10 minutes, of whom 85% wore only surgical masks. all tested negative for sars-cov-2 by rt-pcr. 3 a systematic review of 4 randomized controlled trials on masks showed that medical masks and n95 respirators offer similar protection against viral respiratory infection, including coronavirus, for hcws during non-agps. 4 the effectiveness of medical masks in protecting hcws from sars was inconsistent, and differing levels of exposure may explain such discrepancies. xiao et al 5 reported that masks did not prevent the transmission of influenza in 7 studies. on the contrary, jefferson et al 6 suggested that wearing masks significantly reduced the risk of sars transmission. laboratory experiments have shown that sars-cov-2 may remain viable for up to 3 hours, but clinical data have not demonstrated conclusively that sars-cov-2 is frequently spread via long distance airborne nuclei during routine care or following agps. 7 all hcws with different levels of ppe and exposure time tested negative for sars-cov-2. these findings are consistent with the meta-analysis, which showed the use of both n95 respirators and medical masks was associated with up to 80% reduction in risk of sars. 8 other than the ppe that wore by our hcws, we believe that the rate of clearance of aerosols may also affect the risk of infection in hcws. our general wards have around~6 air exchanges per hour, which reduced air contaminants, assuming that a single air exchange eliminates 63% of airborne contaminants. 9 in the case we presented, none of our hcws wore n95 masks nor goggles. however, none of the 25 individuals at risk developed major symptoms, and serial np swabs have proven that not one of them acquired the infection (table 1) . our observation is therefore consistent with previous reports that have been unable to show that n95 masks were superior to 3-ply masks in preventing transmission to hcws performing agps. further randomized control trial on ascertaining the effectiveness of the n95 respirators or medical masks in preventing hcws from sars-cov-2 are warranted. a cluster randomized clinical trial comparing fit-tested and non-fit-tested n95 respirators to medical masks to prevent respiratory virus infection in health care workers effectiveness of n95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis covid-19 and the risk to health care workers: a case report medical masks vs n95 respirators for preventing covid-19 in healthcare workers: a systematic review and meta-analysis of randomized trials nonpharmaceutical measures for pandemic influenza in nonhealthcare settings-personal protective and environmental measures physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient effectiveness of masks and respirators against respiratory infections in healthcare workers: a systematic review and meta-analysis guidance on the use of respiratory and facial protection equipment acknowledgments. we thank the hcws who consented to participate in the study.financial support. no financial support was provided relevant to this article.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-273541-47n8i2qg authors: mena lora, alfredo j.; ali, mirza; krill, candice; borgetti, scott a.; spencer, sherrie; lavani, romeen; takhsh, eden; bleasdale, susan c. title: feasibility and impact of inverted classroom methodology for coronavirus disease 2019 (covid-19) pandemic preparedness at an urban community hospital date: 2020-10-20 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.1272 sha: doc_id: 273541 cord_uid: 47n8i2qg strategies for pandemic preparedness and response are urgently needed for all settings. we describe our experience using inverted classroom methodology (icm) for covid-19 pandemic preparedness in a small hospital with limited infection prevention staff. icm for pandemic preparedness was feasible and contributed to an increase in covid-19 knowledge and comfort. the disease caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), coronavirus disease 2019 (covid-19), has caused a global pandemic straining healthcare systems worldwide. 1, 2 preparing and responding to any pandemic is challenging. small and safety-net hospitals may have limited staffing and resources when preparing for or responding to pandemics. successful strategies in these settings are of practical significance. small hospitals play a major role in healthcare delivery in the united states: in a recent survey, 70% of hospitals have <200 beds and 10% have <25 beds. 3 smaller hospitals also have limited infection preventionist and infectious diseases staff. 4, 5 a survey of the shea research network showed that smaller hospitals had an average of 1.1 infection preventionists per 100 inpatient census, varying greatly from larger facilities. 5 these staffing disparities pose a significant challenge for pandemic preparedness. the rapidly evolving needs in a pandemic strain human resources and decrease the availability of healthcare workers (hcws) and infection preventionists. an inverted classroom methodology (icm) may help leverage limited human resources during times of significant need, such as pandemic response. icm is a blended learning model in which students interact with new material first and subsequently use class time to discuss the new information. 6 an online self-directed learning phase precedes the instruction phase, where active learning is used to assimilate information and to identify knowledge gaps. icm has gained traction in medical education, and studies have shown improvements in learning, engagement, and student satisfaction. [6] [7] [8] faced with covid-19, our facility used icm as a major tool for pandemic preparedness to leverage our limited infectious diseases and infection preventionist human resources. we assessed the feasibility of icm for pandemic preparedness and its impact on knowledge, attitudes, and perceptions of hcws. we conducted an anonymous cross-sectional survey at a 151-bed urban safety-net community teaching hospital. our organization has 1,098 employees, of whom 671 work in the hospital building. one infectious diseases physician and one infection preventionist are on staff. education via icm started on march 1, 2020. online videos on covid-19 topics were created by the infectious diseases physician using microsoft powerpoint, and they were hosted on the vimeo video platform. privacy settings were set to a private link. videos could not be found via open search. the link could be shared and viewed multiple times. in-person and virtual town halls occurred after dissemination of the videos. town halls were led by the infection preventionist and infectious diseases physician and served as the instruction phase, providing opportunities for questions and knowledge application from the videos. eight town halls occurred each week from march 1 to april 3, 2020. all departments and disciplines were invited. a 30-question survey was conducted to assess hcw attitudes and perceptions about key covid-19 topics before and after icm. an e-mail was sent with a link to the online survey on april 6, 2020. the initial e-mail was followed by reminders at 1 and 2 weeks. responses were submitted anonymously. respondents were not required to answer every question. video utilization statistics for the study period were generated. survey data were collected electronically using microsoft forms. n95 respirator use and the covid-19 census were retrospectively reviewed. in total, 4,312 video plays occurred, of which 2,949 were in a desktop browser, 1,331 were in a mobile phone, and 32 were in a tablet. an average of 67.36 views per day occurred. the most widely seen videos were on personal protective equipment (ppe) use and sars-cov2 transmission dynamics (2,784 views), followed by general information about covid-19 (673 views), covid-19 triage process (287 views), flattening the curve (236 views), and hospital pandemic plans (202 views). in total, we received 247 responses to the survey, representing multiple hospital disciplines and departments (table 1) . videos were rated on likert scales as follows; 78.4% very helpful, 16.7% somewhat helpful, and 4.1% neutral. the impact of icm on hcw attitudes and perceptions about covid-19 was mostly rated positive (27.7%-32.5%) or very positive (42.1%-62.9%) on likert scales (fig. 1) . after icm, comfort selecting ppe was rated 26.7% more favorably and comfort with extended use and reuse was rated 28% more favorably (fig. 1) . daily n95 respirator use decreased from a peak daily average of 253 to 93 after education despite an increase in covid-19 cases from 20% to 55% as a proportion of the daily hospital census. icm was a feasible and efficient way to deliver educational content for pandemic preparedness at a community hospital with limited infection preventionist and infectious diseases physician staff. the videos were easy to create and convenient to access across different devices at any time. this flexibility was valuable for educators and learners through the challenging time constraints of early pandemic planning. town halls served as the instruction phase for education and addressed knowledge gaps on topics such as transmission dynamics, guidance for ppe use, reuse, and extended use. these were held in person and via online videoconferencing platforms and captured different disciplines, departments, and shifts. icm was well received and a better understanding of transmission dynamics and ppe use was reported in our survey. understanding selection, use, re-use and extended use concepts may have contributed to a reduction in n95 use despite an increase in covid-19 cases. a decrease in fear was also reported in our survey. managing fear and fear contagion is important during pandemics. factors involved in healthcare worker (hcw) fear during pandemics include fear of becoming infected themselves and fear of infecting family members, friends, and colleagues. 9,10 studies during the sars-cov-1 outbreak showed that most hcws felt transmission may not be fully avoidable by complying with or maintaining infection control practices. high stress, heavy workload, and sudden changes in guidelines added to fear, fear contagion, and even post-traumatic stress disorder. 10 the use of icm to target high-yield topics on how to stay safe at work and at home may have contributed to this reduction in fear, along with further experience with covid-19 as the pandemic evolved. our approach had its challenges as well. capturing all staff and shifts for town halls can be difficult. we targeted high-risk departments for in-person sessions, such as emergency rooms, inpatient units, and respiratory technologists. virtual town halls provided significant flexibility to reach early and late shifts. our ability to deliver content would be have been much more challenging without icm and was supplemented further with a train-thetrainer programs. icm has been used successfully at various levels of medical and nursing education. this model is now widely used in colleges of medicine nationwide, and icm is gaining momentum in graduate medical education. 6 in these settings, icm was effective in improving knowledge and competence with high student satisfaction. 8 it has also yielded positive academic outcomes in nursing. 7 the use of icm in rapidly changing environments with significant education needs is a natural next step. to our knowledge, this is the first description of its use for pandemic planning and response. we report our experience implementing icm at an urban community hospital with limited infection prevention staff. this model was effective, efficient, and well received by staff of various disciplines and departments. our survey demonstrated a positive impact on knowledge and perceptions on key covid-19 topics, such as modes of transmission, ppe use, and fear. in a pandemic with rapidly evolving knowledge and education needs, icm can be an effective education and preparedness tool. a pneumonia outbreak associated with a new coronavirus of probable bat origin the novel coronavirus originating in wuhan, china antibiotic stewardship in small hospitals: barriers and potential solutions the future supply and demand for infectious disease physicians. the infectious diseases society website infection prevention staffing and resources in us acute-care hospitals: results from the apic megasurvey an introduction to the inverted/flipped classroom model in education and advanced training in medicine and in the healthcare professions the evidence for 'flipping out': a systematic review of the flipped classroom in nursing education flipped or": a modified didactical concept for a surgical clerkship in oral and maxillofacial surgery fear of severe acute respiratory syndrome (sars) among health care workers long-term psychological and occupational effects of providing hospital healthcare during sars outbreak impact of inverted classroom methodology (icm) on healthcare worker (hcw) attitudes and perceptions about covid-19 acknowledgments. we acknowledge the colossal efforts of healthcare workers and essential workers during the covid-19 pandemic.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-318766-vx0dnnxh authors: wendt, ralph; nagel, stephan; nickel, olaf; wolf, johannes; kalbitz, sven; kaiser, thorsten; borte, stephan; lübbert, christoph title: comprehensive investigation of an in-hospital transmission cluster of a symptomatic sars-cov-2–positive physician among patients and healthcare workers in germany date: 2020-06-03 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.268 sha: doc_id: 318766 cord_uid: vx0dnnxh we investigated potential transmissions of a symptomatic sars-cov-2–positive physician in a tertiary-care hospital who worked for 15 cumulative hours without wearing a face mask. no in-hospital transmissions occurred, despite 254 contacts among patients and healthcare workers. in conclusion, exposed hospital staff continued work, accompanied by close clinical and virologic monitoring. on january 27, 2020, the first infection with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) was diagnosed in germany. 1 by may 20, 2020, the number of cases had increased to 176,000. 2 to address the large number of patients at a given time, hospital capacity, especially the availability of intensive care facilities and the number of healthcare workers (hcws), particularly doctors and nurses, are cornerstones and essential pillars in the struggle against the covid-19 pandemic. disease transmission among infected hcws is a major threat that could adversely affect the capacity of hospitals to care for patients and might even endanger patients. 3 we report on a symptomatic sars-cov-2-infected physician who worked in a large 1,030-bed municipal hospital in leipzig, germany. at the time of the report, coronavirus disease 2019 (covid-19) cases in germany were rapidly increasing. the index case physician had traveled to the part of germany with the highest covid-19 rates at that time, thereby visiting pubs and restaurants in the city of stuttgart (federal state of baden-wuerttemberg) on march 12-13, 2020. after returning home, she felt unwell for 2 days and had a sore throat, cough, and fever. despite these symptoms, she went to work at the hospital without wearing a face mask or other protective devices. she remained symptomatic, particularly with subfebrile temperature and frequent coughing. on march 16, 2020, she was working an 8-hour shift in addition to a 4-hour on-call shift. she was making rounds at the hospital, caring for patients, doing admissions, discussing treatments with colleagues, having frequent contact with nurses and other healthcare staff, having lunch and coffee breaks in a small lounge area, and even sitting in a crowded lecture room along with other hcws (supplemental fig. 1 online), as well as listening to employee information on the management of covid-19 patients. during the on-call shift, she saw patients all over the hospital. the next day, she stayed at home, but she returned the following day for another 3 hours of hospital work, still coughing heavily and apparently ill. when noticed, she was immediately sent home after undergoing coronavirus testing (combined nose and throat swab), which was positive for sars-cov-2. to assess sars-cov-2 infection, either copan liquid amies swabs (copan, brescia, italy) or pharyngeal lavage (10 ml saline solution) was used for sampling the nasopharyngeal material of the index physician and all contacts. rna extraction and real-time to further investigate potentially missed transmissions, we attempted to detect iga and igg antibodies against sars-cov-2 in sera, withdrawn on days 15 or16 and 22 or 23 after exposure, by an in vitro diagnostic labeled anti-sars-cov-2 enzyme-linked immunosorbent assay (elisa, euroimmun, lübeck, germany), following the manufacturer's instructions. only descriptive statistics were applied. numerical variables were summarized as means, and categorical variables were given as frequencies or proportions. ethical approval was not required for this study because only anonymous aggregated data were used, and no medical interventions were made on human subjects. sampling of hcws or patients was part of hospital policy. we identified 187 contacts with hcws and 67 contacts with patients. of these, 23 were identified as high-risk contacts, as defined by the world health organization guidance document on covid-19 global surveillance. 4 table 1 summarizes the characteristics of each high-risk contact. all high-risk contacts were subject to active symptommonitoring and committed to wearing a face mask during work. we tested all 254 potential contacts of the symptomatic sars-cov-2-positive index physician, including 67 patients, and 187 nurses and doctors, technical and medical assistants, and other healthcare staff, on day 5 after the exposure by specific rt-pcr from nose and throat swabs or pharyngeal lavage, irrespective of reported symptoms. of 187 tested hcws, 30 (16%) reported minor unspecific symptoms of upper airway infection (sore throat, coughing, sniffing). all tested persons turned out to be sars-cov-2 negative. the 23 high-risk contacts were investigated again 10 days after exposure by specific rt-pcr from nose and throat swabs. test results were negative, again. additionally, all high-risk contacts and the index physician were examined serologically on days 15 or 16 and days 22 or 23 after exposure. despite some iga positive-to-inconclusive ratios, none showed positivity for sars-cov-2 igg antibodies at follow-up except the index physician featuring seroconversion (table 2 ). we tested a large number of possible contact persons of a symptomatic sars-cov-2-infected physician among hcws and patients on day 5 after exposure; all were negative. after a comprehensive investigation of all contact clusters, we identified 23 highrisk contacts (22 hcws and 1 patient) and tested them again on day 10 after exposure. all rt-pcr tests remained negative for sars-cov-2, confirming that there was no transmission of the virus. extensive investigation and testing were performed because viral shedding of sars-cov-2 has been shown in completely asymptomatic individuals, prompting the hypothesis that clinical status is not reliable for triage and further testing. 5 sars-cov-2 has frequently been detected in asymptomatic carriers, for instance, during a cruise ship outbreak in which most of the passengers and staff were tested irrespective of symptoms: 51% of the laboratory-confirmed cases were asymptomatic at the time of confirmation. 6 for further analysis and confirmation of our results, we investigated the serum of all high-risk contacts (n = 23) on days 15 or 16 and 22 or 23 for sars-cov-2-specific antibodies. we found positive iga antibodies at both times but no igg antibodies, confirming the rt-pcr results of zero transmission. the specificities for iga and igg against sars-cov-2 were 91.3% and 100%, respectively. although the calculated performance values were obtained in a small study cohort (n = 24), the specificities were similar to those reported in a previous study and in accordance with the manufacturer's specifications. 7 these results are unexpected. considering an active sars-cov-2 transmission source with a presumably high viral burden and many high-risk contacts inside a hospital, massive spread was anticipated, particularly since a protective face mask was not in use. sars-cov-2 has been shown to persist (at least under experimental circumstances) for up to 72 hours depending on the surface type. 8 in hospitals, surfaces are frequently cleaned and disinfected, and all hcws reported regular handwashing, disinfection, and strict adherence to hygiene rules. recently, the importance of presymptomatic transmission (r p ) has been stressed (r p = 0.9 of an r 0 of 2), and the proportion of symptomatic transmission (r s ) to the basic reproduction number r 0 was calculated to be only 0.8 of an r 0 of 2. 9 a low percentage of transmission to high-risk contacts (5%) has been reported in nonhousehold members. 10 another study in the united states investigated the high-risk contacts of a patient among healthcare personnel (n = 32) and did not find any transmission, confirming our results. however, testing was only done in symptomatic persons after clinical monitoring, and asymptomatic transmission could have been missed. 11 importantly, not every infected person with sars-cov-2 is a super spreader, and not every infected individual in a closed room triggers a superspreading event, although this situation has the potential to do so and therefore must be dealt with as such. 12 in this context, our data support the recommendation to keep high-risk contacts among the hospital staff at work (especially in these difficult times with personnel shortages) when strictly using a protective mask, accompanied by close clinical and virologic monitoring. transmission of 2019-ncov infection from an asymptomatic contact in germany covid-19). world health organization website strengthening icu health security for a coronavirus pandemic global surveillance for human infection with coronavirus disease (covid-2019)-interim guidance. world health organization website evidence of sars-cov-2 infection in returning travelers from wuhan, china japan national institute of infectious diseases website severe acute respiratory syndrome coronavirus 2-specific antibody responses in coronavirus disease 2019 patients aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 quantifying sars-cov-2 transmission suggests epidemic control with digital contact tracing investigation of a covid-19 outbreak in germany resulting from a single travel-associated primary case: a case series first known person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in the usa the role of superspreaders in infectious disease acknowledgments. we kindly acknowledge the enormous personal commitment of ulrike schmidt (study department), and ines geßner as well as gerit görisch, md (both from hospital hygiene department).financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-297886-kxb17zx4 authors: kluger, dan m.; aizenbud, yariv; jaffe, ariel; parisi, fabio; aizenbud, lilach; minsky-fenick, eyal; kluger, jonathan m.; farhadian, shelli; kluger, harriet m.; kluger, yuval title: impact of healthcare worker shift scheduling on workforce preservation during the covid-19 pandemic date: 2020-07-20 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.337 sha: doc_id: 297886 cord_uid: kxb17zx4 reducing severe acute respiratory coronavirus virus 2 (sars-cov-2) infections among healthcare workers is critical. we ran monte carlo simulations modeling the spread of sars-cov-2 in non–covid-19 wards, and we found that longer nursing shifts and scheduling designs in which teams of nurses and doctors co-rotate no more frequently than every 3 days can lead to fewer infections. as the coronavirus disease 2019 (covid-19) pandemic continues, healthcare workers (hcws) report for duty, caring for both covid-19 patients and patients with non-covid-19 conditions. reports from china and italy suggest that hcws are highly vulnerable to covid-19 infection: in italy, 20% of hcws became infected with severe acute respiratory coronavirus virus 2 (sars-cov-2) at the peak of disease spread. 1 preventing covid-19 infections among hcws is critical for their safety and for stability of the healthcare delivery system. this includes stable functioning of non-covid-19 wards, where hcws may be exposed to sars-cov-2infected patients who may not have undergone testing due to low clinical index of suspicion. one approach to reducing infection rates is to optimize staff scheduling to minimize interactions between different hcws and limit the patient pool to which hcws are exposed. despite reports of nosocomial infections, infection of hcws by patients, and transmission of sars-cov-2 from one hcw to another, little is known about the effects of hcw team structure on hospital transmission of sars-cov-2. 2,3 experience from other pandemics is not necessarily applicable because infection and fatality rates differ. therefore, we ran monte carlo simulations to explore various staffing possibilities with the goal of identifying staffing structures to minimize infections among hcws on non-covid-19 wards. for covid-19 wards, in which the rate of patient-to-hcw transmission depends on personal protective equipment (ppe) and types of procedures and patient encounters, alternative input parameter choices for such simulations are needed; here, we solely address staffing in non-covid-19 wards. for the 5 scheduling designs represented in figure 1 , we simulated the spread of sars-cov-2 in hospital wards with various choices of model input parameters. the universal model parameters for covid-19 included incubation period distribution (time from exposure to first symptom) and latent period distribution (time from exposure to becoming infectious.) situation-dependent covid-19 model parameters included preadmission infection probability of an admitted patient, team member infection probability at start of simulation, physician-to-patient, nurse-topatient, patient-to-physician, patient-to-nurse, and hcw-to-hcw transmission probabilities, team-member days of absence after symptom onset, daily sars-cov-2 exposure probability of team members (eg, via elevator use, exposure to other staff), length of patient stay after showing covid-19 symptoms, and length of simulation time. model parameters that varied by hospital setting and service type included average team patient census, average patient hospitalization length, and the number of physicians and nurses on a team and on duty at all times. parameters relevant to patient infectivity and patient acuity are discussed in appendix b (online) and the model is described in further detail in appendix c (online). to illustrate how scheduling decisions affect infection rates, we simulated 2 hospital teams, each including 6 house staff or advanced practice providers (apps) and 3 attending physicians, 2 house staff and apps, and 1 attending physician on rotation at a time (fig. 1 ). the first team had 30 nurses (5 per shift), and the second team had 18 nurses (3 per shift). the average number of patients was set to 15 per day (5 per nurse or 3 per nurse, in settings with different patient acuity). under normal circumstances, personnel rotations are staggered to ensure continuity of care and broad exposure for trainees to attending physicians and patients to enhance their educational experience. rotation duration is also geared toward minimizing hcw fatigue. in a pandemic, these factors are considerably less important than hcw preservation. we compared scheduling options to minimize team failure, defined as the event that at some point there are insufficient attending physicians or house-staff/apps to staff a fully functioning floor or insufficient healthy nurses to limit weekly hours to 48. under all scenarios modeled, each nurse works an average of ≤36 hours per week. figure 1 illustrates 5 staff scheduling designs for a team of 18 nurses, 3 attending physicians and 6 house staff with physician rotation durations of 4 days. figure 2 depicts the outcomes of the 5 staff scheduling scenarios for mean patient hospital stays of 2 and 5 days, typical for maternity and medicine floors, respectively, indicating team failure probability as a function of physician rotation length. we simulated situations in which cohorts of nurses corotate with physician rotations compared to nursing schedules that were independent of physician schedules. although the precise latent period of sars-cov-2 is unknown, the median incubation period is 5.1 days. 4 nurses 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 a ending house sta a house sta b day13 day14 day1 day2 day3 day4 day5 day6 day9 day10 day11 day12 day7 day8 1 1 1 1 1 1 1 1 1 1 1 1 1 nurses 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 a ending house sta a house sta b nurses 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 the plots compare the probability of team failure for 5 different scheduling designs. the designs simulated vary by whether they are staggered versus un-staggered, whether they have 8-hour nurse shifts or 12-hour nurse shifts, and whether nurses work consecutive days or work alternating days. in our simulations with nurses working consecutive days, when the physician rotations are sufficiently short, the nurses work the same number of consecutive days as the physician do. however, if the physician rotations are too long, the nurses are scheduled to work as many consecutive days as possible without exceeding 48 hours of work in the span of 1 week, and without exceeding 36 hours per week on average. notably, due to unknown variables in the model, these plots do not suggest that the actual probability of team failure lies in the 20%-60% range, but rather, the plots are intended to demonstrate the relative improvement of various staff scheduling changes. from the plots above, and from similar plots that we generated with varying choices of the unknown parameters, we observe that scheduling designs with un-staggered rotations, 12-hour nursing shifts over consecutive days are favorable, and further, the probability of team failure is lower when all hcws work at least 3-4 consecutive days. symptoms. 5 without frequent testing, shorter rotations increase the likelihood that infected hcws will be off rotation for 24 hours before initiation of symptoms, while longer rotations expose fewer hcws to the same infectious patient. the rotation length that minimizes failure probability mainly depends on 2 factors: the median sars-cov-2 latent period, which is not precisely known, and the average hospitalization duration. further understanding of the relationship between these factors is needed to make strong recommendations about optimal rotation length. however, in all simulations analyzed, physician and nurse rotation lengths of 1-3 days led to higher team failure rates; shorter rotations resulted in exposure of more hcws to an infected patient. when the average patient stay is much longer than 5 days or when the median latent period is much shorter than 4 days, the benefit of un-staggering rotations decreased (data not shown). when patient stays were short, such as on maternity wards, the advantage of un-staggered rotations was consistent and universal across various parameters. notably, because the actual probability of team failure is sensitive to other unknown parameters, plots such as those in figure 2 should be used only to design optimal scheduling of shifts and not to forecast the actual probability of team failure. our rotation-scheduler r code is available at https://github.com/klugerlab/rotationscheduler. in summary, pandemics necessitate widespread reassessment of workforce planning to ensure backup of sufficient uninfected hcws. using various input variables for our simulations for non-covid-19 services, we make 3 primary observations: (1) having all hcws work at least 3 consecutive days reduces the chance of team failure, (2) longer nursing shifts (12 versus 8 hours) decreases the rate of hcw infection, and (3) avoiding staggering of rotations of attendings, house staff, and nurses reduces the number of infected hcws. when applying this model to the real-world challenge of staffing hospital units, clinical setting variables such as trainee presence, patient acuity, stay length, and nurse-patient ratio will need to be considered. similar modeling can be employed for teams treating known covid-19 patients. in conclusion, alternative staffing methods, in which groups of physicians and nurses share rotations that are at least 3 days long with 12-hour nursing shifts, should be considered for workforce preservation in the covid-19 pandemic. supplementary material. to view supplementary material for this article, please visit https://doi.org/10.1017/ice.2020.337 covid-19 and italy: what next? just the facts: protecting frontline clinicians during the covid-19 pandemic clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application temporal dynamics in viral shedding and transmissibility of covid-19 acknowledgments.financial support. the study was partially supported by the national institutes of health (grant no. k23mh 118999 to s.f.f.) and by the yale spore in skin cancer (grant no. p50 ca121974 to h.m.k. and grant no r01rgm131642 to y.k.). all authors report no conflicts of interest relevant to this article. key: cord-274871-jlquvz51 authors: nori, priya; cowman, kelsie; chen, victor; bartash, rachel; szymczak, wendy; madaline, theresa; punjabi katiyar, chitra; jain, ruchika; aldrich, margaret; weston, gregory; gialanella, philip; corpuz, marilou; gendlina, inessa; guo, yi title: bacterial and fungal coinfections in covid-19 patients hospitalized during the new york city pandemic surge date: 2020-07-24 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.368 sha: doc_id: 274871 cord_uid: jlquvz51 we observed bacterial or fungal coinfections in covid-19 patients admitted between march 1 and april 18, 2020 (152 of 4,267, 3.6%). among these patients, mortality was 57%; 74% were intubated; 51% with bacteremia had central venous catheters. time to culture positivity was 6–7 days, and 79% had received prior antibiotics. metallo-β-lactamase–producing e. cloacae coinfections occurred in 5 patients. few studies have addressed bacterial or fungal coinfections or the emergence of antimicrobial resistance in coronavirus disease 2019 (covid-19) patients. more than 70% may receive antibiotics, but <10% experience coinfections. 1,2 these patients have multiple risk factors for poor outcomes associated with nosocomial infections, such as critical illness, prolonged hospitalization, mechanical ventilation, and immune dysregulation. 1 given the mismatch between empiric prescribing and coinfection rates, recent world health organization guidelines recommend empiric antibiotics only for patients with severe covid-19, using host factors and local epidemiology to drive antibiotic selection. 3 we sought to characterize the microbiology of bacterial and fungal coinfections during the pandemic surge at our medical center with a focus on clinical outcomes, antimicrobial use, and antimicrobial resistance (amr). we conducted a retrospective observational study of covid-19 patients admitted between march 1, 2020, and april 18, 2020. microbiology data were obtained from the laboratory information system (lis). patient demographics, central venous catheter status, icu status, mechanical ventilation status, imaging, laboratory results, administered antibiotics per days of therapy (dot), and disposition (admitted, discharged, deceased) were obtained from the electronic medical record. all cases were reviewed by an infectious diseases (id) specialist to determine (1) the presence of true clinical coinfection and (2) the source. national healthcare safety network (nhsn) criteria were used for central-line-associated bloodstream infections (clabsi). antibiogram data from march 1 to april 23, 2019 versus 2020 (institution-wide) and 2018-2019 (icu-specific) were compared. institutional review board approval was obtained (irb no. 2020-11285). descriptive statistics were summarized using frequencies and percentages, or medians and interquartile ranges (iqrs). bivariate analyses were conducted (χ 2 or fisher exact test). analyses were conducted using sas version 9.4 software (sas institute, cary, nc). all statistical tests were 2-tailed and p values < .05 were considered significant. all adult and pediatric patients with a positive sars-cov-2 pcr result and positive blood or respiratory culture (by matrix-assisted laser desorption/ionization) were analyzed. cases were included if the positive pcr result and microbiology result occurred in the same or preceding admission (within 30 days). blood cultures positive for skin flora that did not grow in multiple cultures or on separate dates were excluded (ie, gram-positive bacilli, coagulase-negative staphylococci [cons], micrococci, kocuria spp). respiratory cultures positive for yeast, normal oral or respiratory flora, mixed bacterial species, and skin flora were excluded. patients with positive urine cultures alone without concurrent bacteremia were excluded. in total, 152 distinct patients were analyzed among 4,267 covid-19 patients admitted between march 1, 2020 and april 18, 2020 (3.6%). of these, 32% of patients were hispanic, 39% were non-hispanic black, and 7% were white. also, 89 patients (59%) were men, and the median age was 62 years (iqr, 52.5-72). moreover, 33% had had preceding healthcare exposure defined as recent hospitalization, residence in a skilled nursing facility, or chronic hemodialysis. in total, 99 patients (65%) were admitted to intensive care units (icus) and 112 patients (74%) received mechanical ventilation (in the icu or ward). overall, 86 patients (57%) died, 24 patients (16%) were discharged, and 42 patients (28%) were still admitted at the time of the analysis. median length of hospitalization was 13 days (iqr, 6-21). in addition, 26 patients (17%) received biologics (eg, anakinra, tocilizumab, sarilumab, or leronlimab) or placebo and 44 patients (29%) received corticosteroids (table 1 ). in total, 91 patients (60%) had positive respiratory cultures, 82 patients (54%) had positive blood cultures, and 21 patients (14%) had both positive blood and respiratory cultures with the same or different organisms. in addition, 13 patients (9%) had polymicrobial cultures ( table 2) . among the 91 patients with positive respiratory cultures, 112 isolates were identified (2) . the 5 most commonly identified organisms were s. aureus (44%), p. aeruginosa (16%), klebsiella spp (10%), enterobacter spp (8%), and e. coli (4%) (fig. 1) . moreover, 17 gram-negative isolates (15%) were multidrug resistant, defined as resistance to at least 1 agent in at least 3 different antibiotic classes. among them, 6 (5%) were carbapenem-resistant enterobacteriaceae (cre). the median time between sars-cov-2 pcr result and positive respiratory culture was 6 days (iqr, 2-8 days). most patients were admitted to icus (93%) and were intubated (95%). in addition, 4 patients (4%) had positive respiratory cultures ≥1 day prior to the sars-cov-2 result, all of whom were admitted from long-term care facilities. among the 82 patients with positive blood cultures, 155 isolates were identified (2). the median time to bacteremia was 7 days (iqr, 3-14 days). also, 44 patients (54%) had a documented central venous catheter at the time of bacteremia. the following sources of infection were determined by an id specialist: catheter (23%), respiratory (13%), genitourinary (9%), gastrointestinal (6%), or multiple (30%) (2) . the nhsn clabsi criteria were met in 13 of 19 cases (68%), and the remainder were considered clinical clabsis or secondary bloodstream infections. the most frequently isolated organisms were staphylococcus aureus (30%), s. epidermidis (12%), streptococcus spp (10%), enterococcus spp (7%), escherichia coli (7%), pseudomonas aeruginosa (6%), candida spp (5%), klebsiella spp (3%), and enterobacter spp (3%) (fig. 1 ). the study cohort included 8 candidemia patients; 7 patients had central venous catheters. also, 7 gram-negative bloodstream isolates (8.5%) were multidrug resistant (mdr), of which 4 (5%) were cre. candidemia was observed in 8 covid-19 patients and in 31 patients overall in this study period (vs 25 in 2019). of 82 patients, 17 (21%) were initially bacteremic then had a subsequent positive sars-cov-2 pcr result. bacteremic episodes occurred during the covid-19 admission (n = 12, 70%) or a prior admission (n = 5, 30%). in addition, 22 patients (27%) had a concurrent positive sars-cov-2 result and bacteremia with a variety of gram-positive and gram-negative bacteria (eg, mssa, mrsa, p. aeruginosa, e. coli, streptococcus spp, etc). of 5,853 covid-19 patients admitted between march 1 and may 31, 2020, 4,130 patients (71%) received at least 1 antibiotic dose of the following agents: doxycycline, azithromycin, levofloxacin, ciprofloxacin, ceftriaxone, cefepime, intravenous vancomycin, and piperacillin/tazobactam. also, 120 patients in this study (79%) had antibiotic exposure in the 30 days preceding positive microbiology. all 21 patients (100%) with mdr infections had received prior antibiotics compared to 99 patients (65%) without mdr infections (p = .01). overall, 149 patients in the study (98%) received antibiotics at some point during their covid-19 hospitalization. the median antibiotic days of therapy (dot) was 8.5 days (iqr, 5-14); 12 days (iqr, 7-20) in patients with multidrug resistance, and 8 days (iqr, [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] in patients without (p = .21). in addition, 107 patients (70%) received >3 antibiotic classes (β-lactams, glycopeptides, macrolides, or tetracyclines). we observed widespread empiric antibiotic use throughout the pandemic and clinically relevant bacterial and fungal coinfections in patients with advanced covid-19 and multiple risk factors for nosocomial infection (mechanical ventilation, central venous catheters, treatment with corticosteroids or biologics, and prolonged hospitalization). although comparative nyc rates of pandemic antibiotic use and nosocomial infections were not available, the bronx had the highest rates of covid-19 hospitalizations and deaths. 4,5 therefore, these observations are expected to a certain extent. 2 blacks and hispanics comprised 71% of our study population, but we were unable to determine the impact of race on mortality due to coinfection. due to strain experienced by the health systems at surge capacity, attention was likely diverted away from monitoring for excess antimicrobial use and nosocomial infections. 2 we are particularly concerned about the number of candidemias that met nhsn clabsi criteria. the potential impact on healthcare-associated infection rates is a significant concern for hospitals. 6 coinfections reported during past coronavirus pandemics were also healthcare associated. 2 blood cultures positive for skin flora were excluded from analysis, but the number of coagulase-negative staphylococci bacteremia cases significantly increased from 110 to 269 over the same period in 2019 versus 2020, suggesting a higher rate of blood culture contamination. although this finding reflects an absolute increase in number of specimens sent, formal observations of blood-culturing technique, and catheter insertion and maintenance procedures are needed to evaluate fidelity to prepandemic infection prevention bundles. the clinical presentation of severe covid-19 may be indistinguishable from bacterial or fungal sepsis, which is likely driving excess antimicrobial use. 1, 7 like earlier studies, we observed a significant mismatch of antibiotic use (71%) versus coinfections (3.6%). 2,6 moreover, 79% of coinfected patients received antibiotics in the 30 days preceding positive cultures and 98% received them during the index covid-19 hospitalization. in the latter group, empiric or targeted antibiotics were administered for a median of 8.5 days, and 70% of patients received >3 antibiotic classes. therefore, antimicrobial stewardship programs have a major contributory role in the pandemic response with rational empiric antibiotic guidelines. 1, 2, 8 we suggest use of "real-time" institutional antibiograms to guide protocol development. to our knowledge, this is the first description of the microbiology and clinical outcomes of bacterial and fungal coinfections during the nyc covid-19 pandemic surge. clinical coinfections were confirmed by an id specialist and contaminants were excluded. goyal et al 9 reported a higher rate of bacteremic patients at a neighboring nyc institution (19 of 338, 5.6%) but did not report specific microbiology or contamination rate. antibiogram data comparing 2018-2019 and 2020 revealed a significant decline in enterobacteriaceae susceptibilities to multiple antibiotics, potentially due to selective antibiotic pressure. although most infections occurred after initial covid-19 diagnosis (70%), 16% of patients had a concurrent positive sars-cov-2 pcr and microbial culture with a variety of bacteria. furthermore, in 2018-2019, there were 279 icu s. aureus clinical isolates versus 151 during the <8 week study period, suggesting a proportionally higher number of s. aureus infections during the pandemic. further study is warranted to determine increased susceptibility to s. aureus and other pathogens similar to that observed during past influenza a pandemics. 10 overall, 70 patients (46%) received either corticosteroids or biologics; however, our study was not designed to detect differences in infection rates or types of pathogens among patients who did or did not receive immunosuppressive medications. this study has several limitations. this is a single-center observational report of only 152 patients with no comparison to matched controls without secondary infection, which is needed to truly assess differences in amr and clinical outcomes. amr due to the pandemic may be exacerbated in cities with pre-existing high prevalence; therefore, our results may not be generalizable to other regions. 1 urine culture results were not reviewed unless patients had concurrent bacteremia. at the onset, respiratory cultures were obtained on a limited basis due to potential for aerosolization; therefore, the true number of concurrent bacterial pneumonias remains unknown. the study was not designed to determine the cause of secondary infection among the numerous possibilities (eg, disruption of host immunity, hospital acquisition, immunosuppressive medications, provider practice changes, etc). regardless, we suggest reinforcement of infection prevention and stewardship best practices. in conclusion, our study confirms widespread antibiotic use in most hospitalized covid-19 patients at our medical center. bacterial and fungal coinfections occurred in <5% but are of significant concern due to their occurrence in the most vulnerable patients. in addition, we observed worsening enterobacteriaceae susceptibility profiles emerging during the brief study period compared to antibiogram data from 2018 to 2019. the pandemic has highlighted the need for close collaboration between stewardship and infection prevention programs to monitor for nosocomial infections, excess antibiotic use, and multidrug resistance. coronavirus disease 2019, superinfections, and antimicrobial development: what can we expect? bacterial and fungal co-infection in individuals with coronavirus: a rapid review to support covid-19 antimicrobial prescribing clinical management of covid-19 interim guidance-may 2020. world health organization website covid-19 data. nyc health website variation in covid-19 hospitalizations and deaths across new york city boroughs impact of covid-19 on traditional healthcare-associated infection prevention efforts clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study involving antimicrobial stewardship programs in covid-19 response efforts: all hands on deck clinical characteristics of covid-19 in new york city secondary bacterial pneumonia by staphylococcus aureus following influenza a infection is saer/s dependent acknowledgments. authors would like to acknowledge dr. liise-anne pirofski, division chief of infectious diseases, montefiore/einstein.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-288122-8hhtondh authors: tsuchida, tomoya; fujitani, shigeki; yamasaki, yukitaka; kunishima, hiroyuki; matsuda, takahide title: development of a protective device for rt-pcr testing sars-cov-2 in covid-19 patients date: 2020-04-13 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.121 sha: doc_id: 288122 cord_uid: 8hhtondh nan to the editor-in december 2019, the novel coronavirus sars-cov-2 emerged in wuhan city, hubei province, china, and has now spread worldwide. 1 currently, the diagnostic gold standard is the reverse transcription-polymerase chain reaction (rt-pcr). from the sensitivity perspective, sputum samples are preferable for examination. 2 if acquiring a sputum sample is difficult, a healthcare worker (hcw) can collect sample from the nasopharynx. 3 getting a sample from the nasopharynx may carry a risk of the patient sneezing or coughing, and the hcw could be potentially exposed to the virus. therefore, hcws are required to wear personal protective equipment (ppe) for each examination and procedure. however, ppe is difficult to don and doff, and donning and doffing carries the risk of infection. furthermore, if the demand for rt-pcr increases under conditions in which medical resources are scarce, it might be difficult to sample and test all specimens. on march 14, 2020, we developed a protective box (product name, star ball shield) to be used in patients with suspected covid-19 during clinical examinations or performance of rt-pcr in collaboration with star ball company, kitakyushu city, japan ( figure 1 ). the shield was made by processing waterproof cardboard and is collapsible and easy to carry. furthermore, the star ball shield permits hcws to run rt-pcr without the risk of exposure. this shield liberates the hcws from the need to don and doff ppe for each clinical examination. once a patient's examination has concluded, the hcw uses alcohol to wipe the surface of the box facing the patient and proceeds to examine the next patient. the star ball shield is extremely helpful in the examination of patients with suspected covid-19. fig. 1 . the photo shows the healthcare worker (hcw) and patient sides of the shield. an acrylic plate is used for the window so that the patient's face can be seen clearly. the hcw wears ppe for examinations but does not need to change ppe for each patient. the disposable gloves used for testing must be changed for each patient. world health organization: novel coronavirus (2019-ncov) situation report-1. world health organization website detection of sars-cov-2 in different types of clinical specimens a manual for sampling and transmission of specimens from patients with suspected 2019-ncov (novel coronavirus) acknowledgments. we are grateful to star ball company for collaborating in the development of the star ball shield and for providing it to our hospital.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-252344-5a0sriq9 authors: saleh, sameh n.; lehmann, christoph u.; mcdonald, samuel a.; basit, mujeeb a.; medford, richard j. title: understanding public perception of coronavirus disease 2019 (covid-19) social distancing on twitter date: 2020-08-06 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.406 sha: doc_id: 252344 cord_uid: 5a0sriq9 objective: social distancing policies are key in curtailing severe acute respiratory coronavirus virus 2 (sars-cov-2) spread, but their effectiveness is heavily contingent on public understanding and collective adherence. we studied public perception of social distancing through organic, large-scale discussion on twitter. design: retrospective cross-sectional study. methods: between march 27 and april 10, 2020, we retrieved english-only tweets matching two trending social distancing hashtags, #socialdistancing and #stayathome. we analyzed the tweets using natural language processing and machine-learning models, and we conducted a sentiment analysis to identify emotions and polarity. we evaluated the subjectivity of tweets and estimated the frequency of discussion of social distancing rules. we then identified clusters of discussion using topic modeling and associated sentiments. results: we studied a sample of 574,903 tweets. for both hashtags, polarity was positive (mean, 0.148; sd, 0.290); only 15% of tweets had negative polarity. tweets were more likely to be objective (median, 0.40; iqr, 0–0.6) with ~30% of tweets labeled as completely objective (labeled as 0 in range from 0 to 1). approximately half of tweets (50.4%) primarily expressed joy and one-fifth expressed fear and surprise. each correlated well with topic clusters identified by frequency including leisure and community support (ie, joy), concerns about food insecurity and quarantine effects (ie, fear), and unpredictability of coronavirus disease 2019 (covid-19) and its implications (ie, surprise). conclusions: considering the positive sentiment, preponderance of objective tweets, and topics supporting coping mechanisms, we concluded that twitter users generally supported social distancing in the early stages of their implementation. on march 11, 2020, the world health organization (who) declared the novel coronavirus (covid-19) outbreak a pandemic and emphasized the need for global governmental commitment to control the threat, citing then 118,319 confirmed cases and 4,292 deaths worldwide. 1 to contain severe acute respiratory coronavirus virus 2 (sars-cov-2), countries closed their international borders. 2 despite travel restrictions, global cases continued to increase 3 requiring enactment of key community mitigation, which garnered significant public attention. 4, 5 these mitigation strategies, named nonpharmaceutical interventions (npis), are approaches outside medications, therapies, and vaccines to prevent further spread of sars-cov-2 and to reduce the strain on the healthcare system. npis fall under 3 main categories: personal, environmental, and community. personal npis refer to behaviors like staying home when sick, coughing or sneezing in a tissue or elbow, wearing a mask, and washing hands with soap and water or using hand sanitizer. environmental npis refer to appropriate surface cleaning of high-throughput areas and commonly used objects. community npis refer to social distancing and closure of areas where large gatherings may occur, such as schools, businesses, parks, and sporting events. used previously for other viral outbreaks such as influenza, 6 social distancing or physical distancing refers to increasing the space between individuals and avoidance of larger gatherings in an attempt to reduce viral transmission. 7 this community npi has been a main components of effectively fighting the covid-19 pandemic. [8] [9] [10] managing and changing public opinion and behavior are vital for social distancing to successfully slow transmission of covid-19, preserve hospital resources, and prevent exceeding the healthcare system's capacity. 11 to affect public opinion, one must first examine and understand it. social media, specifically its microblogging platform twitter, serves as an ideal medium to provide this understanding. twitter has >145 million daily active users 12 and allows individuals to post, repost, like, and comment on 'tweets' of up to 280 characters. analysis of twitter has been used previously within the healthcare realm to understand public sentiment and opinion on topics ranging from diabetes, 13 cancer therapy, 14 and novel healthcare policies such as the affordable care act. 15 within the field of emerging infectious diseases, twitter analysis has been used to study public opinion and sentiment on measles, 16 influenza, 17 and zika virus outbreaks. 18 we hypothesized that performing sentiment, emotion, and content analysis of tweets related to social distancing on twitter during the covid-19 pandemic could provide valuable insight into the public's beliefs and opinions on this policy. we further hypothesized that the knowledge gained could prove valuable for public health communication as well as dissemination and refinement of information strategies. from march 27 to april 10, 2020, we extracted daily relevant samples 19 of english-only tweets related to social distancing and created a 2-week cross-sectional data set of social media activity. we used the rtweet package 20 to access twitter's application programming interface (api) via rstudio version 1.2.1335 (r foundation for statistical computing, vienna, austria). the hashtags #socialdistancing and #stayathome, which were the top trending social distancing hashtags at the time of data extraction, were used to identify tweets related to social distancing. we used 15 of the 89 collected tweet metadata variables in our analysis (table s1 online). we cleaned the tweets by removing characters and words of no or little analytical value and transforming text to its root form. we used python version 3.6.1 software (python software foundation, wilmington, de) for all data processing and analyses. further details are discussed in appendix a (online). institutional review board approval was not required because this study used only publicly available data. we used python's textblob library 21 to perform sentiment analysis for all tweets through natural language processing and text analysis to identify and classify emotions (positive, negative, or neutral) and content topics. textblob applies the afinn sentiment lexicon 22 from a polarity scale of −1 (most negative) to 1 (most positive). we visualized the polarity distribution using bins for strongly negative (−1 to −0.51), negative (−0.5 to −0.01), neutral (0), positive (0.01 to 0.5), and strongly positive (0.51 to 1). we used a recurrent neural network model developed by colneric and demsar to label the primary emotion for each tweet based on ekman's emotional classification (anger, disgust, fear, joy, sadness, or surprise). 23 using χ 2 testing and bonferroni correction to adjust for multiple comparisons, we compared the proportion of each sentiment polarity and emotion for each hashtag. we evaluated changes in effect size between hashtags using the absolute difference in percentage points. we used python's textblob library to perform subjectivity analysis and labeled each tweet from a range of 0 (objective) to 1 (subjective). objective tweets relay factual information, whereas subjective tweets typically communicate an opinion or belief. for the 2 hashtags #stayathome and #socialdistancing, we visualized sentiment using a histogram of values and compared the median sentiment between hashtags using the mann-whitney u test. through terminology matching, we used key words present in social distancing rules (eg, "stay at least 6 feet [2 meters] from other people" or "avoid large gatherings") to identify tweets with potentially objective information about these rules (table s2 online). 7 we manually reviewed 5% of the resulting tweet subset to verify what percentage of these tweets truly included information about social distancing rules and extrapolated prevalence for the full subset of tweets. to understand the major topics being discussed in our tweet sample, we applied an unsupervised machine-learning algorithm called latent dirichlet allocation (lda) 24 using the gensim python library. 25 lda is a commonly used topic-modeling approach to identify clusters of documents (in our case, tweets) by a representative set of words. the most highly weighted words in each cluster provide insight into the content of each topic. lda requires users to input the number of expected topics. to determine the optimal number of topics, we trained multiple lda models using different numbers of topics ranging from 4 to 50 and computed a topic coherence score (produced by comparing semantic similarity of a topic's most highly weighted words) for each lda model. selecting the lda model with the highest score, we ultimately chose 10 topics for the final model. an author without access or insight into the topic model initially labeled the topics using the 20 most frequently used terms ordered by weight. all authors then reached consensus on the topic labels. we identified the prevalence of topics by labeling tweets according to their most dominant topic. we identified example tweets whose content pertained >99% to 1 specific topic ( table 2 , last column). we extracted 1,352,082 tweets during the 2-week period. after removal of repeat and non-english tweets, 574,903 tweets across 347,142 users (range, 1-836 tweets per user; mean, 1.6 tweets per user) were included in the analysis (table 1) . of those tweets, 98.3% were unique. the hashtag #socialdistancing was included in 264,254 tweets and #stayathome was included in 332,075 tweets; 21,453 tweets contained both hashtags. twitter for iphone was the most commonly used platform (31%), followed by twitter for android (27.5%). moreover, <50% of tweets had media (image or video) and more than one-third had a hyperlink. the median user had >3,000 posts and >400 followers at the time of tweeting. also, 5% of accounts were verified, signified by a blue badge next to a user's profile name indicating that an account of public interest is authentic. our tweet data set contained 13,962,279 words and 93,337,108 characters. the 200 most frequently used words associated with each hashtag before processing are illustrated in fig. 1 . after processing, for both #socialdistancing and #stayathome, the most common word was 'day' (20,637 and 28,798 times, respectively). the next 19 most frequent words for #socialdistancing were 'practice' (13, 988 there was net positive sentiment polarity toward both #socialdistancing and #stayathome, with mean polarity scores of 0.150 (standard deviation [sd], 0.292) and 0.144 (sd, 0.287) respectively. positive and neutral tweets accounting for 52.2% and 33.1% of tweets, respectively (fig. 2) . moreover, <15% of tweets were negative and <2% were strongly negative. although statistical differences between polarity categories were detected due to the large sample sizes, the differences in effect sizes were minimal (fig. 2) . neutral and positive tweets had the largest absolute differences. compared to #stayathome, #socialdistancing had 3.6% fewer neutral tweets and 3.2% more positive tweets. tweets tended to be more objective in nature and~30% demonstrated near or complete objectivity (fig. 3) . the median subjectivity scores were similar for #socialdistancing (0.4; interquartile range [iqr], 0-0.59) and #stayathome (0.4; iqr, 0-0.6; p = .13). we matched 6,417 tweets that included key words related to social distancing rules and manually reviewed 320 of them. of the 320 tweets, 249 were confirmed to be related to social distancing rules, yielding a rate of 77.6%. extrapolating this to all social distancing tweets, we estimate that 4,980 (1.1% of all) tweets referenced social distancing rules. joy was the predominant emotion expressed in >50% of tweets with topics ranging from enjoying recreational activities, connecting with family members, and working from home. examples: if you are lucky enough to have even a small garden, now is the time to spend sprucing it up. our spring gardening feature has helpful advice and new ideas to try, to help you make the most of it and #stayathome and surprise was the next most prevalent emotion, and tweets included themes of prolonged policy interventions and discovery of novel talents. examples: to save lives, #socialdistancing must continue longer than we expect. and i played golf with my wife today. odd, i didn't even know she could play. #socialdistancing, #familytime" the least common emotions found in tweets were sadness, disgust, and anger (fig. 4) . we detected statistical differences in all emotions between #stayathome and #socialdistancing tweets. the largest differences in effect size were joy (#stayathome with 6.6% more) and fear (#socialdistancing with 11.9% more). we identified and subjectively labeled the 10 main tweet topics. table 2 displays the mean topic sentiment polarity and subjectivity score, key words, and example tweets. "public opinion and values", "media and entertainment", and "quarantine measures and effects" emerged as the three most prevalent topics in 88,993, 71,589, and 65,229 tweets, respectively. discussion of "spring and good sentiments" had the highest mean polarity of 0.26. "public opinion and values" and "quarantine measures and effects" had the lowest mean polarity of 0.07. mean subjectivity scores for all topics ranged from 0.33 to 0.43, with "public opinion and values" having the highest subjectivity score. understanding the beliefs, attitudes, and thoughts of individuals and populations can aid public health organizations (eg, the who) and government institutions to identify public perception and gaps in communication and knowledge. we analyzed twitter activity around the 2 most common social distancing trending hashtags at the study time to understand emotions, sentiment polarity, subjectivity, and topics discussed related to this npi. tweets predominantly showed positive sentiment polarity. tweets were primarily linked to emotions of joy (~50%), fear, and surprise. anger and disgust were the 2 least common emotions expressed. analyzing key words, we demonstrated that tweets were primarily objective in nature and were used to disseminate public health information. we identified and labeled 10 main topics demonstrating insight into the thoughts and perceptions of the public. social media data and channels provide a rich platform to perform public sentiment analysis and have already been used to examine covid-19 perceptions. one study leveraged social media to distribute a survey to nearly 9,000 individuals in the united states. 26 another large study surveyed 6,000 participants in the 4 . emotion analysis for all tweets and stratified by tweets with the hashtag #socialdistancing and #stayathome. comparison between the two hashtags is done using χ 2 testing. bonferroni correction was used to define statistical significance at a threshold of p = .008 (0.05/n, where n = 6 since 6 comparisons were completed). united kingdom and the united states. 27 despite the robust combined sample size of 15,000 participants, there were inherent limitations to the design. these studies utilize nonprobability sampling like convenience and snowball sampling that are plagued by significant selection bias as well as potential reporting bias, making them prone to sampling error. through probability sampling from the twitter api, we analyzed nearly 575,000 english tweets across 350,000 users, providing a broader understanding of public perception that is likely more representational of the population. using a machine-learning approach, we also explored topics and perceptions without introducing predefined researcher notions, thus limiting the risk of biases inherent to the question design. recent public opinion polls from a similar time period have shown that the overwhelming majority of us citizens favored the continuation of social distancing measures. 28, 29 the positive attitude is clearly reflected in the sentiments found in the analyzed tweet sample. most tweets were either positive or neutral in nature. as public sentiment shifts, we would expect this to be reflected in tweet sentiment as well. for government and public health officials, tweet sentiments may be an important measure to determine the public willingness to continue distancing, which in turn could inform future infection prediction models and social distancing policies. many tweets tend to express an opinion; however, tweets associated with #socialdistancing and #stayathome were predominately objective suggesting that these hashtags were used to transmit objective information potentially serving an important public health function. combined with the large volume of tweets and the finding that 1.1% described social distancing rules, twitter has the potential to fulfill an important educational function for public health messages. joy, fear, and surprise were the dominant emotions for the early phase of social distancing. this correlated well with the topics we discovered, which included leisure activities, community support, and messages of hope (ie, joy), concerns about food insecurity, spreading of the infection, effects of the quarantine (ie, fear), unpredictability of covid and its unforeseen implications (ie, surprise). as time progresses and the effects of social distancing become more prominent, we would anticipate that other themes such as loss of income, unemployment, inflation, and financial burden would increase in frequency. the topics we discovered can be aggregated into 4 larger domains. activities that can be performed during social distancing included 3 topics: media and entertainment, activities, and music and media sharing. tweets concerning the actual rationale and effect of the social distancing included 3 topics: public opinions and values, quarantine measures and effects, and quarantine and isolation. two of these were the most prevalent topics. one domain covered the logistics of staying at home falling under a single topic: supplies, food, and orders. the last domain pertained to messages of support and cheering up others: thank healthcare and reduce spread, community support and businesses, spring and good sentiments. our study has several limitations. first, we used social media data and specifically twitter for our analysis. although there are >300 million monthly active twitter users, our methodology likely introduced some sampling bias to those with internet and technology access. second, we used 2 noncomprehensive trending hashtags to identify the most relevant social distancing tweets. we may have missed alternative terminology or key words such as "self isolation" and "corona lockdown," which appeared as weighted terms in our topic modeling. however, given that these 2 hashtags were the top-trending social distancing hashtags, we expect that these were representative of social distancing during the study period. we recognize that the study period serves as an initial snapshot, rather than a complete evolution, of public perception towards social distancing and that sentiment and topics likely have changed over time. a longitudinal analysis will be a part of future directions. third, despite analyzing a large number of tweets, we used only a subset of tweets during this time frame, which may have resulted in selection bias. having analyzed only english tweets, our conclusions may not be generalizable to non-english speaking populations. since most tweets do not have geolocation, we are also limited in making conclusions based on geographic areas or countries. fourth, a 2017 study 30 found that between 9% and 15% of all twitter accounts are bots, which may have affected our analysis. we used the twitter bot analyzer botometer 31 to analyze a random sample of 3,900 users in our dataset. we found that 90% of users have a <20% chance of being a bot. figure s1 shows the complete probability distribution. excluding the remaining 10% of users did not change sentiment, emotion, or subjectivity analysis. finally, we recognize the risk of labeling bias through assignment of topic themes to weighted terms. we attempted to prevent this by having 2 authors perform the topic modeling and 1 author independently perform the labeling task. in the early phases of social distancing, we were able to successfully obtain and analyze a representative subset of tweets related to this topic. performing sentiment, emotion, and content analysis of tweets provided valuable insight into the public's beliefs and opinions on social distancing. tweets were predominately objective with joy, fear, and surprise as leading emotions. tweets contained social distancing instructions in >1% of tweets. in the early phases of social distancing, tweets were skewed toward leisure activities and discussion of rationale and effect of social distancing. as social distancing progresses and then is lifted, we anticipate sentiment and topics to change. although "attitude is only one antecedent of behavior," the positive emotions, the preponderance of objective tweets, and the topics supporting coping mechanisms led us to conclude that twitter users generally supported the social distancing measure. analyzing tweets about nonpharmaceutical interventions such as social distancing based on content, sentiment, and emotion may prove valuable for public health communication, knowledge dissemination, as well as adjustment of mitigation policies in the future. future research to implement this analysis in real-time using the twitter streaming api 32 could augment directed messaging based on user interest and emotion. covid-19) situation report -52. world health organization website coronavirus: travellers race home amid worldwide border closures and flight warnings. the guardian website where america didn't stay home even as the virus spread. the new york times website the social-distancing culture war has begun. the atlantic website effectiveness of workplace social distancing measures in reducing influenza transmission: a systematic review coronavirus disease 2019 (covid-19) social distancing. centers for disease control and prevention website mathematical assessment of the impact of non-pharmaceutical interventions on curtailing the 2019 novel coronavirus impact assessment of nonpharmaceutical interventions against coronavirus disease 2019 and influenza in hong kong: an observational study covid-19: a look into the modern age pandemic covid-19 strategy update. world health organization website q1 2019 earnings report. twitter website diabetes on twitter: a sentiment analysis utilizing twitter data for analysis of chemotherapy public response to obamacare on twitter disease detection or public opinion reflection? content analysis of tweets, other social media, and online newspapers during the measles outbreak in the netherlands in 2013 pandemics in the age of twitter: content analysis of tweets during the 2009 h1n1 outbreak identifying key topics bearing negative sentiment on twitter: insights concerning the 2015-2016 zika epidemic search tweets-standard search api. twitter website cran r project website textblob: simplified text processing a new anew: evaluation of a word list for sentiment analysis in microblogs emotion recognition on twitter: comparative study and training a unison model latent dirichlet allocation parallelized latent dirichlet allocation. gensim website us public concerns about the covid-19 pandemic from results of a survey given via social media knowledge and perceptions of covid-19 among the general public in the united states and the united kingdom: a cross-sectional online survey just 14% of americans support ending social distancing in order to reopen the economy, according to a new poll kff health tracking pollearly april 2020: the impact of coronavirus on life in america. kaiser family foundation website online human-bot interactions: detection, estimation, and characterization botornot: a system to evaluate social bots filter real-time tweets. twitter website acknowledgments.financial support. no financial support was provided relevant to this article. supplementary material. to view supplementary material for this article, please visit https://doi.org/10.1017/ice.2020.406 key: cord-287303-b7vg439c authors: piché-renaud, pierre-philippe; groves, helen e.; kitano, taito; arnold, callum; thomas, angela; streitenberger, laurie; alexander, laura; morris, shaun k.; science, michelle title: healthcare worker perception of a global outbreak of novel coronavirus (covid-19) and personal protective equipment: survey of a pediatric tertiary-care hospital date: 2020-08-12 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.415 sha: doc_id: 287303 cord_uid: b7vg439c objective: in this study, we aimed to capture perspectives of healthcare workers (hcws) on coronavirus disease 2019 (covid-19) and infection prevention and control (ipac) measures implemented during the early phase of the covid-19 pandemic. design: a cross-sectional survey of hcws. participants: hcws from the hospital for sick children, toronto, canada. intervention: a self-administered survey was distributed to hcws. we analyzed factors influencing hcw knowledge and self-reported use of personal protective equipment (ppe), concerns about contracting covid-19 and acceptance of the recommended ipac precautions for covid-19. results: in total, 175 hcws completed the survey between march 6 and march 10: 35 staff physicians (20%), 24 residents or fellows (14%), 72 nurses (41%), 14 respiratory therapists (8%), 14 administration staff (8%), and 14 other employees (8%). most of the respondents were from the emergency department (n = 58, 33%) and the intensive care unit (n = 58, 33%). only 86 respondents (50%) identified the correct donning order; only 60 (35%) identified the correct doffing order; but the majority (n = 113, 70%) indicated the need to wash their hands immediately prior to removal of their mask and eye protection. also, 91 (54%) respondents felt comfortable with recommendations for droplet and/or contact precautions for routine care of patients with covid-19. hcw occupation and concerns about contracting covid-19 outside work were associated with nonacceptance of the recommendations (p = .016 and p = .036 respectively). conclusion: as part of their pandemic response plans, healthcare institutions should have ongoing training for hcws that focus on appropriate ppe doffing and discussions around modes of transmission of covid-19. the novel coronavirus disease (covid-19) pandemic presents a significant infection control challenge within healthcare settings. 1, 2 published studies from various countries have highlighted a significant proportion of healthcare-related infections as well as infections among healthcare workers (hcws), especially in the early phase of the pandemic. [3] [4] [5] these findings are consistent with healthcare-associated infections previously documented early within the middle east respiratory syndrome coronavirus (mers-cov) outbreak and the severe acute respiratory syndrome (sars) outbreak. [6] [7] [8] a number of published studies from prior sars and mers-cov outbreaks have highlighted the significant impact of such outbreaks on hcw morale and levels of concern that may impact perceptions and confidence in infection prevention and control (ipac) measures as well as adherence to these approaches. [9] [10] [11] [12] [13] indeed, lack of confidence in institutional control measures can result in absenteeism, which in turn can have significant impacts on delivery of care within an outbreak setting. 13, 14 during the 2003 sars outbreak in canada, inconsistent use of ppe and lack of adequate infection control training were among the factors contributing to the infection of hcws. 15 in this study, we aimed to capture attitudes and knowledge of hcws regarding covid-19 and ipac measures in the early phase of the covid-19 pandemic, especially related to ppe. we also sought to identify factors influencing hcw knowledge and self-reported use of personal protective equipment (ppe), concerns about contracting covid-19, and acceptance of the recommended ipac precautions for covid19 . this evaluation of the perspectives of hcws on ipac measures from the early phase of the pandemic provides invaluable information regarding the potential causes of initial nosocomial transmission of covid-19 and ways to mitigate them moving forward. this is a cross-sectional study consisting of a self-administered survey for hcws working at the hospital for sick children, in toronto, canada. as the only pediatric tertiary-care hospital in toronto, our center is uniquely positioned in regard to the current outbreak, given our previous experience with the sars outbreak in 2003. 10 the survey was distributed to clinicians and nonclinicians in emergency, intensive care, and pediatric wards as well as ambulatory clinics. responses were recorded over a 5-day period from march 6 to march 10, 2020, using convenience sampling. an ethics review was completed through the quality improvement process at the hospital. the survey instrument consisted of a series of questions developed by the infectious diseases, occupational health and safety and ipac unit at our hospital. the survey was distributed by email to an electronic mailing list of 951 clinical and nonclinical hcws of the hospital for sick children from the emergency department, intensive care unit, pediatric wards, and ambulatory clinics. an initial email was sent on march 6 with a reminder on march 9. responses were collected anonymously using research electronic data capture (redcap). 16 the survey instrument was developed using previously published surveys delivered during similar viral outbreaks of global significance (sars and mers-cov). [10] [11] [12] [17] [18] [19] following initial validation by internal testing with ipac and infectious diseases teams, the survey was subsequently pilot tested with a selected sample of hcws to ensure comprehension and to resolve ambiguities. the finalized survey consisted of 19 questions divided in 3 sections: (1) baseline demographic characteristics and previous relevant training including ppe training, hand hygiene training, and covid-19-specific ppe training; (2) knowledge, attitudes, and practices regarding ppe use; and (3) accessed sources of information and concerns regarding covid-19. covid-19 ppe training was done in person with a hands-on demonstration of donning and doffing by the nurse educators as well as by the occupational health and safety team (ie, occupational hygienists). a video of the proper donning and doffing sequence was shown in addition to printed instructional materials and the public health ontario donning and doffing posters. information on the recommended equipment for care of patients with covid-19 and other covid-19 ipac measures was also given. this training was made mandatory for all hcws working at our institution, including new hires and current staff, starting in early january 2020. our aim was to retrain as many hcws as possible, but not all of them could be trained in-person for a number of reasons, including vacations and conflicting schedules. to evaluate ppe knowledge, hcws were asked the order in which they would don (put on) and doff (remove) ppe equipment. for both donning and doffing questions, a score of 1 was attributed if the correct order was identified, and a score of 0 was given for an incorrect order. the correct order for donning was defined in accordance with public health ontario guidelines: (1) perform hand hygiene, (2) put on gown, (3) put on mask or n95 respirator, (4) put on eye protection, (5) put on gloves. 20 the correct doffing order was defined as follows: (1) remove gloves, (2) remove gown, (3) perform hand hygiene, (4) remove eye protection, (5) remove mask or n95 respiratory, (6) perform hand hygiene. 20 respondents were also asked to report their usual use of ppe for droplet and/or contact precautions using a likert scale: never (1), rarely (2), occasionally (3), frequently (4) and every time (5) . because the current evidence suggests that the mode of transmission of sars-cov-2 is through direct contact and respiratory droplets, the ontario ministry of health updated its recommendation on march 12 to the use of droplet and/or contact precautions for routine care of patients with covid-19 and airborne precautions only for patients requiring aerosol-generating medical procedures (agmps). 21, 22 this was a change from the previous recommendation of n95 for all patients and based on experience from healthcare settings in which hcws have not acquired covid-19 while using droplet and contact precautions for routine care, including in other canadian provinces. 23 in anticipation of this change to be aligned with the provincial recommendations, the survey included questions around the acceptance of this recommendation, and what information would help hcws feel comfortable making the change. hcw concern regarding being exposed or contracting covid-19 at work and outside work was assessed using the following 5-point likert scale: not at all concerned (1), neutral (2), somewhat concerned (3), very concerned (4) and extremely concerned (5) . lastly, participants were prompted to provide comments on their use of ppe, ipac precautions for covid-19, and their satisfaction with the information provided to hcws by the institution. the detailed survey can be found in appendix 1 (online). responses were analyzed using statistical package for social sciences version 25.0 (spss, chicago, il). baseline demographic characteristics were reported for each category using absolute numbers and percentages. the χ 2 test and the fisher exact test were performed to estimate the significance among categorical study variables where appropriate. analysis of variance (anova) was performed to assess to estimate the significance between ordinal variables. nonclinical hcws (administration) were not included in the analysis of occupation on donning and doffing scores. differences were considered statistically significant at p < .05. missing answers were excluded from the analysis after confirmation that the underlying demographics were not substantially different from those analyzed, therefore minimizing selection bias. thematic analysis was performed in respect to respondents' free text comments to identify common themes. in total, 175 hcws completed the survey, which corresponds to a response rate of 18.4%. among them were 35 staff physicians (20%), 24 residents or fellows (14%), 72 nurses (41%), 14 respiratory therapists (8%), 14 administration staff (nonclinical, 8%), 14 other employees (8%), and 1 unknown. also, 34 respondents (19%) reported having worked in the healthcare system during the 2003 sars outbreak in toronto. one-third of the respondents were from the emergency department (n = 58, 33%), one-third were from the intensive care unit (n = 58, 33%), and the other third were from the ward, the ambulatory clinic or other settings, such as specialty consulting services and patient support services. detailed characteristics of the respondents are reported in table 1 . survey responses were recorded in the 5 days immediately before the covid-19 outbreak was declared a pandemic by the world health organization (who). the study timing and number of responses in relation to the covid-19 outbreak in canada and pandemic declaration are detailed in figure 1 . at the time of the survey, cases of covid-19 in canada were mainly reported among returning travelers or their contacts. in total, 86 respondents (50%) identified the correct order for donning ppe, and 60 (35%) identified the exact correct doffing a score of 1.00 was given as the value obtained was above 1. c a score of 0 was given as the value obtained was below 0. order. also, 113 (70%) identified the need to perform hand hygiene prior to removal of their face mask and/or eye protection. those who reported receiving previous training related to ipac in the past 2 years (either general ppe training, hand washing training or covid-19 specific ppe training) had significantly higher doffing ppe scores than those without reported training. comparison of other baseline demographics and their impact on ppe knowledge are also presented in table 1 . no other factors had a statistically significant impact on ppe knowledge. with respect to usual ppe use for patients requiring droplet and/or contact precautions, respondents who received ppe training in the past 2 years reported using the most elements of ppe and more frequently than those who did not report ppe training. there was no statistical difference for the use of eye protection. these results are reported in appendix 2 (online). in general, respondents were more concerned about being exposed or contracting covid-19 at work than about contracting it outside work. baseline demographics and other factors influencing concerns about contracting covid-19 at work and outside work are detailed in table 2 . notably, hcws from the emergency department were the most concerned about contracting covid-19 at work. administration staff were the group most concerned about contracting covid-19 outside work. use of social media as a primary source of information was associated with increased concern of contracting covid-19 both at work and outside work, whereas satisfaction with institution-provided information on covid-19 was associated with lower concern. every age group had similar concerns about contracting covid-19 both at work and outside work. with respect to the use of droplet and/or contact precautions for the routine care of suspect or confirmed covid-19 patients, 91 of 167 respondents (54%) felt comfortable with this recommendation. we detected a statistically significant association between hcw occupation and acceptance of the recommendations (p = .016). nurses and respiratory therapists indicated that they would need more information compared with physicians, residents, and other staff. thematic analysis of the respondents' comments allowed us to identify facilitators for ppe implementation, acceptance of covid-19 ipac measures, and information transmission regarding covid-19. hcws indicated that they would be more likely to accept the recommendation for droplet and/or contact precautions for the routine care of patients with covid-19 if they were more confident in their knowledge of ppe donning and doffing. they also had concerns about ppe availability in their workplace and feared that an impending shortage could influence guidance around ipac measures. respondents reported that thorough information on transmission modes of covid-19 would facilitate their acceptance of the recommendation. respondents preferred information that was tailored to their occupation and provided by the fewest sources possible. our findings provide insight into hcw attitudes and knowledge of covid-19 and the related ipac measures during the early phase of the pandemic. covid-19-specific ppe training had the most significant impact on hcws knowledge of ppe donning and doffing. the early implementation of ipac and ppe trainings may therefore have mitigated the nosocomial spread of covid-19. hcws were most concerned about being exposed or contracting covid-19 at work, and half of the respondents from our study reported being comfortable with recommendations for droplet and/or contact precautions for routine care of patients with covid-19. approximately one-third of the respondents were able to correctly identify the appropriate order to remove ppe equipment. this finding was of concern because incorrect doffing order has been shown to lead to increased contamination of hcw clothing and the surrounding environment, potentially leading to hcw infections. 24,25 ppe training with a focus on ppe doffing was identified as a priority for all hcws caring for patients with suspected or confirmed covid-19, regardless of their previous work experience. given that 30% of hcws did not report the need to perform hand hygiene immediately before removal of face mask and/or eye protection in our survey, we identified this as an important focus of ppe training at our institution because it was a source of hcw contamination during the sars outbreak. 26 with the feedback from this survey, we also created an online learning module for all hcws at our institution that incorporated lessons learned, including modes of transmission of covid-19, proper protection needed for specific clinical tasks, and a focus on the importance of the correct sequence of doffing ppe. the online module made it easier to reach all hcws and to provide further reinforcement and learning opportunities, compared to in-person trainings. notably, our study captured hcw concerns about contracting covid-19 early in the outbreak, just days before it was declared a pandemic by the who, at which time not all hcws had received ppe refresher training. having a thorough insight into hcw attitudes and knowledge of ipac measures from the early phase of the pandemic is important to understanding the causes of covid-19 infection among hcws. most hcw infections occurred early in the covid-19 outbreak. 5, 27 in ontario, 4,230 hcws have been infected, which represents 17.5% of the 24,202 confirmed covid-19 cases as of may 14, 2020. as few as 3.1% of the infected hcws were documented to have acquired covid-19 nosocomially. 27 unfortunately, no data on the adequacy of ppe used by hcws infected nosocomially are available. based on the results of our study, initial gaps in hcw ppe knowledge, especially related to doffing order, may have contributed to nosocomial infections among hcws in the early phase of the pandemic. in our study, hcws from the emergency department had the highest level of concern regarding contracting covid-19 at work, which is not surprising given the volume and acuity of patients they see. this finding is in keeping with previous experience of the 2003 sars outbreak in toronto, during which hospital emergency departments were important sites for sars transmission in the early part of the epidemic. 28 recently, tan et al 29 assessed the psychological impacts of covid-19 on hcws in singapore, and 68 of the 470 surveyed participants (14.5%) screened positive for anxiety. in our study, using social media as a source of information was strongly associated with hcw concerns regarding contracting covid-19, both at work and outside work. this finding affirms previous assumptions that the use of social media may induce anxiety regarding covid-19 in users and therefore should not be promoted as the main source of information. 30 however, it is important to acknowledge the possibility that direction of causality in our study may be the reverse, and hcws that have greater concerns about contracting covid-19 are more likely to consume more information surrounding the pandemic, including a greater diversity of information sources. this hypothesis is reinforced by the fact that using public health website and moh communications as sources of information was also associated with increased concerns about contracting covid-19 at work. our study has some limitations. first, respondents were recruited using convenience sampling, which could therefore limit the external validity of our study. the studied population was relatively young: 42% were aged 30-39 years. although most of our results reflect those of previous studies on viral outbreaks of global significance, a lack of standardized methodologies between studies limits such comparison. moreover, in view of the cross-sectional nature of the study, we were only able to capture hcw knowledge and perceptions within a limited period. this study has provided important insight into hcw knowledge and attitudes toward covid-19 and ipac measures during the early phase of the pandemic. to ensure that ipac responses accurately reflect gaps in knowledge and to identify specific facilitators to continuous improvement, follow-up assessments are also required. a consistent framework through which ipac knowledge can be assessed should also be developed, allowing for comparisons at national and international levels as well as rapid dissemination of hospital epidemic response plans. with this survey, we aimed to contribute to this important topic and to provide an adaptable framework with which to generate context-specific ipac plans. covid-19) technical guidance: infection prevention and control/wash. world health organization website occupational risks for covid-19 infection risk factors of healthcare workers with corona virus disease 2019: a retrospective cohort study in a designated hospital of wuhan in china covid-19 and italy: what next? coronavirus disease 2019 (covid-2019) infection among health care workers and implications for prevention measures in a tertiary hospital in wuhan, china an outbreak of sars among healthcare workers comparative analysis of eleven healthcare-associated outbreaks of middle east respiratory syndrome coronavirus (mers-cov) from comparative epidemiology of human infections with middle east respiratory syndrome and severe acute respiratory syndrome coronaviruses among healthcare personnel psychosocial effects of sars on hospital staff: survey of a large tertiary-care institution paediatric emergency department staff perceptions of infection control measures against severe acute respiratory syndrome middle east respiratory syndrome (mers): comparing the knowledge, attitude and practices of different health care workers knowledge and attitude towards the middle east respiratory syndrome coronavirus among healthcare personnel in the southern region of saudi arabia surge capacity and casualization: human resource issues in the post-sars health system diverse implications of a national health crisis: a qualitative exploration of community nurses' sars experiences cluster of cases of severe acute respiratory syndrome among toronto healthcare workers after implementation of infection control precautions: a case series the redcap consortium: building an international community of software platform partners middle east respiratory syndrome risk perception among students at a university in south korea questionnaire-based analysis of infection prevention and control in healthcare facilities in saudi arabia in regards to middle east respiratory syndrome design and validation of a questionnaire to measure the attitudes of hospital staff concerning pandemic influenza removing and putting on personal protective equipment. public health ontario website air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient covid-19 and the risk to healthcare workers: a case report covid-19-what we know so far about routes of transmission. public health ontario website self-contamination during doffing of personal protective equipment by healthcare workers to prevent ebola transmission impact of doffing errors on healthcare worker self-contamination when caring for patients on contact precautions sars and the removal of personal protective equipment covid-19 infections among healthcare workers and transmission within households investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada psychological impact of the covid-19 pandemic on health care workers in singapore the pandemic of social media panic travels faster than the covid-19 outbreak acknowledgments. we thank the infection prevention and control team at the hospital for sick children (richard wray, krista cardamone, megan clarke, and renee friedman) and occupational health and safety for their guidance in the creation of the survey, their help in the redaction of this manuscript, and their essential work in the implementation of infection prevention and control measures at our hospital in the context of the current covid-19 pandemic.financial support. no financial support was provided relevant to this article.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-339516-xfwxtjry authors: nakashima, tsutomu; suzuki, hirokazu; teranishi, masaaki title: olfactory and gustatory dysfunction caused by sars-cov-2: comparison with cases of infection with influenza and other viruses date: 2020-05-05 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.196 sha: doc_id: 339516 cord_uid: xfwxtjry nan to the editor-among the symptoms of sars-cov-2 infection (or covid-19), olfactory or gustatory dysfunction may possibly present first or may be the only symptom. 1 three japanese professional baseball players complained of smell and taste dysfunction. although 2 of them had neither fever nor cough, a viral polymerase chain reaction (pcr) test revealed that all 3 were sars-cov-2 positive (the chunichi newspaper, march 27, 2020). two nurses working in the national cancer center hospital underwent the viral pcr test because they had similar symptoms, and they were both sars-cov-2 positive, although they had neither fever nor cough (asahi shimbun newspaper [digital], march 28, 2020). olfactory dysfunction is caused by blockage of the nasal airways or disturbance of the sensory system, including olfactory receptor cells, and the nervous system. as the olfactory receptor cells adjoin the upper part of the nasal cavity, the receptor cells are vulnerable. viral infection was the most common cause of loss of olfactory function. with this viewpoint, we reviewed the available literature on olfactory and gustatory dysfunction caused by influenza and other viruses. postviral infection olfactory dysfunction was more common in women and elderly people. [2] [3] [4] the influenza and parainfluenza type 3 viruses were reported to be causative of olfactory loss most frequently. seasonal changes in the incidence of olfactory loss have been reported with respect to influenza and parainfluenza type 3 infections, occurring most frequently in winter and spring, respectively. 2,5 flanagan et al 6 reported that the proportion of persons who received influenza vaccination was significantly lower among those with olfactory dysfunction than that in a control group. however, the adverse effect of olfactory dysfunction due to influenza vaccination was also reported. dotty et al 7 attributed 9 of 4,554 patients (0.19%) with olfactory dysfunction to influenza vaccination. suzuki et al 8 confirmed the presence of various viruses in the nasal discharge of patients with postviral infection olfactory dysfunction, such as rhinovirus, parainfluenza virus, epstein-barr virus, and coronavirus. significant recovery was not observed after 24 weeks in almost all of the patients. 8 in contrast, olfactory dysfunction due to hepatitis virus was recovered within 6 weeks in almost all cases. 9 in acute viral hepatitis, hyposmia, dysosmia, and dysgeusia are common symptoms. as smell and taste are closely associated; persons with olfactory dysfunction and normal gustatory function often complain that they "cannot taste coffee." 9 some recent reports described early improvement of olfactory and gustatory dysfunction in many covid-19patients. according to the newspaper, olfactory and gustatory function in the professional baseball players also returned to normal relatively soon. however, only short-term follow-up investigation has been conducted regarding the effect of sars-cov-2 infection on the chemosensory function. hwang 10 reported that anosmia induced by sars-cov continued for >2 years in a 27-year-old woman. we believe that epidemiological investigation is required regarding the effect of sars-cov-2 on the olfactory and gustatory functions in terms of the frequency, time course, and relationship with other symptoms. olfactory and taste disorder: the first and only sign in a patient with sars-cov-2 pneumonia an epidemiological study of postviral olfactory disorder clinical evaluation and symptoms of chemosensory impairment: one thousand consecutive cases from the nasal dysfunction clinic in san diego gender difference in chinese adults with postviral olfactory disorder:a hospital-based study post-infectious olfactory dysfunction exhibits a seasonal pattern association of decreased rate of influenza vaccination with increased subjective olfactory dysfunction influenza vaccinations and chemosensory function identification of viruses in patients with postviral olfactory dysfunction hyposmia in acute viral hepatitis olfactory neuropathy in severe acute respiratory syndrome: report of a case financial support. this study was supported by chouju iryo kenkyu kaihatsuhi 19-30 from the ministry of health, labor, and welfare of japan.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-339611-m58iv5wy authors: diao, mengyuan; zhang, sheng; chen, dechang; hu, wei title: the novel coronavirus (covid-19) infection in hangzhou: an experience to share date: 2020-03-05 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.62 sha: doc_id: 339611 cord_uid: m58iv5wy nan to the editor-hangzhou, the capital of zhejiang province in china, was confronted with the pandemic of a novel coronavirus (covid-19) that originated in wuhan, hubei province. 1 according to the health commission of zhejiang province, 2 6 cases were first reported on january 19, 2020, and the cumulative cases reached 169 as of february 20, 2020. the situation in hangzhou was once rather severe-it was the top-ranking city with respect to the number of confirmed cases in zhejiang province at the beginning of the epidemic. since the hangzhou government took rigorous measures to contain the epidemic, positive trends have been observed. the daily number of newly confirmed cases has sharply decreased within the last week, and only 1 case was confirmed from february 17 to 20. similarly, hangzhou reported no deaths in its administrative region. we used a regression of logincidence over time model 3 to provide a fitted trajectory for the actual daily incidence to verify the control effect. as shown in figure 1 , the optimal splitting point, defined as the peak number of daily new cases simulated by the model, occurred on january 25. this peak occurred about a week after launching the highest level of emergency public health alert and response in hangzhou, which indicates that the prevention and control measures may have been effective. overall, 6 major measures were taken to control and prevent the spread of covid-19 in hangzhou. first, aware of the seriousness of the situation, on january 23, 2020, the zhejiang province authorities launched a level i public health incident alert, the highest level of emergency public health alert and response in the nation's public health management system. as the top level of china's public health alert system, this measure imposed the maximal limit on movement by people. second, further action was taken on february 3, 2020, when most districts of hangzhou announced that every community would be kept under closed management and that only 1 family member was allowed to leave the house to buy daily living supplies every 2 days. third, "noncontact delivery," a new delivery method, was adopted by many express delivery companies to reduce contagion risk. fourth, to reduce the concentration of personnel to avoid the risk of cross infection, online working and network teaching were encouraged for workers and students, respectively. these measures were supported by mobile technology companies. fifth, to meet the need to resume production and curb the transmission of the virus as far as possible, hangzhou arranged chartered transportation to help numbers of migrants return to their work places. lastly, in cooperation with alipay, hangzhou adopted the health quick-response (qr) code system on february 11, 2020, which were designated by green, yellow, or red. people who wanted to get into hangzhou needed to submit their travel history and health information online in advance. residents with a green code indicated they had a low current risk of being infected, while residents with yellow or red codes were quarantined for 7 or 14 days and were required to report their health condition daily to exclude infection before the code was changed to green. this health surveillance system has now been applied in most cities in zhejiang province and will be promoted in other provinces. although the effect of prevention and control measures is evident, hangzhou continues to face huge challenges owing to its large immigrant population. however, this city has already learned much from this epidemic, and we hope that some of our experiences will assist others in their regions. fig. 1 . the impact of a public emergency health alert on the daily incidence of covid-19 infection in hangzhou. the fitted trajectory shows the probable daily incidence with 95% confidence interval derived from existing data using a log-incidence over time regression model. the split point is the optimal date to split the epicurve into two phases, which best fits the model. other interventions include restricted movement outside the home, noncontact delivery, online work and teaching, etc. clinical features of patients infected with 2019 novel coronavirus in wuhan, china epidemic situation of new coronavirus pneumonia in zhejiang province, 2020. health commission of zhejiang province website epidemic curves made easy using the r package incidence acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-262520-480kgpp2 authors: kim, yun jeong; choe, jae young; kwon, ki tae; hwang, soyoon; choi, gyu-seog; sohn, jin ho; kim, jong kun; yeo, in hwan; cho, yeon joo; ham, ji yeon; song, kyung eun; lee, nan young title: how to keep patients and staff safe from accidental sars-cov-2 exposure in the emergency room: lessons from south korea’s explosive covid-19 outbreak date: 2020-07-30 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.376 sha: doc_id: 262520 cord_uid: 480kgpp2 objectives: we report our experience with an emergency room (er) shutdown related to an accidental exposure to a patient with coronavirus disease 2019 (covid-19) who had not been isolated. setting: a 635-bed, tertiary-care hospital in daegu, south korea. methods: to prevent nosocomial transmission of the disease, we subsequently isolated patients with suspected symptoms, relevant radiographic findings, or epidemiology. severe acute respiratory coronavirus 2 (sars-cov-2) reverse-transcriptase polymerase chain reaction assays (rt-pcr) were performed for most patients requiring hospitalization. a universal mask policy and comprehensive use of personal protective equipment (ppe) were implemented. we analyzed effects of these interventions. results: from the pre-shutdown period (february 10–25, 2020) to the post-shutdown period (february 28 to march 16, 2020), the mean hourly turnaround time decreased from 23:31 ±6:43 hours to 9:27 ±3:41 hours (p < .001). as a result, the proportion of the patients tested increased from 5.8% (n=1,037) to 64.6% (n=690) (p < .001) and the average number of tests per day increased from 3.8±4.3 to 24.7±5.0 (p < .001). all 23 patients with covid-19 in the post-shutdown period were isolated in the er without any problematic accidental exposure or nosocomial transmission. after the shutdown, several metrics increased. the median duration of stay in the er among hospitalized patients increased from 4:30 hours (interquartile range [iqr], 2:17–9:48) to 14:33 hours (iqr, 6:55–24:50) (p < .001). rates of intensive care unit admissions increased from 1.4% to 2.9% (p = .023), and mortality increased from 0.9% to 3.0% (p = .001). conclusions: problematic accidental exposure and nosocomial transmission of covid-19 can be successfully prevented through active isolation and surveillance policies and comprehensive ppe use despite longer er stays and the presence of more severely ill patients during a severe covid-19 outbreak. results: from the pre-shutdown period (february [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] 2020) to the post-shutdown period (february 28 to march 16, 2020) , the mean hourly turnaround time decreased from 23:31 ±6:43 hours to 9:27 ±3:41 hours (p < .001). as a result, the proportion of the patients tested increased from 5.8% (n=1,037) to 64.6% (n=690) (p < .001) and the average number of tests per day increased from 3.8±4.3 to 24.7±5.0 (p < .001). all 23 patients with covid-19 in the post-shutdown period were isolated in the er without any problematic accidental exposure or nosocomial transmission. after the shutdown, several metrics increased. the median duration of stay in the er among hospitalized patients increased from 4:30 hours (interquartile range [iqr], 2:17-9:48) to 14:33 hours (iqr, 6:55-24:50) (p < .001). rates of intensive care unit admissions increased from 1.4% to 2.9% (p = .023), and mortality increased from 0.9% to 3.0% (p = .001). conclusions: problematic accidental exposure and nosocomial transmission of covid-19 can be successfully prevented through active isolation and surveillance policies and comprehensive ppe use despite longer er stays and the presence of more severely ill patients during a severe covid-19 outbreak. (received 1 may 2020; accepted 21 july 2020) on march 11, 2020, the world health organization (who) declared the coronavirus disease 2019 (covid-19) a global pandemic. 1 the first patient in south korea was reported on january 19, 2020. 2 since the 31st korean case, who was the first in daegu, was diagnosed on february 18, 2020, the number of covid-19 patients increased explosively because of a cluster infection among a religious group called shincheonji, which accounted for~70% of the daegu cases. 3 as of march 14, 2020, the number of confirmed patients in the daegu region accounted for~74 % of all of the korean cases ( fig. 1) . 4 to cope with this major epidemic crisis, daegu was designated a special disaster area on march 15, 2020. many emergency centers in daegu were consecutively and repeatedly closed, and medical staff on duty and inpatients were quarantined because of accidental exposure to a covid-19 patient who had not been isolated. 5 our emergency room (er), which has~30,000 patient visits annually, is a regional emergency center designated by the ministry of health and welfare and 1 of 6 major ers in daegu. as of 2018, 13.5% of all er patients in daegu city had visited our er. 6 on february 23, 2020, a 77-year-old male patient visited our er in an ambulance. he presented with gradual deterioration of mental status, cough, sputum production, and vomiting for 3 days. he was not isolated and was closely monitored in the er for 31 hours until a severe acute respiratory syndrome coronavirus-2 (sars-cov-2) reverse-transcriptase polymerase chain reaction (rt-pcr) test was performed. subsequently, his wife and he were confirmed to have covid-19. among a total of 110 persons (47 patients or guardians and 63 healthcare workers [hcws]) who were shown to have had contact with them by epidemiological investigation and closed-circuit television (cctv) monitoring, we determined that 5 people (1 patient and 4 hcws) needed to be quarantined for 14 days because of inappropriate personal protective equipment (ppe). the er was closed for 55 hours from 3:50 p.m. on february 25 to 10:30 p.m. on february 27, 2020, while we investigated the close contacts, decontaminated the area, and established new protocols to ensure the safety of the er. protecting hcws and patients from sars-cov-2 while maintaining functional emergency medical care were critical in responding properly to this outbreak. 7 we implemented new interventions, including active isolation, surveillance, and comprehensive use of ppe in the er, to prevent recurrence of an er shutdown and nosocomial transmission of covid-19. we performed this research to analyze the effects of our interventions during this outbreak. this cross-sectional, observational study was conducted in a 635-bed, tertiary-care, academic hospital in daegu, south korea, from february 10 to march 16, 2020. the medical records for all patients visiting the er during the study period were retrospectively reviewed. after the er shutdown, we implemented following interventions in the er: (1) triage facilities were set up outside the er (fig. 2) . (2) sars-cov-2 rt-pcr testing and chest x-ray were performed outside the er for most patients who needed to be hospitalized, and these patients were admitted after their covid-19 status was established. (3) respiratory samples were obtained in the contaminated area ( fig. 2b ) using drive-through or walk-through testing access for patients in stable condition. (4) patients with respiratory symptoms, fever, abnormal chest x-ray findings, or any epidemiologic relevance to covid-19 were isolated. (5) a portable negative-pressure isolation chamber was employed for covid-19 patients and for patients whose covid-19 status had not been identified but who needed to be moved inside the hospital beyond the er. (6) a universal mask policy and a comprehensive use of ppe were established. (7) the number of doctors on duty was increased from 8 to 11 and from 23 to 34 for nurses. (8) real-time communications were established between members of the covid-19 patient management task force. for this analysis, we defined the pre-shutdown period as february 10-25, 2020, and the post-shutdown period as february 28 to march 16, 2020 . we compared the patient outcomes and durations of er stay from both periods. before the er shutdown, sars-cov-2 rt-pcr was performed by an outside laboratory; after the er shutdown, it was performed in our laboratory in the hospital. we expanded the regular working shifts of laboratory personnel from the usual 3 shifts to 4 shifts to shorten the turnaround time from sampling to obtaining a result. rna was extracted from clinical samples with an automated nucleic acid extraction platform libex (xian tianlong science &technology, xi'an, china). sars-cov-2 was detected by rt-pcr using a powerchektm 2019 ncov real-time pcr kit (kogenebiotech, seoul, korea) and a cfx96 real-time pcr detection system (bio-rad, berkeley, ca). the statistics for these rt-pcr tests were analyzed, including the total number of tests, average number of tests per day, and turnaround time of tests in the er between the pre-shutdown period and the post-shutdown period. this study was exempt from review by the institutional review board of the kyungpook national university chilgok hospital (no. knuch 2020-03-034). after the er shutdown, we designated the clean area (blue letters) and the contaminated area (red letters) separated by entrance 2. we set up a triage including a reception area, a laboratory, a chest x-ray area, and a resuscitation room (isolation room 6 or 7) outside the er using intermodal containers. we built airborne infection prevention systems in the isolation rooms 1, 2, 3, 4, 6 and 7 and x-ray 2 and laboratory rooms using mobile negative-air machines. we reduced the number of beds in zones a, b, and c to 14 and widened the interbed distance to 2 m. high-resolution closed-circuit televisions and portable patient monitors were installed in all of the isolation rooms to monitor vital signs, level of consciousness, and patient movement. continuous variables were expressed as the means ± standard deviation or median (iqr) and were compared using the student t test or the mann-whitney u test. categorical variables were compared with the pearson χ 2 test or the fisher exact test. the time lengths are expressed as hh:mm (ie, hours and minutes). all tests of significance were 2-tailed; p ≤ .05 was considered significant. the results were analyzed using spss version 21.0 software (ibm, armonk, ny). in total, 1,727 patients were treated in the er during entire study period (pre-shutdown, n = 1,037; post-shutdown, n = 690) ( table 1 ). the proportions of the patients in whom sars-cov-2 rt-pcr was performed increased from 5.8% to 64.6% (p < .001), and the average number of tests per day increased from 3.8±4.3 to 24.7±5.0 (p < .001) from the pre-shutdown period to the postshutdown period (table 1) (fig. 1) . among the 690 patients in the post-shutdown period, 245 (35.4%) patients were not tested because they had already been tested (n = 85); they were discharged directly from the er after asymptomatic short er stays (n = 153). also, 6 patients died in the er after short er stays. the mean turnaround time decreased from 23:31 ±6:43 hours to 9:27±3:41 hours (p < .001) from the pre-shutdown period to the post-shutdown period. from february 10 to june 14, a total of 9,177 sars-cov-2 rt-pcr tests were performed in our hospital. these included 934 tests for hcws who had symptoms or any accidental exposure to the covid-19 patients or who were taking care of covid-19 patients. also, 3,585 rt-pcr tests were performed for all er patients who were hospitalized; 641 rt-pcr tests were performed for inpatients who had symptoms or were quarantined; 1,033 tests were preoperative screening tests; 508 tests were performed for preadmission screening; and 1,782 tests were performed for outpatients. during the outbreak, tests for all hcws taking care of covid-19 patients had been routinely performed every 2-4 weeks. in addition, all hcws, inpatients, and their guardians were monitored daily for their symptoms and had screening tests any time they had symptoms. through those tests and symptom monitoring, no evidence of person-to-person transmission of sars-cov-2 was detected in our hospital from february 10 to june 14. the number of patients (7 versus 23) confirmed with covid-19 in the er increased from the pre-shutdown period to the post-shutdown period ( table 1 ) (fig. 1 ). among 7 patients confirmed in the pre-shutdown period, 3 patients were admitted to the covid-19 general care ward, and 4 patients were diagnosed after discharge. in total, 23 covid-19 patients in the post-shutdown period were isolated in the er without any problematic accidental exposure and nosocomial transmission. among them, 10 patients were admitted to the covid-19 general care ward, 2 patients were admitted to the covid-19 intensive care unit (icu), 6 patients were discharged from er, 3 patients were transferred to other hospitals, and 2 patients who came to the er in cardiac arrest died and were confirmed positive for covid-19 posthumously. the rates of icu admission (1.4% vs 2.9%, p = .023) and mortality (0.9% vs 3.0%; p = .001) in the er increased from the preshutdown period to the post-shutdown period (table 1) . among 9 deceased patients in the pre-shutdown period, 2 patients died after cpr, 3 patients in cardiac arrest died after cpr, and 3 patients died with a do-not-resuscitate (dnr) order. among 21 deceased patients in the post-shutdown period, 3 patients died after cpr, 8 patients in cardiac arrest died after cpr, and 10 patients died with a dnr order. the 30-day mortality rates among patients admitted to the icu were not different between the preshutdown period and the post-shutdown period: 21.4% (3 of 14) versus 30.0% (6 of 20) (p = .577). the median duration of stay in the er among hospitalized (general care ward and icu) patients increased between the pre-shutdown period and the post-shutdown period: 4:30 hours (iqr, 2:17-9:48) versus 14:33 hours (iqr, 6:55-24:50) (p < .001). the median duration of stay outside the er for tests and waiting in the post-shutdown period was 00:44 hours (iqr, 00:17-01:33). in 2015, south korea experienced the largest outbreak (186 cases and 38 deaths) of middle east respiratory syndrome (mers) outside the middle east because of massive transmissions from a single, nonisolated patient in an overcrowded er. 8, 9 this experience caused hospitals in the city of daegu, which had the first large outbreak of covid-19 outside china, to respond actively and promptly to the accidental exposure to covid-19 patients who were not identified for isolation at triage in the er. in daegu, 40 temporary er closures took place, and 6 level-1 or level-2 ers were shut down 27 times for 769 hours from february 18 to march 26, 2020. 5 to prevent er shutdown and nosocomial transmission of covid-19, many ers in daegu revised triage procedures and performed active surveillance and isolation and implemented a universal mask policy and comprehensive use of ppe, similar to our hospital. consequently, these ers could operate successfully, even amid a severe covid-19 outbreak. 5,10 however, performing triage procedures, testing (laboratory and chest x-ray), and resuscitation outside the er can increase the duration of stay in the er and can affect patient outcomes. in fact, overcrowding and long duration of stay in the er in general hospitals have been a constant problem in korea. according to the 2015 nationwide survey of ers, the average duration of stay among 414 ers in korea was 6 hours and 45 minutes; the average duration of stay at 20 ers listed in the order of long stay was 14 hours. 11 durations were becoming shorter through much effort but became longer again in the covid-19 outbreak. the rates of icu admission and mortality were higher after the interventions were implemented. the patients who came to the er in cardiac arrest and died after cpr and those who died with dnr order comprised the majority of mortality cases. therefore, we suspect think that patients with severe conditions could not come to the er as easily as before because of the saturation of healthcare facilities associated with the covid-19 outbreak in daegu, or they were reluctant to come to the er promptly for fear of being infected with covid-19. for example, 3 covid-19 patients in daegu died at home while waiting for hospitalization. 10 early identification and rapid isolation of patients with covid-19 are crucial to interrupting the spread of this virus. 12, 13 the world health organization (who) also emphasized that countries need to implement strong measures to detect and achieve laboratory confirmation of their cases early. 14 in korea, the ministry of food and drug safety urgently approved a diagnostic kit for sars-cov-2 rt-pcr and required certified private hospitals to use that kit beginning in february 2020. 15 the high level of test performance made it possible for us to test most patients to be hospitalized and for these patients to wait in the isolation room until the test results were obtained. when they needed to be moved inside the hospital for emergency operations or procedures before test results were obtained, we used a portable negative-pressure isolation chamber and comprehensive ppe. we previously reported on a patient undergoing appendectomy in a negative-pressure operating room with medical personnel wearing comprehensive ppe and including a powered air-purifying respirator. 16 he had a positive sars-cov-2 result after surgery but did not cause any nosocomial transmission of the virus. the drive-through screening system, which was first implemented at our hospital on february 23, 2020, was of great help in speeding up safe respiratory sample collection. 17 sars-cov-2 transmission occurs mainly through respiratory droplets and contact, and airborne transmission may be possible during aerosol-generating procedures (agps). in this context, the who currently recommends droplet and contact precautions for suspected or confirmed covid-19 patients and airborne precautions for agps. 18 however, appropriate selection and use of respiratory ppe during the covid-19 crisis remains controversial. 19 the korean centers for disease control and prevention (kcdc) recommended airborne and contact precautions in any situation involving contact with a suspected or confirmed patient, based on the experience of the 2015 mers outbreak. 20 the kcdc initially recommended coveralls with shoe covers and double gloves for contact precautions; eye shield, face shield, and goggles for eye protection; n95 respirators or equivalent for respiratory protection; and powered air-purifying respirators when agps are performed. 20 long-sleeved, water-resistant gowns and kf94 masks are recommended in the revision of previous recommendations. following this kcdc guideline, we strengthened the level of the required ppes in the er to ensure safety in the events of accidental sars-cov-2 exposure. we think the strengthened ppe and universal mask policies played a crucial role in protecting hcws and patients and guardians from accidental exposure to sars-cov-2 in the er. although ppe was difficult to obtain in the early stages of this outbreak, similar to the situation in other large cities, the supply was never exhausted. the korean government and local city authorities controlled the consumption and supply of this critical element of care. 10 healthcare facilities and hcws had the highest priority for obtaining ppe. the role of the government and local city authorities was crucial for controlling the supply and demand of ppe during the outbreak. the er, which serves as a gatekeeper for hospitals, is expected to be the area most exposed to sars-cov-2. if healthcare facilities fail to organize an effective system for screening, isolating, and testing suspected cases, an increased number of patients and confusion in the er can turn an er into the epicenter of a hospital-associated outbreak. 21, 22 the value of intermodal containers used for extra space outside the er (fig. 2b) and mobile negative-air machines used in the aiirs was demonstrated in korea during the mers outbreak. 21 the temporary aiirs in our icu using mobile negative-air machines has played a crucial role in managing critically ill covid-19 patients. 23 however, intermodal containers and mobile negative-air machines are only temporary equipment. conventional or mobile telephone communication in the contaminated area was used as much as possible to reduce contact between hcws and patients. telemedicine can be useful for improving infection control during the covid-19 pandemic. 17, 24, 25 to smooth the flow of patients, key personnel from the various departments (eg, administration, infectious diseases, respiratory diseases, emergency medicine, covid-19 general care and icu nursing teams, and the infection control team) conducted real-time communication using a mobile messaging application to assess the availability of beds, patient acceptance capabilities, and hospitalization process. the integrated response between our team representative and the out-of-hospital emergency system operated by the local government was critical in managing covid-19 patients properly and preventing accidental sars-cov-2 exposure in each er. this study has several limitations. first, this study describes the experience of only 1 hospital, and the results may not be generalizable. however, our successful experience could be modified as a suitable model for er operation in other areas during the covid-19 crisis. we have provided detailed information for the measures we implemented. second, this study is a retrospective, observational study. because multiple interventions were implemented simultaneously, it is difficult to clearly determine which intervention worked significantly. however, a controlled experimental trial was not realistically possible during this swiftmoving outbreak. in conclusion, problematic accidental exposure and nosocomial transmission of the covid-19 can be successfully prevented through active isolation and surveillance polices and comprehensive ppe use despite longer er stays and the presence of more severely ill patients during a covid-19 outbreak. who declares covid-19 a pandemic the first case of 2019 novel coronavirus pneumonia imported into korea from wuhan, china: implication for infection prevention and control measures korean society for antimicrobial therapy, korean society for healthcare-associated infection control and prevention, and korea centers for disease control and prevention revised triage and surveillance protocols for temporary emergency department closures in tertiary hospitals as a response to covid-19 crisis in daegu metropolitan city emergency medical service statistics covid-19: protecting healthcare workers is a priority middle east respiratory syndrome coronavirus (mers-cov) outbreak in south korea, 2015: epidemiology, characteristics and public health implications mers-cov outbreak following a single patient exposure in an emergency room in south korea: an epidemiological outbreak study gawande atul a. how south korea responded to the covid-19 outbreak in daegu developing the data analysis-based emergency room congestion predictive model for the resolution of overcrowded emergency room the critical role of laboratory medicine during coronavirus disease 2019 (covid-19) and other viral outbreaks laboratory readiness and response for novel coronavirus (2019-ncov) in expert laboratories in 30 eu/eea countries emergency committee regarding the outbreak of novel coronavirus (2019-ncov). 2020. world health organization (who) website. https:// www.who.int/news-room/detail/30-01-2020-statement-on-the-secondmeeting-of-the-international-health-regulations-(2005)-emergency-committeeregarding-the-outbreak-of-novel-coronavirus-(2019-ncov) approving emergency use of new diagnostic kit for covid-19 and expanding test facility to certififed private hospitals appendectomy in patient with suspected covid-19 with negative covid-19 results: a case report drive-through screening center for covid-19: a safe and efficient screening system against massive community outbreak infectionprevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125 controversies in respiratory protective equipment selection and use during covid-19 personal protective equipment for healthcare workers during the covid-19 pandemic emergent strategies for the next phase of covid-19 the risk of cross infection in the emergency department: a simulation study crucial role of temporary airborne infection isolation rooms in an intensive care unit: containing the covid-19 outbreak in south korea a brief telephone severity scoring system and therapeutic living centers solved acute hospital-bed shortage during the covid-19 outbreak in daegu a double triage and telemedicine protocol to optimize infection control in an emergency department in taiwan during the covid-19 pandemic: retrospective feasibility study acknowledgments. we appreciate all of the staff members who participated in coping with the covid-19 outbreak in the kyungpook national university chilgok hospital.financial support. this study was supported by a research grant from the daegu medical association covid-19 scientific committee. all authors report no conflicts of interest relevant to this study. key: cord-297641-bgmib6xb authors: meng, xiujuan; huang, xun; zhou, pengcheng; li, chunhui; wu, anhua title: alert for sars-cov-2 infection caused by fecal aerosols in rural areas in china date: 2020-04-07 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.114 sha: doc_id: 297641 cord_uid: bgmib6xb nan to the editor-on march 11, 2020, the world health organization (who) director declared that >118,000 covid-19 cases had been confirmed in 114 countries, that 4,291 people had lost their lives, and that covid-19 could be characterized as a worldwide pandemic. 1 the virus causing covid-19, designated as severe acute respiratory syndrome coronavirus 2 (sars-cov-2), is closely related to sars-cov. 2 in 2003, a sars-cov outbreak at amoy gardens in hong kong led to 329 confirmed cases of infection and 42 deaths. 3 subsequent studies suggested that the plumbing and ventilation systems at amoy gardens interacted to allow transmission of the sars virus and that high concentrations of viral aerosols in the plumbing were the primary mode of transmission in this outbreak. test results indicated that the hydraulic action caused by flushing toilets generated huge quantities of aerosols in vertical sewer pipes or sanitary risers. 4 recent studies found that sars-cov-2 can be detected in feces and urine of covid-19 cases, especially the asymptomatic cases. 5 sars-cov can persist in feces from infected people for as long as 4 days, and sars-cov-2 may persist in feces longer. based on these characteristics, sars-cov-2 is prone to cause outbreaks in the community, particularly in rural areas. excreta treatment in scattered rural areas is generally decentralized and selfprocessing. in concentrated areas, residents mainly use flush toilets, which can generate huge quantities of aerosols; the ventilation and plumbing systems in these places are not effective for maximal hygiene. the feces may form high concentrations of viral aerosols that travel through the air to cause infection. 6 to prevent the spread of fecal aerosols, we recommend the following points. first, to avoid widespread viral aerosols in concentrated areas, state-of-the-art ventilation and plumbing systems should be constructed and maintained. flouring half liter of water into each bathroom floor drain should be done weekly. in addition, the toilet lid should be covered when flushing the toilet to prevent aerosolization, and the toilet lid should be wiped with a disinfectant after flushing the toilet. second, a safety program for environmental monitoring and feedback is an effective way to prevent the spread of sars-cov-2. be alert to sewer gas, unusual noises, or bubbles in pipes and toilets, and respond immediately. 4 third, 3-segment septic-tank toilets and biogas tank toilets are the main sanitary toilets used in rural areas, and more effective raw sewage management should be explored in these areas. another important aspect is natural ventilation, which can reduce viral density and is the most effective measure to reduce the risk of airborne contagion. 7 by managing the feces of covid-19 patients, we can effectively minimize the risks of viral spread in the community. although the covid-19 is described as a pandemic, we believe that our efforts can render this pandemic controllable. world health organization website. https:// www.who.int/dg/speeches/detail/who-director-general-s-opening-remarksat-the-media-briefing-on-covid severe acute respiratory syndromerelated coronavirus: the species and its viruses-a statement of the coronavirus study group emergencies preparedness, response: update 95 -sars: chronology of a serial killer environmental transmission of sars at amoy gardens detection of novel coronavirus by rt-pcr in stool specimen from asymptomatic child, china. emerg infect dis national health commission of the people's republic of china website natural ventilation for the prevention of airborne contagion financial support. this work was supported by the research fund of emergency project of prevention and control for covid-19 of central south university (grant no. 160260003). all the authors declare no conflicts of interest related to this article. key: cord-323826-nxst9poy authors: amir-behghadami, mehrdad; gholizadeh, masoumeh title: electronic screening through community engagement: a national strategic plan to find covid-19 patients and reduce clinical intervention delays date: 2020-05-04 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.188 sha: doc_id: 323826 cord_uid: nxst9poy nan to cope with a sudden outbreak of covid-19, the community needs to be screened, and whether the infection has occurred and the dynamics of when it is contagious need to be understood more fully. the iranian ministry of health and medical education designed and has been implementing an electronic national screening system (https://salamat.gov.ir/) using a modern information network technology. 10 after logging information (eg, national code, date of birth, phone number) into the system, iranian residents answer some questions about covid-19 symptoms, immunosuppression, and some chronic diseases, as well as the presence of others suspected of having covid-19 disease among their relatives. those suspected of having the disease receive a message regarding their health status, and healthcare providers then call them and guide them. also, the their residences are disinfected and other family members are quarantined if required. if they do not improve within 3 days, they are referred to the emergency department of a hospital. some screening-related information is provided in table 1 . this self-screening plan has been successful through government implementation and community engagement. during the pandemic, many efforts have been made to find effective and efficient solutions for the initial management of covid-19 globally. one of the significant factors, which is been emphasized today, is the important role of community engagement in the management and screening of infected patients. people's attitudes toward the disease and understanding of its consequences if left untreated have played an important role in encouraging their participation in self-screening through designed website. the government has allocated >17,000 health houses and >9,000 comprehensive health centers in urban, suburban, and rural areas throughout the country to support the plan. these centers, as community health centers, play an important role in these efforts; they are responsible for delivering integrated care services to the population in geographically defined areas. 11 in addition, this plan is consistent with the overall goal of developing health systems, strengthening their capacity to meet the needs of the community, and achieving universal health coverage. in conclusion, a successful electronic screening system was developed and introduced to combat the covid-19 pandemic in iran. on one hand, this system helps in the initial identification of patients with covid-19 infections and prevents any delay in clinical interventions. on the other hand, it prevents nonemergency referrals to emergency departments of hospitals. implementing a simple strategy can be effective for the health system in dealing with this pandemic. therefore, sharing our successful experience, which was the result of good cooperation and cohesion between the government and community, may be helpful for authorities in other countries. based on available data, we considered patients with death outcome, as well as those admitted to icu or under mechanical ventilation, as more severe cases. the information in this chart is based on hospitalized cases, and outpatients are not included in this calculation. inclusion of outpatients and asymptomatic cases would decrease the proportion of severe cases. c to increase the sample size, the analysis of death cases was performed using the data from the previous week. reference: daily situation report on covid-19, ministry of health and medical education, ir iran. the extent of transmission of novel coronavirus in wuhan, china, 2020 clinical features of patients infected with 2019 novel coronavirus in wuhan, china epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study a case of 2019 novel coronavirus in a pregnant woman with preterm delivery the importance of designing and implementing a participatory surveillance system: an approach to early detection and prevention of novel coronavirus (2019-ncov) novel coronavirus (2019-ncov) situation report -38. world health organization website covid-19) situation report -82. world health organization website iranian ministry of health and medical education website mapping the incidence of the covid-19 hotspot in iran-implications for travellers home-to-home program to be launched to combat covid-19. tehran times website effectiveness of the health complex model in iranian primary health care reform: the study protocol acknowledgments.financial support. no financial support was provided relevant to this article.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-277776-5r9comw2 authors: john, amrita r.; raju, shine; cadnum, jennifer l.; lee, kipum; mcclellan, phillip; akkus, ozan; miller, sharon k.; jennings, wayne d.; buehler, joy a.; li, daniel f.; redmond, sarah n.; braskie, melissa; hoyen, claudia k.; donskey, curtis j. title: scalable in-hospital decontamination of n95 filtering face-piece respirator with a peracetic acid room disinfection system date: 2020-10-12 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.1257 sha: doc_id: 277776 cord_uid: 5r9comw2 background: critical shortages of personal protective equipment, especially n95 respirators, during the coronavirus disease 2019 (covid-19) pandemic continues to be a source of concern. novel methods of n95 filtering face-piece respirator decontamination that can be scaled-up for in-hospital use can help address this concern and keep healthcare workers (hcws) safe. methods: a multidisciplinary pragmatic study was conducted to evaluate the use of an ultrasonic room high-level disinfection system (hlds) that generates aerosolized peracetic acid (paa) and hydrogen peroxide for decontamination of large numbers of n95 respirators. a cycle duration that consistently achieved disinfection of n95 respirators (defined as ≥6 log(10) reductions in bacteriophage ms2 and geobacillus stearothermophilus spores inoculated onto respirators) was identified. the treated masks were assessed for changes to their hydrophobicity, material structure, strap elasticity, and filtration efficiency. paa and hydrogen peroxide off-gassing from treated masks were also assessed. results: the paa room hlds was effective for disinfection of bacteriophage ms2 and g. stearothermophilus spores on respirators in a 2,447 cubic-foot (69.6 cubic-meter) room with an aerosol deployment time of 16 minutes and a dwell time of 32 minutes. the total cycle time was 1 hour and 16 minutes. after 5 treatment cycles, no adverse effects were detected on filtration efficiency, structural integrity, or strap elasticity. there was no detectable off-gassing of paa and hydrogen peroxide from the treated masks at 20 and 60 minutes after the disinfection cycle, respectively. conclusion: the paa room disinfection system provides a rapidly scalable solution for in-hospital decontamination of large numbers of n95 respirators during the covid-19 pandemic. results: the paa room hlds was effective for disinfection of bacteriophage ms2 and g. stearothermophilus spores on respirators in a 2,447 cubic-foot (69.6 cubic-meter) room with an aerosol deployment time of 16 minutes and a dwell time of 32 minutes. the total cycle time was 1 hour and 16 minutes. after 5 treatment cycles, no adverse effects were detected on filtration efficiency, structural integrity, or strap elasticity. there was no detectable off-gassing of paa and hydrogen peroxide from the treated masks at 20 and 60 minutes after the disinfection cycle, respectively. conclusion: the paa room disinfection system provides a rapidly scalable solution for in-hospital decontamination of large numbers of n95 respirators during the covid-19 pandemic. (received 2 july 2020; accepted 3 september 2020) the coronavirus disease 2019 (covid-19) pandemic has revealed inadequacies within our healthcare systems, including the critical shortage of personal protective equipment (ppe). 1, 2 single-use disposable ppe such as n95 filtering face-piece respirators (ffrs) and surgical face masks are being worn for extended periods or reused until they become soiled or visibly damaged. shortages of ppe have been detrimental to the morale of healthcare workers (hcws) and places them at risk for infection, disability, and death. [3] [4] [5] among all ppe, the critical shortage of n95 ffrs has been most pronounced. 6, 7 at the onset of the outbreak, the centers for disease control and prevention (cdc) recommended that n95 ffrs be used for all interactions with confirmed or suspected covid-19 patients. the cdc subsequently modified its guidance regarding ppe required while caring for patients with covid-19. 8 presently, both the cdc and the world health organization (who) recommend the use of n95 ffrs for all aerosol-generating procedures (agps) performed on confirmed covid-19 patients and persons under investigation (pui). 9, 10 given the shortage of n95 respirators, the cdc has provided updated guidance for extended use and limited reuse of these respirators by hcws. 11 several strategies have been proposed for conserving ppe: repurposing other devices to be used as ffrs; creating ffrs at home; and decontaminating n95s using ultraviolet-c germicidal irradiation, dry heat, moist heat, or vaporized hydrogen peroxide. [12] [13] [14] [15] vaporized hydrogen peroxide (vhp) was given provisional us food and drug administration (fda) emergency use authorization (eua) for the decontamination of used n95 respirators. 16 however, vhp decontamination is a labor-and time-intensive process due to a long treatment cycle, and it requires the shipment of used n95 respirators to a central-processing center. 17 the fda has also granted an eua for other sterilization devices that are currently in use in several hospitals. this eua allows for in-hospital disinfection of used n95 ffrs; however, these devices are limited by the number of n95 ffrs that can be processed at a given time. an effective n95 respirator disinfection process that will allow on-site reprocessing with rapid turnaround times, ease of use with existing personnel expertise, and scalability to process large quantities of respirators is urgently needed. we previously reported that a high-level disinfection cabinet that generates aerosolized peracetic acid (paa, also known as peroxyacetic acid) and hydrogen peroxide was effective for disinfection of n95 respirators. 18, 19 here, we expanded on these promising findings by evaluating the use of this technology on a larger scale. a multi-institutional study was conducted at university hospitals cleveland medical center (uhcmc), case western reserve university (cwru), national aeronautical and space administration (nasa) glenn research center, and the cleveland veterans' affairs medical center (vamc) to evaluate the use of an ultrasonic room disinfection system that generates aerosolized paa and hydrogen peroxide for disinfecting large numbers of n95 respirators. the proposed paa disinfection experiments were approved by an internal safety review at university hospitals cleveland medical center (uhcmc). the microbiologic analyses were approved by the biosafety committee at the vamc. institutional review board approval was not obtained because human subjects were not enrolled in the study. the paa high-level disinfection system (hlds; ap-4, altapure, mequon, wi) was placed in the center of a room measuring 16.3 feet × 16 feet × 9.5 feet (2,447 cubic feet; 5 m × 4.8 m × 2.9 m; 69.6 cubic meters) ( fig. 1a-e) . the device uses ultrasonic vibrations to generate a dense cloud of submicron droplets of paa, consisting of peracetic acid (0.18%), hydrogen peroxide (0.88%), water (98.58%), and the remainder is inert ingredients. 20 the aerosol eventually decomposes into nontoxic end products: water vapor, acetic acid (vinegar), and oxygen. the decontamination cycles consisted of 4 phases: an aerosol deployment phase (ie, release of paa submicron aerosols into the room), a dwell phase (ie, aerosols left to stand in the room), a scrub phase (ie, aerosol is dehumidified and drawn through activated charcoal filters), and a vent phase (ie, fresh air is allowed to circulate by opening the manual vents enabling clearance of residual vapors and drying of the masks). the ventilation in the test room was modified to allow the influx and circulation of fresh air at the end of the scrub cycle. an extra air scrubber (hj-200, altapure, mequon, wi) was deployed to minimize vent times by accelerating the clearance of residual paa. the deployment and dwell times are directly responsible for microbial reduction, whereas the scrub and the vent cycles influence the clearance of residual paa vapors to recommended safety levels. there are no specific osha standards for paa. 21 the american conference of governmental hygienists (acgih) has set a threshold limit value (tlv) of 0.4 ppm as a 15-minute short-term exposure limit (stel). 21-23 the acute exposure guideline (aegl-1) limit recommended by the us environmental protection agency (epa) is 0.17 ppm (0.52 mg/m 2 ). 24 before the start of the disinfection cycle, the aerosol deployment, dwell, scrub, and vent times were manually configured using the application programming interface (api). the deployment and dwell times were adjusted to provide effective disinfection of the masks with the least amount of exposure to paa. the paa concentrations in the room were measured in real time using a paa sensor (safecide, chemdaq, pittsburgh, pa). at the end of the vent cycle, the paa concentrations were 0.12 ppm, below the aegl-1 limit of 0.17 ppm. the 15-minute time-weighted average of paa concentration after the decontamination cycle was 0.08 ppm, well below the 15-minute stel of 0.4 ppm. we evaluated 3 test cycles to identify a cycle time that achieved consistent disinfection of bacteriophage ms2 and g. stearothermophilus spores inoculated onto n95 respirators. the shortest cycle tested was 44 minutes: deployment phase, 12 minutes; dwell phase, 8 minutes; scrub phase, 8 minutes; and vent phase, 16 minutes. based on these results, the cycle times were incrementally adjusted to achieve an optimal cycle time. the optimal cycle was identified as the shortest cycle at which disinfection was consistently achieved: deployment phase, 16 minutes; dwell phase, 32 minutes; scrub phase, 12 minutes; and vent phase, 16 minutes. this cycle was then repeated up to 5 times with sterile masks that were subsequently analyzed for structural integrity and instantaneous filtration efficiency and underwent load testing. the model 1860 n95 (3m, minneapolis, mn) respirator was studied because it was the respirator used at the study hospital. in total, 20 new respirators were tested from 2 different lots from the hospital inventory. two n95 respirators were used for each decontamination test cycle. the test and control respirators were inoculated with~10 6 colony-forming units (cfu) of g. stearothermophilus spores and 10 6 plaque-forming units (pfu) of bacteriophage ms2 on the outer and inner surfaces of the respirator as previously described. 18, 25, 26 the test organisms were suspended in 8% simulated mucus, 27 and 10 μl aliquots were pipetted onto the respirator surface and spread with a sterile loop to cover an area of 1 cm 2 and allowed to air dry. the test n95 respirators were suspended using metallic 's' shaped hooks from shelving carts at a height of~2 m and exposed to paa submicron droplets. the control masks were left untreated at room temperature, maintained at 20°c (68°f). following disinfection treatments, the inoculated sections of the n95 respirators were cut out and vortexed for 1 minute in 1 ml phosphate-buffered saline with 0.02% tween 80. serial dilutions were then plated on selective media to quantify viable organisms. broth enrichment cultures were used to assess for recovery of low levels of g. stearothermophilus spores. all tests were performed in triplicate. log 10 cfu or pfu reductions were calculated by comparing recovery from treated versus untreated control respirators. the contact angle on the surface of untreated and treated n95 respirators was measured with a contact angle meter (kernco instruments, el paso, tx). a micropipette was used to place a small droplet of deionized water on the surface (outer green layer) of ã 1.2-cm × 2.5-cm section cut from each mask with scissors. contact angle (θ) for each of 3 drops was measured using the goniometer scale on the instrument for each sample and the range of angles documented. the outer (green) fabric of the mask was examined using scanning electron microscopy (sem). samples of~2.5 cm × 2.5 cm cut from each mask with scissors were coated with a 10-nm layer of platinum to reduce charging in the electron beam and then mounted to a~10-cm pin-mount platen with conductive carbon tape for sem viewing. a tescan maia-3 scanning electron microscope was used to view the fibers in each mask sample. the test parameters were set as follows: accelerating voltage, 1 kv; working distance, 15 mm; beam intensity, 8 (resulting in an absorbed current of~180 pa); and spot size,~28 nm. at each sterilization cycle, 3 samples (3 cm long) were cut from elastic straps of 2 masks (n = 6 per group). samples were clamped at a materials testing machine (testresources, minnetonka, mn) and were loaded for 2 consecutive loading and unloading cycles under tension at a rate of 1 mm/s. the testing profile included 2 consecutive cycles of load relaxation such that the sample was stretched 3 times the original length, was held at constant deformation for 5 minutes, and was unloaded. load values at peak deformation ('load 1' and 'load 2') and load-relaxation values for each cycle ('relaxation 1' and 'relaxation 2') were recorded. as such, relaxation represents the capacity of straps to retain a load over time. the elasticity of samples was from the slope of the line connecting the zero load with the peak load in the load deforma-tion plot. a nonparametric kruskal-wallis test was used at a significance level of p < .05. filtration efficiency of the n95 masks following exposure to paa vapor evaluation of filtration efficiency was performed at ics laboratories (brunswick, oh). n95 respirators subjected to multiple runs of the optimal cycle were subjected to testing for filtration efficacy in accordance with niosh standard teb-apr-stp-0059. 28 the masks were conditioned for 25 hours and were then subjected to instantaneous aerosol loading. upon exhibiting instantaneous filtration efficiency exceeding 95%, the remaining respirators were subjected to full loading. flow rate, initial resistance, and initial penetration data were recorded. following the optimal disinfection cycle, an n95 ffr was taken out of the decontamination room and allowed to air dry in a room with a fan blowing at 500 cubic feet per minute (cfm; 1.41 cubic meters per minute). the n95 ffrs were tested for off-gassing after the optimal disinfection cycle and at 20-minute intervals. testing was concluded once 2 consecutive tests showed no off-gassing for paa or hydrogen peroxide. figure 2 depicts the off-gassing set up. as shown in figure 3 , 6 log 10 reductions in g. stearothermophilus spores were achieved on inoculated 1860 n95 ffrs with all cycle durations. for bacteriophage ms2, 6 log 10 reductions were achieved on the inoculated 1860 n95 ffrs with the 16-minute aerosol deployment phase and the 32-minute dwell phase (total cycle time, 76 minutes) and the 19-minute aerosol deployment phase and 32-minute dwell phase (total cycle time, 87 minutes). based on these results, the optimal disinfection cycle time was determined to be a deployment time of 16 minutes and a dwell time of 32 minutes. structural integrity of the n95 masks following exposure to aerosolized paa an sem analysis revealed evidence of bubbles on the surface of the paa-treated respirator outer fabric fibers, which appeared to increase with the number of paa cycles (fig. 4a-f) . energy dispersive spectroscopy dot map images of the bubble feature on paa cycle 4 outer mask fabric indicated that the bubbles were high in oxygen, phosphorous, and nitrogen, based on the bright areas of the dot map images. the overall spectrograph showed that the surface was predominantly carbon, oxygen, and phosphorous. the contact angle remained at 97-99°with repeated cycles of paa disinfection. we thereby concluded that the hydrophobicity of the outer layer was preserved. elasticity of straps (as reflected by stiffness) and the capacity of straps to retain load over time (as reflected by relaxation) were not affected by the number of sterilization cycles (fig. 5) . p values ranged from 0.27 to 0.505. filtration efficacy of the n95 masks following exposure to paa vapor table 1a , 1b shows the results of filtration efficiency on the masks subjected to 5 cycles of paa treatment. we did not detect a decrease in filtration efficiency for up to 5 cycles of paa disinfection. at 20 minutes after the optimal disinfection cycle, the paa off-gassing was measured at 0.00 ppm. at 60 minutes after the optimal disinfection cycle, the hydrogen peroxide off-gassing was measured at 0.00 ppm. table 2 lists the full results. the goal of this investigation was to address the urgent need for an effective n95 respirator decontamination process allowing onsite reprocessing with rapid turnaround times, ease of use, and scalability to process large numbers of respirators. we found that the paa room disinfection system was easy to set up and operate and that it was effective for disinfection of n95 respirators with a total cycle time of 1 hour and 16 minutes. microbiological agents chosen to test for disinfection were based on guidance provided by the fda eua document. 29 during the ebola outbreak, the cdc recommended the use of disinfectants that were registered to be effective against nonenveloped viruses (compared to enveloped viruses) such as sars-cov-2 because they were more resistant to disinfection. 30, 31 bacteriophage ms2 is a nonenveloped virus that has been used as a surrogate in studies investigating airborne rna viral pathogens as well as disinfectant studies performed by the us epa. [32] [33] [34] geobacillus stearothermophilus spores have been used in the study of paa decontamination of surfaces. 35 our findings are consistent with previous studies that have demonstrated the efficacy of the paa disinfection system. both the room hlds and a high-level disinfection cabinet were effective in reducing pathogens, including c. difficile spores, on steel-disk carriers by >6 log 10 cfu. 25, 36 however, an extended cycle with the disinfection cabinet was required to achieve a 6 log 10 reduction in bacteriophage ms2 inoculated on n95 respirators. 18 in the current study, an extended cycle (identified as the optimal disinfection cycle in our experiments) was also required to achieve a 6 log 10 reduction in bacteriophage ms2 or g. stearothermophilus spores on n95 respirators. similarly, battelle 17 reported a prolonged vhp cycle time with a total time of 480 minutes for n95 decontamination. our results demonstrate that the n95 respirators retain their structural integrity, outer surface hydrophobicity, and strap elasticity for at least 5 repeated cycles of paa treatment. however, on a microscopic level, we observed evidence of visible bubbling on the nonwoven polypropylene fibers of the outer layer, which increased proportionally with the duration of exposure to paa. the significance of these bubbles is unclear at this time. it could be indicative of a trend toward loss of structural integrity with continued exposure to paa. these changes, however, did not affect the filtration efficiency of the treated masks. off-gassing of paa from the treated mask was undetectable after just 20 minutes of air drying. this finding may be explained by the inherently unstable nature of the compound leading to its rapid decomposition. 17, 37 hydrogen peroxide off-gassing was undetectable after 60 minutes of air drying. the paa room disinfection system offers several advantages over other technologies being evaluated for ppe decontamination. the technology is substantially more effective than ultraviolet-c (uvc) light for n95 decontamination. 18, 38 the aerosols allow complete coverage of all surfaces on the masks, thus eliminating the concerns about 'shadow areas' with uvc germicidal irradiation. 39 compared to vhp, the cycle times with paa are shorter with rapid turnaround times. 17, 40 this time savings can be vital for healthcare systems to achieve decontamination of large numbers of n95 ffrs. the platform is scalable and can be replicated in real-world hospital settings. we conservatively estimate that~2,000 n95 respirators can be effectively disinfected in a room with the dimensions of the test room (2,447 cubic feet or 69.6 cubic meters), with capacity increasing in proportion to the room dimensions. an estimated 15,000-20,000 n95 ffrs can be decontaminated per day with this method. the disinfection room can be set up relatively easily with simple modifications to the ventilation setups in most hospital rooms. the device can be operated with minimal training. the paa room hlds is currently used for terminal disinfection of patient rooms in some centers across the united states and abroad and can be readily repurposed for n95 decontamination without much added cost. the paa room disinfection system has some disadvantages. the paa aerosols are hazardous: the ventilation system must be closed and the room must be sealed during operation. the ap-4 hlds is designed to disinfect rooms of varying sizes, but a single device does not effectively disinfect spaces >4,000 cubic feet (113.25 cubic meters). however, the software allows for synchronous use of multiple ap-4 devices if larger decontamination room setups are considered. our study has some limitations. only 1 model of n95 ffr was evaluated. construction and materials of n95 respirators vary; thus, further studies are needed with other models. our sample size was small, in keeping with the need to preserve n95 ffrs for hcws. we only evaluated n95 structural integrity and filtration efficiency for up to 5 treatment cycles. despite these limitations, our study has the advantage of including assessments by a multidisciplinary group which helped evaluate the different factors that would affect the reusability of an n95 ffr. in conclusion, we found that a paa room hlds was effective for the decontamination of n95 respirators with a short cycle time. no adverse effects on filtration efficiency, structural integrity, or strap elasticity were detected after 5 treatment cycles. the paa room hlds system provides a rapidly scalable solution for hospitals requiring in-hospital disinfection of n95 respirators. chemdaq for their altapure ap-4 room disinfection system and safecide e-cell paa and hydrogen peroxide remote monitoring system for use in this study, respectively. they did not provide input on the study design or the interpretation of results. financial support. no financial support was provided relevant to this article. a the cycle length was a dwell of 16 minutes and a deploy of 32 minutes (optimal cycle). 'n'× indicates number of times the n95 ffr was treated with this cycle. challenges to the system of reserve medical supplies for public health emergencies: reflections on the outbreak of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) epidemic in china this is war: we must tackle shortages hampering covid-19 effort coronavirus: ppe shortage creating 'immense distress' for nurses despite promises of more masks, doctors and nurses have to reuse n95s characteristics of health care personnel with covid-19-united states where are all the masks? new york times website enforcement guidance for respiratory protection and the n95 shortage due to the coronavirus disease 2019 (covid-19) pandemic. occupational safety and health administration website healthcare infection prevention and control faqs for covid-19 interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings national institute for occupations safety and health. recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings conserving supply of personal protective equipment-a call for ideas is the fit of n95 facial masks effected by disinfection? a study of heat and uv disinfection methods using the osha protocol fit test vapor h2o2 sterilization as a decontamination method for the reuse of n95 respirators in the covid-19 emergency investigating decontamination and reuse of respirators in public health emergencies. us food and drug administration website final report for the bioquell hydrogen peroxide vapor (hpv) decontamination for reuse of n95 respirators. us food and drug administration website effectiveness of ultraviolet-c light and a high-level disinfection cabinet for decontamination of n95 respirators n95 mask decontamination using standard hospital sterilization technologies paracetic acid. occupational safety and health administration website health hazard information sheet: peroxyacetic acid. us department of agriculture website american conference of governmental industrial hygienists (acgih) guide to occupational exposure values peracetic acid: acute exposure guideline levels. us environmental protection agency website evaluation of an automated room decontamination device using aerosolized peracetic acid contamination of health care personnel during removal of personal protective equipment development of a physiologically relevant dripping analytical method using simulated nasal mucus for nasal spray formulation analysis determination of particulate filter efficiency level for n95 series filters against solid particulates for non-powered, air-purifying respirators standard testing procedure. revision 3.2. centers for disease control and prevention website enforcement policy for face masks and respirators during the coronavirus disease (covid-19) public health emergency (revised) disinfection, and sterilization: types, action, and resistance interim guidance for environmental infection control in hospitals for ebola virus evaluating low concentration hydrogen peroxide vapor for inactivation of ebola virus surrogates phi6 and ms2 bacteriophage. us epa decontamination conference evaluating the environmental persistence and inactivation of ms2 bacteriophage and the presumed ebola virus surrogate phi6 using low-concentration hydrogen peroxide vapor evaluation of filters for the sampling and quantification of rna phage aerosols evaluation of peracetic acid fog for the inactivation of bacillus anthracis spore surrogates in a large decontamination chamber efficacy of a multipurpose high level disinfection cabinet against candida auris and other health care-associated pathogens pubchem database. peracetic acid, cid=6585. national center for biotechnology information website assessment of n95 respirator decontamination and re-use for sars-cov-2. medrxiv 2020 uv light dosage distribution over irregular respirator surfaces. methods and implications for safety institution of a novel process for n95 respirator disinfection with vaporized hydrogen peroxide in the setting of the covid-19 pandemic at a large academic medical center acknowledgments. we extend our gratitude to uh ventures for providing the infrastructure for this study. we would like to thank altapure and conflicts of interest. c.j.d. discloses research funding from clorox, pdi and pfizer. o.a. discloses stipend/ equity from collamedic. all other authors have no conflicts of interest to disclose. key: cord-326599-n0vmb946 authors: leung, char title: the difference in the incubation period of 2019 novel coronavirus (sars-cov-2) infection between travelers to hubei and non-travelers: the need of a longer quarantine period date: 2020-03-18 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.81 sha: doc_id: 326599 cord_uid: n0vmb946 data collected from the individual cases reported by the media were used to estimate the distribution of the incubation period of travelers to hubei and non-travelers. upon the finding of longer and more volatile incubation period in travelers, the duration of quarantine should be extended to three weeks. an epidemic of viral pneumonia started in wuhan, the capital of hubei province in china, in december 2019. a new coronavirus was identified and named by the world health organization as sars-cov-2. it has been found that it is genetically similar to sars-cov and mers-cov 1 . recently, snakes have been suggested as the natural reservoirs of sars-cov-2, assuming that the huanan seafood wholesale market in wuhan is the origin of the virus 2 . different preventive measures have been implemented by health authorities with the 14-day quarantine being the commonly used. while previous studies have estimated the incubation period of sars-cov-2 to help determining the length of quarantine, it has recently been observed that some patients rather had mild symptoms such as cough and low-grade fever or even no symptoms 3 and that the incubation period might have been 24 days 4 , constituting greater threats to the effectiveness of entry screening. against this background, the present work estimated the distribution of incubation periods of patients infected in and outside hubei. because the details of most cases were reported by the media and were not available on the official web pages of the local health authorities in china, three searches for individual cases reported by the media between 20 th january 2020 and 12 th february (first cases outside hubei reported on 20 th january 2020) with search terms "pneumonia" and "wuhan" and "age" and "new" in chinese were performed on google from 7 th , 8 th , and 9 th february. the inclusion of the search term "age" intended to narrow down the search results since the presence of "age" in an article implied a description of an individual case. individual cases with time of exposure and symptom onset as well as type of exposure were eligible for inclusion. there was no language restriction. since most patients did not have complete information about the source of infection, the time of exposure was allowed to be a time interval within which the exposure was believed to lie. in contrast, patients could recall the exact date of symptom onset. the present paper considered two types of exposure, (i) traveling to hubei, china, and (ii) contact with the source of infection such as an infected person or places where infectious agents stayed. for data accuracy, only confirmed cases outside hubei province and within china were considered. the following data were abstracted, (i) location at which the case was confirmed, (ii) gender, (iii) age, where f and s were the cdf of the incubation period and the time of symptom onset, respectively. therefore, to find the maximum likelihood estimates of  , the maxima of the sum of the individual log-likelihood functions, either the results of maximum likelihood estimation are shown in table 1 . the aic suggested that the weibull distribution provided the best fit to the data. both indicator variables of the shape and scale parameters were significant in the weibull model, suggesting different incubation period distributions between the two groups of patients. [ table 1 here] the very first observation of the incubation period of sars-cov-2 came from the national health such difference might be due to the difference in infectious dose since travelers to hubei might be exposed to different sources of infection multiple times during their stay in hubei. in contrast, patients with no travel history to hubei were temporarily exposed to their infected relatives, friends or colleagues with mild or even no symptoms. it is possible that the incubation period of non-travelers was highly volatile, as suggested by the higher variance in the gamma model that provided slightly poorer fit. this could potentially pose a threat to the effectiveness of the existing preventive measures. the duration of quarantine period must be considered with caution. as a comparison, previous studies on the incubation period for sars-cov-2 are shown in table 2 . the 95 th percentiles reported in previous studies varied between 10.3 and 13.3 days, consistent with the current practice of quarantine period of 2 weeks. however, the present study found that the 95 th percentile of non-travelers could be 14.6 days and up to 17.1 days under 95% level of confidence. coupled with the high variability of the incubation period, it is suggested that the duration of the quarantine period of 3 weeks is deemed more suitable. [ a novel coronavirus from patients with pneumonia in china homologous recombination within the spike glycoprotein of the newly identified coronavirus may boost cross-species transmission from snake to human a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster clinical characteristics of 2019 novel coronavirus infection in china estimating incubation period distributions with coarse data early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia incubation period of 2019 novel coronavirus (covid-19) infections among travellers from wuhan key: cord-278987-3s5p9yw6 authors: hirotsu, yosuke; maejima, makoto; nakajima, masumi; mochizuki, hitoshi; omata, masao title: environmental cleaning is effective for the eradication of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) virus in contaminated hospital rooms: a patient from the diamond princess cruise ship date: 2020-04-17 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.144 sha: doc_id: 278987 cord_uid: 3s5p9yw6 nan oxygen from day 4 to day 15. after careful clinical management, the patient's overall status improved. rt-pcr showed that his sputum was positive for sars-cov-2 on day 11. subsequently, nasopharyngeal swabs were negative on days 17, 22, and 29. the patient stayed in room a for 3 days, during which he had the sars-cov-2 infection. after cleaning room a, 5 environmental samples were examined by rt-pcr. all samples were negative for sars-cov-2 and were positive or negative for rpp30 (table 1) . after the patient left room a, he resided in room b for 20 days. ten environmental samples were collected after cleaning. all 10 samples from room b were negative for sars-cov-2 and were positive or negative for rpp30 (table 1) . sars-cov-2 is detectable in several types of clinical samples including bronchial lavage fluid, nasopharyngeal swab, pharyngeal swab, sputum, saliva, and feces. 4, 5 transmission of sars-cov-2 via surfaces in hospitals is of great concern to medical staff and patients. blocking the potential routes of transmission is essential for preventing the spread of sars-cov-2. 6 a recent study showed that environmental contamination can occur via contact with patients with sars-cov-2 and upper respiratory tract symptoms. 7 after cleaning, all areas were negative for sars-cov-2; therefore, thorough cleaning is sufficient for sars-cov-2 decontamination. this study had several limitations. first, rt-pcr was not performed before cleaning because of the risk of nosocomial transmission. therefore, a comparison of the viral loads of high-touch areas before and after cleaning is required. second, this study involved a single patient, and further studies are required to confirm these findings. in summary, our data indicate the effectiveness of environmental cleaning for sars-cov-2 decontamination. this information is useful for infection control strategies and may alleviate the concerns of medical staff. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 double-quencher probes improved the detection sensitivity of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) by one-step rt-pcr detection of sars-cov-2 in different types of clinical specimens consistent detection of 2019 novel coronavirus in saliva persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient acknowledgments. we thank all of the medical and ancillary hospital staff and the patients for consenting to participate. we thank suzanne leech, phd, from the edanz group for editing a draft of this manuscript. conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-287167-rc9a5xs5 authors: kyaw, win mar; hein, aung aung; xiaozhu, zoe zhang; lee, lay tin; lin, cui; ang, brenda; chow, angela title: healthcare worker acute respiratory illness cluster in 2020: could it be from covid-19? date: 2020-07-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.364 sha: doc_id: 287167 cord_uid: rc9a5xs5 nan to the editor-since the emergence of coronavirus disease 2019 (covid-19) caused by severe acute respiratory coronavirus virus 2 (sars-cov-2) in china, >45,000 confirmed cases including >60 healthcare workers (hcws) have been reported in singapore. 1,2 healthcare workers (hcws) are at increased risk of nosocomial covid-19 infection. 3 in 2003, almost one-third of ward-based hcws at tan tock seng hospital (ttsh) in singapore were infected with the severe acute respiratory syndrome (sars) from an index patient. 4 after the sars nosocomial outbreak, web-based staff sickness surveillance systems have been established at ttsh for the early detection of hcw clusters of acute respiratory infection (ari). [5] [6] [7] additionally, a risk-based approach to the use of personal protective equipment (ppe) by hcws, with full ppe donned in high-risk areas and minimally surgical masks in low-risk areas were implemented. 7 during the covid-19 pandemic, a team of public healthtrained personnel maintained close monitoring of staff sickness reporting to identify ari clusters among the 12,000 hcws working at the 1,600-bed ttsh and its collocated 330-bed national centre for infectious diseases, the national referral centre for covid-19 response. we examined the epidemiology of ari clusters identified in hcws in the first 27 weeks of 2020, and we compared them with the ari clusters in 2019. an ari cluster was defined as ≥3 hcws or ≥5% of the total staff strength (whichever was higher) from the same work location reporting aris within 4 consecutive days. each ari cluster was followed-up with active case findings and infection prevention measures, including enhanced hand hygiene and enforcement of adherence to appropriate ppe and referral of sick staff to the in-house occupational health clinic (ohc). nasal and throat swabs were taken from symptomatic hcws who worked at the ohc. samples were sent to the national public health laboratory for influenza polymerase chain reaction (pcr) and respiratory multiplex pcr (filmarray respiratory panel 2) tests. sars-cov-2 pcr testing was implemented in 2020 at the start of the covid-19 pandemic. during the 79-week study period, the mean weekly number of staff absences due to ari was 142 (standard deviation [sd], 62). more than half of the ari clusters were identified among hcws who worked in inpatient wards (n = 55, 64%). other clinical areas (eg, pharmacy, physiotherapy, operating theatres, and outpatient clinics) accounted for more than one-quarter of the clusters (n = 25, 29%). the remaining clusters were identified among hcws who worked in nonclinical areas (n = 6, 7%) (fig. 1) . in total, 47 ari clusters were identified in the entire year of 2019, and 39 clusters were identified in first 27 weeks of 2020. compared to the first 27 weeks of 2019 (n = 28), the number of ari clusters identified among staff working in inpatient wards in 2020 (n = 39) was significantly lower: 49% versus 78%, respectively (or, 0.26; 95% ci, 0.09-0.78; p = .016). median cluster sizes were slightly larger: 8 (iqr, 6-21) for 2020 versus 7 (iqr, 4-10) for 2019 (or, 1.07; 95% ci, 0.99-1.15; p = .067). median cluster duration was longer in 2020 than in 2019: 22 days (iqr, 13-40) versus 19 days (iqr, 13-25), respectively (or, 1.02; 95% ci, 0.98-1.06; p = .290). among ari clusters, almost twice the number of clusters in 2020 had at least 1 respiratory pathogen identified (n = 11, 28%) compared with 2019: 11 (28%) versus 6 (21%), respectively (p = .531). rhinovirus was the most common viral pathogen detected in both years: 6 clusters (15%) in 2020 and 3 clusters (11%) in 2019. this possibly reflects the most common circulating noninfluenza viral pathogen among ari episodes in the community. 8 human coronaviruses 229e/hku1/oc43 were detected in both years: 4 clusters (10%) in 2020 and 1 cluster (4%) in 2019. adenovirus was identified in 8% of ari clusters in 2020, although it was not detected in any of the ari clusters in 2019. parainfluenza viruses (5%) were also detected during the first 27 weeks of 2020 but not in 2019. influenza viruses were detected in 2 clusters in 2019 but in none of the clusters in 2020. sars-cov-2 virus was not detected in any of the hcw ari clusters in 2020. since start of the pandemic, despite an increase in ari clusters detected, sars-cov-2 has not been detected. this absence reflects the adequate protection of hcws from acquiring sars-cov-2 infection in the hospital. notably, no pathogen was identified in hcw ari clusters after epidemiological week 14 in 2020, and a downward trend of the weekly number of staff aris reported from epidemiological week 17. no staff ari cluster was identified after epidemiological week 19. these trends are likely the consequence of hospital-wide enhanced infection prevention measures (eg, safe distancing, having meals alone, and the donning of surgical masks at all times in all hospital areas) instituted since epidemiological week 15 in 2020 (ie, the week ending april 11, 2020). close surveillance of staff absenteeism due to ari and epidemiological investigations of hcw ari clusters with screening for respiratory viruses and sars-cov-2 are crucial as covid-19 pandemic emergency responses relax, economic activities resume, and travel bans are lifted. because it is unlikely that covid-19 infections will taper off soon around the world, countries should consider having all hcws wear surgical masks at all times in healthcare settings. covid-19 cases among healthcare workers and support staff: gan kim yong. channel news asia website covid-19 situation report. ministry of health singapore website transmission of covid-19 to health care personnel during exposures to a hospitalized patient the outbreak of sars at tan tock seng hospital-relating epidemiology to control use of healthcare worker sickness absenteeism surveillance as a potential early warning system for influenza epidemics in acute care hospitals surgical masks for protection of healthcare personnel against pandemic novel swine-origin influenza a (h1n1)-2009: results from an observational study responding to the covid-19 outbreak in singapore: staff protection and staff temperature and sickness surveillance systems detection of viral respiratory pathogens in mild and severe acute respiratory infections in singapore acknowledgments. authors acknowledge members of surveillance team and infection control team who conduct staff sickness absenteeism surveillance throughout.financial support. no financial support was provided relevant to this manuscript. all authors report no conflicts of interest relevant to this manuscript. key: cord-329886-3z4kps8l authors: gupta, kalpana; bellino, pamela m.; charness, michael e. title: adverse effects of nasopharyngeal swabs: three-dimensional printed versus commercial swabs date: 2020-06-11 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.297 sha: doc_id: 329886 cord_uid: 3z4kps8l nan to the editor-to date, >6 million tests for covid-19 have been performed in the united states, with the vast majority utilizing nasopharyngeal sampling. 1 the need for large-scale testing in the covid-19 pandemic has created a global shortage of commercial nasopharyngeal swabs. one approach to this shortage has been the 3-dimensional (3d) printing of nasopharyngeal swabs. swabs printed on a 3d printer (3d swab) differ somewhat from commercially produced swabs: they having larger heads, less flexibility, and a plastic rather than cotton or polyester fiber tip. these 3d swabs are class 1 medical devices, and their diagnostic efficacy has been validated through field testing. 2 guidance on the safe collection of nasopharyngeal samples using commercial swabs is available in text and video format 3,4 ; however, no data are available on the adverse effects of either commercial or 3d swabs, making it difficult to assess their relative safety. to expand testing at our medical center, we printed the northwell prototype 3d swab using specifications obtained from the technology transfer office at the university of south florida. as part of our safety assessment of this prototype, we identified adverse effects of np swabbing in employees using both commercial and 3d swabs. epistaxis occurred immediately or shortly following the removal of the swab in 5.0% of employees tested with the 3d swab and in 8.3% of employees tested with the commercial swab (table 1) . epistaxis was usually mild and self-limited, although 1 employee required an emergency department visit for ongoing epistaxis after testing with a commercial swab. other minor adverse effects included nasal discomfort, headache, earache, and rhinorrhea, which typically lasted hours to a day. our finding that epistaxis is equally common after the use of 3d and commercial swabs provides reassurance that 3d swabs are a safe alternative to commercial swabs. however, the~5%-10% incidence of epistaxis after nasal swabbing with either commercial or 3d swabs warrants caution in testing individuals at increased risk for bleeding. nursing home residents have been disproportionately affected by covid-19, and a recent point prevalence study of medicare fee-for-service beneficiaries found that almost half of 37,787 nursing home residents were treated with oral anticoagulants. 5 rates of epistaxis after nasal swabbing should be studied in larger populations, including the elderly, and individuals at increased bleeding risk should be monitored after the procedure. fortunately, less invasive methods of sars-cov-2 detection, such as midturbinate or saliva sampling, are on the horizon. the covid tracking project website open development and clinical validation of multiple 3d-printed nasopharyngeal collection swabs: rapid resolution of a critical covid-19 testing bottleneck nasal (anterior nasal) specimen collection for sars-cov-2 diagnostic testing how to obtain a nasopharyngeal swab specimen changes in anticoagulant utilization among united states nursing home residents with atrial fibrillation from 2011 to 2016 acknowledgments. we are grateful to michael kulig, elena buckley, andrew risio, jennifer bryant, and dr. steven brecher for their efforts in implementing our 3d-printing of nasopharyngeal swabs.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-300138-1s87msv2 authors: jang, youngeun; son, hyo-ju; lee, seungjae; lee, eun jung; kim, tae hyong; park, se yoon title: olfactory and taste disorder: the first and only sign in a patient with sars-cov-2 pneumonia date: 2020-04-20 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.151 sha: doc_id: 300138 cord_uid: 1s87msv2 nan to the editor-severe acute respiratory syndrome corona virus 2 (sars-cov-2), first reported in wuhan city of hubei province of china, has now rapidly spread throughout the world. 1 genome sequencing showed that the causal agent of coronavirus disease 2019 (covid-19) is a β-coronavirus belonging to subgenus of severe acute respiratory syndrome (sars) viruses but a different clade. 2 common clinical manifestations include fever, cough, fatigue, dyspnea, and myalgia or arthralgia. 3 recently, giacomelli et al 4 reported that 20 of 59 (33.9%) of sars-cov-2-positive hospitalized patients had an olfactory or taste disorder. 4 sars-cov-2 can be transmitted in the asymptomatic or paucisymptomatic stages; therefore, olfactory and taste disorders can be significant signs for its early detection to control transmission. we found that olfactory and taste disorders can be the first and only signs of covid-19 pneumonia. a 42-year-old man was admitted to the soonchunhyang university seoul hospital in the republic of korea (rok) for isolation and care for covid-19 on march 26, 2020. he had been self-quarantined for 14 days since march 12 due to close contact with a confirmed sars-cov-2-positive patient, who was his cohabitant. in rok, close contacts are tested for sars-cov-2 after 14 days of quarantine to exclude asymptomatic infections. although he had no clinical symptoms or signs of covid-19 such as fever, myalgia, cough, and sore throat, on march 26 (the final day of his quarantine) he was confirmed positive based on a polymerase chain reaction (pcr) test (rdrp gene, cycle threshold value of 30.28 on sputum and 33.47 on nasopharyngeal and oropharyngeal swab). the governmental investigation team considered this an asymptomatic infection. however, the patient had developed problems with smell and taste simultaneously on march 14, after 2 days of quarantine. he did not have rhinorrhea or nasal obstruction but complained of a metallic taste in his mouth. the symptoms persisted for >2 weeks. we graded the olfactory and taste disorder on a visual analog scale of 0 to 10 (0 anosmia and 10 no olfactory or taste disorder). on quarantine day 3 (march 14), he had grade 5 symptoms, which improved by quarantine day 14 (march 26). on day 4 of hospitalization, we performed chest computed tomography (ct), which showed unilateral patchy or nodular ground-glass opacities and airspace consolidations in the right-middle and right-lower lobes. this case of a sars-cov-2-positive patient with radiologically proven pneumonia on chest ct, who presented with only olfactory and taste disorders and no other clinical manifestations, suggests that previous cases with asymptomatic infections could have been misclassified. considering the viral load in our patient, which was measured after 14 days of quarantine, sars-cov-2-positive patients, even when paucisymptomatic, could have relatively high viral titers, which could contribute to the rapid transmission of sars-cov-2. 5,6 moreover, because transmission can occur in the early course of infection, identification of such initial symptoms can help with the early detection of sars-cov-2. with this report, we emphasize the necessity for more intensive screening criteria for sars-cov-2 infections to ensure their appropriate identification and the prompt quarantine of suspected patients to help prevent the transmission of this virus. covid-19) situation reports. world health organization website genomic characteristics and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor blinding clinical characteristics of coronavirus disease 2019 in china self-reported olfactory and taste disorders in sars-cov-2 patients: a cross-sectional study sars-cov-2 viral load in upper respiratory specimens of infected patients transmission of 2019-ncov infection from an asymptomatic contact in germany acknowledgments. we thank all of our colleagues and staff of our hospital who devoted their time and expertise to make soonchunhyang university seoul hospital safer during the covid-19 outbreak.financial support. no financial support was provided relevant to this article.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-332196-03cklmm3 authors: kennedy, amy j.; hilmes, mary k.; waddell, linda; bartow, alexandrea b.; baxter, carla m.; hadi, christiane m.; snyder, graham m.; merlin, jessica s. title: retesting for severe acute respiratory coronavirus virus 2 (sars-cov-2): patterns of testing from a large us healthcare system date: 2020-08-10 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.413 sha: doc_id: 332196 cord_uid: 03cklmm3 nan to the editor-coronavirus disease 2019 (covid-19), a respiratory illness caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), has caused a global pandemic, leading to significant morbidity and mortality. 1, 2 accurate testing is essential to the identification and treatment of new cases of covid-19 in the inpatient and outpatient settings. in the united states, the initial focus of covid-19 testing has been on ensuring adequate access to large-scale testing via a public health approach. however, given the limitations in efforts to ensure widespread access, individual hospitals and healthcare systems have worked to ensure that enough tests are available to meet clinical demand. often decisions on who to test are left to individual clinicians, which leads to questions about when and who to retest for covid-19, how often false positives or negatives might occur, and the duration of positivity. 3 research regarding why retesting for sars-cov-2 might be indicated or what results might be expected is lacking. this report describes patterns of sars-cov-2 nucleic acid polymerase chain reaction (pcr) retesting in inpatients and outpatients within a large us healthcare system. we aimed to learn more about potential reasons for retesting and test characteristics. we performed a retrospective chart review of all inpatients and outpatients aged ≥18 years receiving care within the university of pittsburgh medical center (upmc) with ≥2 sars-cov-2 pcr tests with an initial test between march 3 and may 3, 2020, and a subsequent test before may 21, 2020. upmc operates 40 academic, community, and specialty hospitals and 700 doctors' offices and outpatient sites across pennsylvania, new york, and maryland. widespread testing within upmc at individual clinician discretion became available in march 2020, and recommended asymptomatic screening of preoperative patients began in may 2020. we collected demographic characteristics, setting of care, reason for retesting, certain covid-19 risk factors (ie, nursing home resident, immunocompromised, healthcare worker, covid-19 exposure, travel history), and the date of tests, allowing for calculation of time between tests. pcr testing was performed using a lab-derived assay and through a commercial laboratory. descriptive statistics were performed overall and for 4 groups: (1) initial positive test, any subsequent result(s) positive; (2) initial positive test, any subsequent result(s) negative; (3) initial negative test, any subsequent result(s) negative; and (4) initial negative test, any subsequent result(s) positive. these groups were not mutually exclusive and were constructed to learn as much as possible about testing characteristics. for example, within group 1, the potential length of time a test could remain positive (even if a subsequent test was then negative). the university of pittsburgh institutional review board approved this study. among >30,000 initial tests, 485 were repeated; 259 were inpatients (53.6%) and 230 were outpatients (46.7%) at the time of initial test. most individuals (348, 71.9%) had 2 tests and 136 (28%) had ≥3 tests. most patients were white (78%), aged 41-80 years (71.6%), and had symptoms of fever (35.1%), cough (37.2%), or shortness of breath (32.0%) at baseline (table 1) . among 74 patients with an initial positive test, 35 (47%) had any subsequent positive result (group 1) and 39 (53%) had any subsequent negative result (group 2). the median time between an initial and last positive test was 18 days (interquartile range [iqr], 13; range, 2-39), and the median time between an initial positive and first negative test was 23 days (iqr, 12; range, 3-43). the most common reason for repeat testing was inpatient discharge planning, followed by discontinuation of inpatient isolation (table 1) . among 418 patients with an initial negative test, only 15 (3.6%) had any subsequent positive result (group 4), while 403 (96.4%) had any subsequent negative result (group 3). the most common reason for repeat testing was preoperative asymptomatic screening (n = 154, 31.3%), followed by clinical suspicion for a false negative (n = 108, 22.0%). for those who went from negative to positive, median time between tests was 8 days (iqr, 12; range, 1-23). in this retrospective study of a large us healthcare system, we found that retesting for sars-cov-2 was uncommon and often resulted in multiple negative tests. most individuals were retested due to preprocedural asymptomatic screening or clinical suspicion for covid-19 disease. in this population, pcr positivity persisted for a median of 18 to 23 days, and repeat testing after an initial negative test infrequently yielded a positive result. prior studies have suggested that pcr positivity may persist beyond symptoms or infectivity; our findings suggest a potential time frame for this persistence. 4 most repeat tests ordered after an initial negative test were also negative, which is consistent with other emerging findings. 5, 6 the main limitation of this study is that testing was conducted only in individuals in whom it was clinically indicated, and only at the clinician's discretion, which limited our ability to draw conclusions about differences between test groups or to calculate a true false-negative rate. in summary, we found that retesting for sars-cov-2 was rare and usually resulted in multiple negative tests. future research should work to identify predictors of initial false negatives and to provide a more refined estimation of duration of infectivity. characteristics and outcomes of 21 critically ill patients with covid-19 in washington state hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019-covid-net, 14 states overcoming the bottleneck to widespread testing: a rapid review of nucleic acid testing approaches for covid-19 detection positive rt-pcr test results in patients recovered from covid-19 variation in falsenegative rate of reverse transcriptase polymerase chain reaction-based sars-cov-2 tests by time since exposure utility of retesting for diagnosis of sars-cov-2/covid-19 in hospitalized patients: impact of the interval between tests financial support. the first author was supported by a hrsa t32 training grant (grant no. t32hp22240) for the duration of the data analysis and writing of the manuscript.conflicts of interest. the authors declare no conflict of interest. key: cord-300245-9vckgxt0 authors: wong, shuk-ching; lam, germaine kit-ming; auyeung, christine ho-yan; chan, veronica wing-man; wong, newton lau-dan; so, simon yung-chun; chen, jonathan hon-kwan; hung, ivan fan-ngai; chan, jasper fuk-woo; yuen, kwok-yung; cheng, vincent chi-chung title: absence of nosocomial influenza and respiratory syncytial virus infection in the coronavirus disease 2019 (covid-19) era: implication of universal masking in hospitals date: 2020-08-17 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.425 sha: doc_id: 300245 cord_uid: 9vckgxt0 universal masking for healthcare workers and patients in hospitals was adopted to combat coronavirus disease 2019 (covid-19), with compliance rates of 100% and 75.9%, respectively. zero rates of nosocomial influenza a, influenza b, and respiratory syncytial virus infection were achieved from february to april 2020, which was significantly lower than the corresponding months in 2017–2019. the study was conducted in a healthcare network comprising an acute-care, university-affiliated, teaching hospital and 4 extendedcare hospitals with a total of 3,100 beds in hong kong. with the outbreak of covid-19 pneumonia in wuhan, china, our response plan changed from the alert level to the serious response level on january 4, 2020, and it further elevated to the emergency level on january 25, 2020 in hong kong. 3 universal masking was implemented for all hcws on january 4, 2020 and enforcement began on january 25, 2020. surgical masks were provided to all patients. in addition to the active surveillance and early isolation of suspected cases for rapid molecular diagnosis, the hospital infection control team also provided intensive training to hcws through forums, department visits, and face-to-face training of donning and doffing of personal protection equipment. 3, 4 hand hygiene practice was enforced. hand hygiene compliance was performed according the world health organization (who) protocol. compliance with universal masking by hcws and patients was monitored by infection control nurses (icns) at the bedside in wards with an open cubicle setting. the design of wards was not changed in 2020. upon each 20-minute ward visit, icns also recorded episodes in which hcws and patients wore the surgical masks improperly (defined as the mask not fully covered the nose or mouth) or did not perform hand hygiene immediately after touching the external surface of masks. in addition to the diagnosis of covid-19, nasopharyngeal aspirates or nasopharyngeal swabs were collected from patients with fever or respiratory symptoms to rule out other respiratory viral infections, including influenza a, influenza b, and respiratory syncytial virus (rsv) using xpert xpress flu/rsv (cepheid, sunnyvale, ca) (supplementary file 1 online). icns assessed the laboratory results to identify nosocomial respiratory viral infection, which was defined as patients with onset of fever or respiratory symptoms >48 hours of hospital admission, and they advised appropriate infection control measures to prevent hospital outbreak. we monitored the incidence of nosocomial acquisition of influenza a, influenza b, and rsv from february 2020 to april 2020, after enforcement of universal masking began on january 25, 2020. this period represents within the common seasonal influenza surge in hong kong, which occurs from january to april and from july to august (rsv infection occurs throughout the year in hong kong). the corresponding months (february-april) in 2017, 2018, and 2019 were chosen as the preintervention period for comparison. the χ 2 test was used to compare independent categorical variables between groups. p < .05 was considered statistically significant. the number of patients tested for influenza a, influenza b, and rsv during hospitalization was comparable between the 2 periods ( table 1) . absence of nosocomial influenza a, influenza b, and rsv infection was achieved from february to april 2020 in our healthcare network. the number of nosocomial influenza a, influenza b, and rsv cases per month and per 1,000 patient days per month were significantly lower than during the preintervention period ( table 1) . the overall monthly hand hygiene compliance (mean ± sd) from february to april 2020 was 73.3 ± 2.1%, which was comparable to the corresponding figure in the preintervention period (76.9 ± 3.6%) (p = .14). in a 3-week audit from may 18, 2020, to june 5, 2020, 74 ward visits were made by icns. the compliance rates of wearing surgical masks among hcws was 100% (889 of 889) and among adult patients was 75.9% (1,155 of 1,522). improper wearing of surgical mask was significantly more observed among patients (132 of 1,155, 11.4%) than hcws (11 of 889, 1.2%) (p < .001). in contrast, significantly more hcws (29 of 889, 3.3%) touched the external surface of their surgical mask than patient did (18 of 1,155, 1.6%) (p = .01) ( table 2 ), but none of them performed hand hygiene immediately after touching their mask. for the infection control measures against respiratory viruses other than sars-cov-2, it is the general practice for our hcws to adopt droplet precautions by wearing surgical masks within 1 m of patient contact and by practicing hand hygiene. however, lower numbers of sporadic cases of nosocomial influenza a, influenza b, and rsv were observed in the preintervention period despite of our infection control practice. in the covid-19 era, hcws and patients were additionally required to wear surgical masks at all times in hospitals. although the hand hygiene compliance of hcws was comparable before and during the covid-19 era, the policy of universal masking may be an important contributing factor in achieving zero nosocomial infections of influenza a, influenza b, and rsv. universal masking may reduce the shedding of sars-cov-2, or other respiratory viruses, from symptomatic and asymptomatic persons and thus reduce the environmental contamination, as illustrated in our recent study. 5 in addition, wearing surgical masks may also prevent the maneuvers of nose picking and eyes touching, a subconscious behavior 6 that poses a risk of self-inoculation of pathogens from the environment via the contaminated hands. this factor is the reason we have highly promoted our institutionally designed sixth moment, "hand hygiene before touching your mucous membrane," together with the practice of who five moments for hand hygiene. 7, 8 compliance with universal masking was monitored between may and june 2020, 4 months after the activation of emergency response level when universal masking was implemented in our hospitals. compliance with universal masking among hcws remains 100%, suggesting that the practice of universal masking among hcws is sustainable in the covid-19 era. however, a few hcws wore surgical masks improperly and did not practice hand hygiene immediately after touching the external surface of masks, which indicates the need for further education. understandably, not all audited patients wore surgical masks because of their unconsciousness or unstable clinical conditions. however, wearing of surgical masks by either hcws or patients in hospital successfully prevented nosocomial influenza a outbreak in the 2009 pandemic. 9 in our hamster model for covid-19, surgical mask partition placed between cages housing sars-cov-2-infected hamsters and cages housing exposed naive hamsters significantly reduced the rate of non-contact transmission. 10 universal masking in hospitals in the covid-19 era deserves further investigation. given the others enhanced infection control measures for covid-19 pandemic in 2020 as potential cofounding variables, universal masking appears to be a key measure to control the transmission of respiratory viruses, as well as achieving zero nosocomial transmission of covid-19, influenza a, influenza b, and rsv in our healthcare network. note. hcws, healthcare workers; na, not applicable because we only observed the compliance of wearing surgical mask in adult patients; obgyn, obstetrics and gynecology. a improper wearing of surgical mask is defined as that the nose or mouth is not fully covered by the surgical mask. b none of them practice hand hygiene immediately after touching the external surface of mask. c including adult intensive care unit, clinical oncology, accidental and emergency unit, and mixed ward. d 11 hcws: 9 nurses and 2 supporting staff. e 29 hcws: 9 doctors, 9 nurses, 9 supporting staff, and 2 allied health staff. universal masking in hospitals in the covid-19 era: is it time to consider shielding? universal masking in hospitals in the covid-19 era escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (covid-19) due to sars-cov-2 in hong kong absence of nosocomial transmission of coronavirus disease 2019 (covid-19) due to sars-cov-2 in the pre-pandemic phase in hong kong air and environmental sampling for sars-cov-2 around hospitalized patients with coronavirus disease 2019 (covid-19) face touching: a frequent habit that has implications for hand hygiene is it possible to achieve 100% hand hygiene compliance during the coronavirus disease 2019 (covid-19) pandemic? directly observed hand hygiene-from healthcare workers to patients prevention of nosocomial transmission of swine-origin pandemic influenza virus a/h1n1 by infection control bundle surgical mask partition reduces the risk of non-contact transmission in a golden syrian hamster model for coronavirus disease 2019 (covid-19) acknowledgement. we thank our healthcare workers for fighting against the covid-19 pandemic.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-339903-5ybwxyc8 authors: tabary, mohammadreza; araghi, farnaz; nasiri, soheila; dadkhahfar, sahar title: dealing with skin reactions to gloves during the covid-19 pandemic date: 2020-05-08 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.212 sha: doc_id: 339903 cord_uid: 5ybwxyc8 nan recommendations for the prevention of allergic reactions to gloves are summarized in fig. 1 . urticaria can be treated with antihistamines and the elimination of the antigen. h 1,2 blockers can be used before coming into contact with latex devices; however, latex avoidance is superior to this protocol. 4 plastic gloves, considered as hypoallergenic polyvinylchloride (pvc) gloves, are also used among hcws. contact allergic reaction to pvc has also been reported as a result of allergy to many additives used in these gloves, including carba mix, mercaptobenzothiazole (mbt), thiuram mix, mixed dialkyl thioureas, and black rubber mix. 5 allergic contact dermatitis has been reported in numerous case reports. lesions may also become generalized in some patients. a patch test can be used to confirm the diagnosis. topical corticosteroids are considered as the best choice of treatment; however, patients should be advised to use other types of gloves, 5 although allergic contact dermatitis may coexist with immediate hypersensitivity to latex. 5 nitrile, neoprene, and polyurethane are also used in plastic gloves. hand dermatitis has been reported with these types of materials. the patch test is recommended in suspicious cases. application of topical and oral steroids can mitigate the symptoms but the benefits should be weighed against the risks of side effects. 6 glove-related hand urticaria should also be considered as a differential diagnosis; it is caused by dermographism upon the application of the glove. pain, burning, and pruritus in the affected area, and systemic symptoms such as fever are not present in glove-related hand urticaria. further, nitrile gloves are more likely to cause this phenomenon because they are rigid and less flexible. 7 some types of powder used in gloves have been associated with an increased risk of skin roughness due to altering glove ph. 8 glove powder has been reported to cause allergic reactions, and hand eczema has been reported to decrease significantly after using powder-free gloves. 9 thus, the use of powder-free gloves is recommended in the current pandemic situation. hcws are also encouraged to wear double gloves when handling covid-19 patients' airways, blood, urine, and other body fluids. the outer glove should be the first equipment to be removed. 2 drive-through screening center for covid-19: a safe and efficient screening system against massive community outbreak perioperative care provider's considerations in managing patients with the covid-19 infections natural rubber latex allergy latex allergy: diagnosis and management contact allergy to allergy to allyl glycidyl ether present as an impurity in 3-glycidyl-oxypropyl-trimethoxysilane, a fixing additive in silicone and polyurethane resins glove-related hand urticaria: an increasing occupational problem among healthcare workers glove powder affects skin roughness, one parameter of skin irritation glove powder in the hospital environment-consequences for healthcare workers acknowledgments.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-284402-629pxjo1 authors: chan, derwin k. c.; zhang, chun-qing; weman-josefsson, karin title: why people failed to adhere to covid-19 preventive behaviors? perspectives from an integrated behavior change model date: 2020-05-15 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.245 sha: doc_id: 284402 cord_uid: 629pxjo1 nan to the editor-many preventive behaviors such as the practice of hand, personal, and respiratory hygiene; maintaining social distance (eg, staying home); and cleaning and disinfection are recommended for the prevention of the new coronavirus (covid-19). however, a growing number of reports have revealed individuals' violations to these covid-19 preventive behaviors. 1 these violations might endanger the community by increasing the risk of an outbreak of covid-19. the uptake of and adherence to health behaviors, including behaviors related to the prevention of infectious diseases (eg, covid-19), are likely highly dependent on individuals' motivation, intention, and other decision-making factors. 2 we aim to apply an integrated behavior change model of health psychology to explain why individuals fail to comply and adhere to these behaviors. the integrated model of self-determination theory 3 and the theory of planned behavior 4 is a behavior change model that utilizes the concepts of 2 widely used psychological theories. the integrated model outlines the processes by which psychological need support, and motivations directly and indirectly link to the social cognition beliefs, intention, and behavior ( fig. 1) . 5 in the integrated model, 5 when social environments are supportive to individuals' basic psychological needs of autonomy, competence, and relatedness, individuals are more likely to endorse autonomous motivation (ie, acting for inherent interest, satisfaction, personal goals, and values) than controlled motivation (ie, acting due to external contingencies, internal pressure, or sense of ego). they are also more likely to have more favorable social cognition beliefs (ie, attitude, subjective norm, and perceived behavioral control) and intentions and to demonstrate behavioral adherence in health behaviors. the psychological pathways illustrated in the integrated model have been supported by evidence from various health contexts and cultures, 5,6 including preventing h1n1 transmission during a pandemic. 2 we believe that the integrated model can explain why some people have failed to adhere to the recommended behaviors for covid-19 prevention. why people do or do not adhere to covid-19 prevention recommendations a number of countries have set up legislation regarding social distance measures (eg, stay-home restriction), quarantine, and lockdown/travel ban. these legislative actions are classic examples of external factors that foster the development of controlled motivation. according to the integrated model, 5 individuals who are driven by controlled motivation (ie, acting due to external contingencies, internal pressure, or sense of ego) may adhere to the advisory behavior as soon as the external factors (eg, contingencies of following covid-19 preventive behaviors or not) are present, but they are more vulnerable to nonadherence in the long term than those who hold autonomous motivation (ie, acting for inherent interest, satisfaction, personal goals, and values) for the action. individuals driven by controlled motivation alone might consider violations of health legislations when they perceive that the risks of getting caught or negative health consequences are low. 7 at present, the enforcement of some new covid-19 prevention legislations (eg, social distancing measures) could be extremely challenging when the surveillance involves a large geographical area or population. governments or public health organizations should consider noncoercive strategies that are aligned with basic psychological needs to foster individuals' autonomous motivation of covid-19 prevention. in addition to law enforcement, other social situations and environmental factors are supportive or detrimental to the motivational and social cognition factors affecting covid-19 prevention. in support to the psychological factors in the integrated model 5 , there are social situations or personal beliefs that facilitate autonomous motivation (eg, "preventing covid-19 is what i want to do because i am responsible for my own health"), attitude (eg, accessible online information about the values of covid-19 prevention), subjective norms (eg, family or friends who are following the covid-19 preventive strategies say i should do the same), and perceived behavioral control (eg, training resources that make it easier for me to correctly apply covid-19 preventive behavior such as hand hygiene). in contrast, some social circumstances are detrimental to motivational and social cognition factors. for instance, advice on the necessity of wearing face masks in community settings has been inconsistent across different nations and health organizations, 8 which might discourage individual autonomous motivations (eg, "do i really want to prevent covid-19 in this way?") and attitudes (eg, "are there any points to wearing a face mask for the prevention of covid-19?"). the shortage of personal protective equipment (ppe) 9 might impair an individual's sense of competence and perceived behavioral control (eg, "lack of ppe has made the prevention of covid-19 challenging and uncontrollable"). discrimination toward, alienation of, and labeling of individuals who wear face masks in public areas 10 or social groups that encourage the ignorance of social distance measures 1 might undermine an individual's relatedness and subjective norms in the context of covid-19 prevention. governments and health organizations should be aware of these factors and should implement policies and social strategies that facilitate the motivational and social cognition factors affecting covid-19 prevention. in conclusion, the integrated model of self-determination theory and the theory of planned behavior explains why some individuals fail to adhere to the preventive behaviors of covid-19. we hope our discussion may raise the awareness of governing bodies and public health sectors regarding the importance of considering individuals' motivation and social cognition beliefs when implementing covid-19 preventivon measures in the community. fears 'lockdown parties' will increase global spread of coronavirus. 2020. the guardian website preventing the spread of h1n1 influenza infection during a pandemic: autonomy-supportive advice versus controlling instruction intrinsic motivation and self-determination in human behavior from intentions to actions: a theory of planned behavior integrating the theory of planned behaviour and self-determination theory in health behaviour: a metaanalysis the trans-contextual model of autonomous motivation in education: conceptual and empirical issues and meta-analysis self-determined motivation in sport predicts anti-doping motivation and intention: a perspective from the trans-contextual model rational use of face masks in the covid-19 pandemic critical supply shortages-the need for ventilators and personal protective equipment during the covid-19 pandemic why wearing a face mask is encouraged in asia the integrated model of self-determination theory and the theory of planned behavior acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-331130-vr8kczes authors: chirico, francesco; nucera, gabriella; magnavita, nicola title: hospital infection and covid-19: do not put all your eggs on the “swab” tests date: 2020-05-27 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.254 sha: doc_id: 331130 cord_uid: vr8kczes nan to the editor-in healthcare settings, including long-term care facilities, hospital administrators have a legal obligation to set up a risk assessment strategy to carry out effective prevention and control measures during the management of suspected and confirmed cases of covid-19 infection. 1 hospitalized inpatients and residents in care homes are often elderly and immunedepressed patients with comorbidities; thus, they are at high risk of infection and mortality. special attention and efforts to protect or reduce transmission should be also applied in healthcare providers because depletion of the healthcare workforce not only will affect health care but also will contribute to the spread of the outside hospitals. according to european centres for disease control and prevention (eu-cdc) guidelines, 1 each hospital should constitute a 'covid-19 preparedness and response committee' and should prepare a specific plan, including a number of administrative and structural measures for patient and healthcare management. undoubtedly, the most important measure in reding the likelihood of nosocomial infection is early isolation of patients with covid-19, or at least maintaining a safe distance between those who are awaiting diagnosis. however, a number of recent studies showed that patients with mild or nonspecific symptoms can escape isolation and thus introduce sars-cov-2 into hospitals, leading to clusters of nosocomial infections. 2 to minimize the risk of spreading, mass testing with nasopharyngeal and oropharyngeal (np/op) swab of all patients has been proposed, 2,3 associated with mass testing of both symptomatic and asymptomatic healthcare workers. 4 even the use of these expensive and demanding mass strategies, however, cannot be considered a measure of absolute guarantee. indeed, xie et al 5 observed typical covid-19 chest lesions via computed tomography (ct) scans in 5 patients with a negative or weakly positive swab test (rt-pcr test). another patient with a chest x-ray showing interstitial pneumonia but with a negative rt-pcr test was reported by winichakoon et al. 6 kumar et al 7 reported the case of a patient with pneumonia and negative nasopharingeal swab who tested positive some days later with a bronchial lavage sample. bandirali et al 8 found that asymptomatic or minimally symptomatic patients may have abnormalities in chest x-rays after 14 days of quarantine, with a sensitivity of rt-pcr testing of 59%. 8 cao et al 9 observed that patients with negative to rt-pcr tests may have specific igg and/or igm for sars-cov-2 at recovery stage. 9 in reality, the sensitivity of an np/op swab in the course of disease ranges between 42% and 71% 6 and depends on sampling technique, timing within the clinical course of covid-19, and viral loads detected in the swab. 6 in conclusion, given the fact that negative np/op swabs do not rule out covid-19 diagnosis, we propose that all the patients hospitalized with pneumonia be subjected to swab obtained by deep tracheal aspirate, which has a lower risk of aerosolization. 10 we further recommend that suspected infection be checked with a combination of repeated rt-qpcr tests and chest ct scan. all patients hospitalized without respiratory symptoms should also be checked with repeated rt-qpcr tests and chest x ray before admission in hospital wards. moreover, healthcare providers should be tested regularly with serological test and swabs and symptom monitoring. finally, a policy of universal masking and eye shielding for all healthcare providers involved in direct patient care is needed. infection prevention and control and preparedness for covid-19 in healthcare settings -third update. eu-cdc european centre for disease prevention and control coronavirus disease 2019 (covid-19): protecting hospitals from the invisible asymptomatic transmission, the achilles' heel of current strategies to control covid-19 covid-19: the case for health-care worker screening to prevent hospital transmission chest ct for typical 2019-ncov pneumonia: relationship to negative rt-pcr testing negative nasopharyngeal and oropharyngeal swab does not rule out covid-19 sars-cov-2 infection in a 76-year-old man with negative results for nasopharyngeal swabs and possible nosocomial transmission chest x-ray findings in asymptomatic and minimally symptomatic quarantined patients in one nosocomial cluster following with a familial cluster of covid-19 cases: the potential transmission risk in patients with negative swab tests surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-310026-j418v75n authors: miller, jemima h.; opat, stephen s.; shortt, jake; kotsanas, despina; dendle, claire; graham, maryza title: impact of coronavirus disease 2019 (covid-19) pandemic isolation measures on the rate of non–covid-19 infections in hematology patients date: 2020-10-20 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.1279 sha: doc_id: 310026 cord_uid: j418v75n nan (received 3 september 2020; accepted 4 october 2020) laws concerning social distancing and restrictions on public life have been implemented globally during the covid-19 pandemic. in turn, hospitals have changed their practice, from reduced visitation hours to stronger emphasis on hand hygiene. it would not be surprising, therefore, if transmission of non-covid-19 infections were to decrease during this time, and data have started to emerge to support reduced incidence. 1 in this study, we aimed to assess whether the incidence of non-covid-19 infections had changed in a population of hematology patients while they have been subject to changes in infection control practices during the covid-19 pandemic (appendix 1 online). the hematology patient cohort was selected for the study population because they are often more susceptible to infections (from underlying disease or treatment), which, in turn, can result in higher rates of morbidity and mortality. 2 the outcomes of this study will be used to inform continuation of isolation and infection control measures as the pandemic continues to evolve and afterward. monash health is a large, tertiary-care health network in southeastern australia with a 32-bed hematology inpatient service. hematology inpatients admitted between january 24 and may 23 (inclusive) for 2019 and 2020 were included in the study, a 4-month period from when the first patient with covid-19 in australia was admitted to monash health (january 24, 2020) and the equivalent dates the year prior to minimize effects of seasonal variation. typical presentations for hospital admission included febrile neutropenia and elective inpatient chemotherapy. all respiratory pathogen polymerase chain reaction (pcr), fecal pathogen pcr, and blood culture results from the cohorts were collated, and the proportion and breakdown of positive results were analyzed. multiplex pcr assays (ausdiagnostics, mascot, australia) included targets for pathogens (appendix 2 online). the rates of infection for each year were compared using the χ 2 test or the fisher exact as required. statistical significance was set at p < .05. statistical analyses were performed using stata version 12.1 software (statacorp lp, college station, tx). any organism identified more than once in an individual patient within 7 days was considered a duplicate result. regarding blood cultures, some organisms (listed in appendix 2 online) were defined as contaminants if they were isolated in a single culture, but they were defined as pathogens if they were isolated in >1 culture within 7 days in the same patient. overall, 1,598 patients were admitted in the 2019 date range and 1,488 were admitted in 2020. the difference in infection rates was statistically significant for respiratory pcr (20.27% vs 10.90%; p = .01) but not for fecal pcr (8.00% vs 6.76%; p = 1.00) or blood cultures (3.27% vs 3.41%; p = .88) ( table 1) . respiratory pcr virus swabs were procured in patients with respiratory infective symptoms and/or fever, and asymptomatic patients were not routinely tested. in 2019, 22 of the swabs were taken in the first 48 hours of presentation, and 24 were taken in 2020. the incidence of respiratory virus infection was lower in 2020 with 29 of 143 (20.27%) positive tests in 2019 compared to 29 of 266 (10.90%) in 2020 (p = .01). no cases of covid-19 were identified. the incidence of all respiratory viruses was lower in 2020 except for respiratory syncytial virus and rhinovirus/enterovirus (table 1) . there was no significant difference in the incidence of fecal pathogens, with 6 of 75 positive tests (8.00%) in 2019 compared to 5 of 74 (6.76%) in 2020 (p = .77). the rates of positive blood cultures were similar, with 27 of 826 positive isolates (3.27%) in 2019 compared with 28 of 822 (3.41%) in 2020, p = .88. gram-negative bacilli were isolated in 19 positive blood cultures in both years. excluding skin flora isolates, gram-positive organisms were isolated in 8 blood cultures in 2019 and 7 in 2020. the percentage of positive respiratory pcr results was significantly lower in 2020 than 2019, when the hospital implemented changes in infection control practices and visitor restrictions during the covid-19 pandemic (appendix 1 online). the notable increase in the rates of rhinovirus/enterovirus in 2020, however, may be due to reduced activity of alcohol-based hand sanitizers on nonenveloped viruses. 3 blood cultures and fecal pcr results did not show statistically different rates of infection; these were mostly commensals or infections less affected by droplet precaution measures implemented during the pandemic. although similar numbers of blood cultures and fecal pcr samples were taken each year, we attribute the increased number of respiratory pcr samples taken in 2020 to heightened awareness for testing during the pandemic. greater than 75% of all positive respiratory pcr samples were taken within 48 hours of admission, and although the results are unlikely to solely reflect community exposure (ie, our hematology patients frequently attend day treatment centers and other hospital services), a limitation is the difficulty in accounting for the expected reduction of circulating non-covid-19 respiratory viruses in the community due to government restrictions and public behavior. in hematology patients, viral infections are an important cause of morbidity and mortality. 4,5 therefore, increased awareness and utilization of infection control measures is vital for reducing rates of infection. although our study was retrospective, we found a reduced rate of viral respiratory infection when stricter measures were in place at our hospital. this is a useful indication of their effectiveness, and incorporation into general hematology infection control can be considered. further studies are warranted to assess the extent and duration of the impacts resulting from increased use of hand-sanitizer, limiting ward visitation, and social distancing on reducing infections within the hematology patient population. .88 gram-positive bacteria a 10 13 .52 staphylococcus aureus 0 3 staphylococcus spp (coagulase negative) 1 3 other gram-positive bacteria 2 3 gram-negative bacteria a 19 19 .99 escherichia coli 6 1 0 klebsiella spp 3 7 pseudomonas aeruginosa 3 0 enterobacter cloacae complex 2 0 other gram-negative bacteria 5 2 note. pcr, polymerase chain reaction. a includes cultures in which >1 organism was isolated. unintended consequence: influenza plunges with public health response to covid-19 in singapore clinical characteristics, outcomes, and risk factors for mortality in patients with cancer and covid-19 in hubei, china: a multicenter, retrospective, cohort study efficacy of ethanol against viruses in hand disinfection respiratory syncytial virus infection in patients with hematological diseases: single-center study and review of the literature viral infections in patients with hematological malignancies acknowledgments.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. in cases of a repeat positive blood culture within 7 days with the same organism, the isolate was defined as pathogen. key: cord-291265-qmylxndp authors: moravvej, zahra; soltani-moghadam, reza; ahmadian yazdi, azam; shahraki, kianoush title: covid-19 pandemic: ophthalmic practice and precautions in a tertiary eye hospital in iran date: 2020-04-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.164 sha: doc_id: 291265 cord_uid: qmylxndp the coronavirus disease 2019 (covid-19) has currently caused a global health threat. ophthalmic care settings pose a risk of cross-infection. the preventive strategy regarding ophthalmic practice in response to the outbreak is discussed. this is the first report form a tertiary eye hospital in iran and second of its kind worldwide. to the editor-the novel coronavirus 2019 (sars-cov-2) outbreak has reached a critical state, and >200 countries worldwide have been affected. iran was among the first countries that encountered the virus at a nationwide threat level. 1 the pandemic has imposed numerous burdens on society and the healthcare system. medical specialties involve various examinations that may put patients and practitioners at risk of infection. ophthalmic instruments may act as medium for viral transmission and ophthalmic healthcare facilities pose a risk of cross infection. 2, 3 a recent review suggested that as coronaviruses are able to develop a wide range of ocular manifestations; thus, ophthalmologists should be cautious to prevent possible transmission through ocular tissue. 4 cases of conjunctivitis have been reported in covid-19 patients. 5, 6 in one report, 2 patients tested positive for sars-cov-2 using reverse-transcription polymerase chain reaction (rrt-pcr) assay of conjunctival secretions. 5 moreover, the nasolacrimal duct may act as a pathway to transfer the virus from the eye to the nasopharynx. 7 here, we address the prevention strategies employed against covid-19 according to assessments of infection control experts and ophthalmologists, in amiralmomenin hospital a tertiary referral eye hospital in guilan, iran. to the best of our knowledge, this is the second report to describe the actions employed in an ophthalmology hospital setting. 8 at our institution preventive measures were applied in 3 main aspects outlined below. the appointments of patients needing ophthalmic examinations (including those who had undergone corneal graft, cataract and vitreoretinal surgeries) were rearranged and other nonurgent appointments were deferred. patients with a medical history of immune-suppression were appointed to be examined on a specific day. all elective ophthalmic surgeries and procedures were postponed, and patients were notified in advance; however, urgent ocular operations continued as normal. the daily number of patient referrals to the ophthalmic emergency unit decreased at an average of 58% compared to the previous month's daily average. this decrease was due to the hospital's relational unit advising local residents to seek ophthalmic care only when essential. patients referring to the emergency unit were screened at the point of entry. the ophthalmic complaint was evaluated at triage by an eye-care nurse, and nonemergent conditions were requested to return for examination after the outbreak resolved. if the patient was physically capable, the companion would be asked to wait outside. all patients were asked about any related symptoms and underwent temperature screening. according to who definitions, 9 suspected covid-19 cases would be isolated and transferred to a covid-19 referral center for further evaluation. a safe distance (1.5 m) was assured between patients who were required to sit in the waiting room. effort was made to maintain minimum waiting and consultation time. to avoid redundant visits to the hospital, patients who were managed in an outpatient setting were contacted via phone by eye-care professionals at appropriate intervals. those who needed inpatient care (eg, open globe injuries, orbital cellulitis) were hospitalized, and separate single rooms were assigned in the ward. hospitalized patients were checked for symptoms of covid-19 and fever on a regular daily basis. environmental surfaces frequently touched by staff and patients, such as light switches, door knobs, and nursing stations were cleaned according to centers for disease control and prevention (cdc) recommendations. 10 the examination and waiting room floor were cleaned on a 4-hour routine with suitable disinfectants (eg, sodium hypochlorite, 70% ethanol, or an alternative disinfectant). after each patient left the room, the equipment used, including the chin and head rests of the slit-lamp, direct and indirect ophthalmoscope, were cleaned with equipment detergent. instruments that came into contact with the patient, such as contact lenses and ultrasound probes were cleaned according to the manufacturer's instructions. the goldmann applanation tonometer's head piece was cleaned with 70% ethanol or hydrogen peroxide 3% before and after use. the aforementioned instruments were rinsed under running water to remove disinfectants and to prevent damage to the cornea. healthcare personnel were asked to refrain from leaving the province. personnel were also monitored for any signs of sars-cov-2 infection at the beginning of every shift. healthcare providers with suspicious symptoms stopped working and were given a 14-day leave of absence. they were isolated and they sought medical treatment according to their condition. the personal protective equipment for the eye-care nursing staff, ophthalmology residents, and attending eye surgeons included latex gloves, eye protection (goggles or face shields), a surgical-style face mask, a long-sleeved fluid-resistant gown, and disposable shoe covers. prepacked sets including the aforementioned equipment were prepared for each individual and were delivered at the beginning of every shift. as advised by the european society for cataract and refractive surgery (escrs), protective shields were installed on slit-lamps. the ophthalmologists used single-use cotton-swab applicators during examination to avoid touching the patient's face and eyelid. hand washing was mandatory between each patient. gloves were disposed after contact with the patient and hand washing with an alcohol-based antiseptic was performed subsequently. in the midst of this crisis, hospitals continue to face shortages of personal protective equipment. we designated special safety measures including appropriate hand washing technique between each patient; other practices, such as the extended use of face masks, were also instructed. transparency films were cut out to make face shields and plastic bags were used as shoe covers. the number of staff was also limited. these management strategies helped overcome the shortage and limit the spread of the virus. the experience and preventive strategies mentioned should be of help in similar ophthalmic or subspecialty healthcare facilities. ophthalmologists and local infection control teams should consider the regional viral extent when applying preventive measures. hopefully, appropriate precautions will shorten the pandemic period and benefit the whole world. coronavirus covid-19 global cases by the american academy of ophthalmology website 2019-ncov transmission through the ocular surface must not be ignored can the coronavirus disease 2019 (covid-19) affect the eyes? a review of coronaviruses and ocular implications in humans and animals evaluation of coronavirus in tears and conjunctival secretions of patients with sars-cov-2 infection the infection evidence of sars-cov-2 in ocular surface: a single-center cross-sectional study the possibility of covid-19 transmission from eye to nose stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from hong kong global surveillance for covid-19 caused by human infection with covid-19 virus: interim guidance. world health organization website interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-354749-zkgb16ae authors: chen, gang; zhou, yangzhong; zhang, lei; wang, ying; hu, rong-rong; zhao, xue; song, dan; xia, jing-hua; qin, yan; chen, li-meng; li, xue-mei title: core principles for infection prevention in hemodialysis centers during the covid-19 pandemic date: 2020-04-06 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.109 sha: doc_id: 354749 cord_uid: zkgb16ae nan to the editor-the covid-19 outbreak began at the end of december 2019, and >600,000 confirmed cases had been reported worldwide by the end of march 2020. the world health organization declared a global pandemic. 1 nosocomial transmission was severe in some locations, and the burden to the health system was extreme. 2 hemodialysis centers, which generally serve high volumes of highly mobile dialysis patients, have an exceptionally high risk of exposure during this outbreak period. in a general tertiary-care hospital, dialysis centers routinely accept patients from outpatient clinics and emergency rooms, further adding to the difficulty of preventing nosocomial infection. 3 dialysis patients, commonly regarded as immune compromised, are likely to develop severe illness as a result of close contact in a medical unit. droplet spread and close contact are the main routes of covid-19 transmission. 4 thus, the hemodialysis center in our hospital implemented multiple strategies for infection prevention, including area management and integrated symptom monitoring, in the context of this pandemic. based on various levels of exposure to the mobile population, our hospital environments were classified as low-risk, mediumrisk, high-risk, and extremely high-risk, and the dialysis center belongs to the high-risk category. we avoid moving across the area by designing a specific walking route for our patients entering the hemodialysis center. medical staff wears personal protective equipment (ppe) when inter-area contact is inevitable. for example, n95 masks and protective glasses are required when entering the fever clinic. we advise the use of hand sanitizer whenever staff return to the hemodialysis center. in the dialysis center, a 1-way route is followed by our patients, and mask-wearing and hand sanitizing by the patients are ensured. during the dialysis session, we provide necessary education on maintaining social distancing and self-protection. between the 2 dialysis shifts, we strictly leave at least 30 minutes for environmental and air disinfection, and we utilize a chlorine-containing disinfectant to clean our dialysis facilities. [6] [7] [8] we monitor and respond to our regular patients' symptoms in an integrated way. between the dialysis sessions, we strictly record the body temperatures and any suspicious respiratory symptoms of our patients. for patients referred from other departments in the hospital, we collect records of their contact history, temperature, and potential warning symptoms before admission. based on this information, all of our patients are classified into 3 categories (table 1) . a negative sars-cov-2 swab test is needed for patients in category c before their dialysis session can be scheduled. in emergency cases, we perform continuous renal replacement therapy (crrt) in a separate place, preferably in a negative-pressure ward, before completely ruling out covid-19 for these patients. 5, 6 notably, patients with a positive swab test are sent to designated hospitals for further treatment. medical staff are strictly required to maintain hand hygiene and to wear a mask at work. n95 masks and protective goggles are used when operating crrt for patients in category c. the equipment used is disinfected between patients, and medical waste is packed and labeled separately to avoid potential contamination. 7 the waste liquid generated during crrt is discharged according to the requirements of the medical wastewater discharge standards. 8 in addition to the strategies summarized above, we promote work-life balance for staff and encourage patients to take the initiative to participate. our hemodialysis center has strived to achieve zero infection during the ongoing covid-19 outbreak. covid-19: who declares pandemic because of "alarming levels" of spread, severity, and inaction clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china infection control in hemodialysis units: a quick access to essential elements novel coronavirus pneumonia diagnosis and treatment plan (provisional 7th edition) national health commission of the people's republic of china expert advice in hemodialysis room (center) to prevent and control the outbreak of novel coronavirus pneumonia expert team of chinese medical association nephrology branch. recommendations for prevention and control of novel coronavirus infection in blood purification center (room) from the chinese medical association nephrology branch (trial version 1) national environmental protection administration & national administration of quality supervision, inspection and quarantine. standards for the discharge of waters in medical institutions acknowledgments. the work is made possible through an isn sister renal key: cord-324204-y8eckkyb authors: stevens, michael p.; patel, payal k.; nori, priya title: involving antimicrobial stewardship programs in covid-19 response efforts: all hands on deck date: 2020-03-13 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.69 sha: doc_id: 324204 cord_uid: y8eckkyb nan to the editor-to our knowledge, no formal recommendations exist for the inclusion of antimicrobial stewardship programs (asps) in disaster planning or emergency response preparedness efforts. 1 a pubmed search utilizing the search terms "antimicrobial stewardship" and "disaster planning" was performed on march 4, 2020, and yielded no results. asps are now ubiquitous. they often include pharmacists and physicians with advanced infectious diseases training, and they are a valuable part of hospital safety and quality programs. in some hospitals, compartmentalization of stewardship and epidemiology functions have developed over time to meet distinct institutional needs. however, domains should coalesce for purposes of emergency preparedness. the current sars-cov-2/covid-19 outbreak highlights numerous opportunities where asps can support emerging pathogen response and planning efforts. an informal twitter poll was initiated on march 1, 2020, asking the infectious diseases and antimicrobial stewardship communities whether asps at their health systems had been involved in sars-cov-2/covid-19 outbreak response or preparation. this yielded 254 responses: 30% noted direct involvement, 28% indicated indirect involvement, and 39% indicated no involvement in emergency response efforts or planning. although formalized study is needed, real-time insights from the community provided valuable information. we identified multiple potential areas where asps can support emergency response efforts, and these are summarized in figure 1 . asps that are integrated with hospital infection prevention programs have an advantage in response efforts to emerging pathogens in that (1) they are likely to have pre-existing infection prevention skills and experience, (2) they are likely to be involved in response efforts early, and (3) they will have access to and influence with key stakeholders. because asps and infection prevention programs share similar technology infrastructure, data, and metrics, program integration has many advantages. 2 response efforts to novel respiratory viruses like sars-cov-2/covid-19 represent an opportunity for programs to formally integrate, to develop crosscoverage capabilities, and to create shared leadership opportunities. asps can support sars-cov-2/covid-19 response efforts in numerous ways within the context of their normal daily activities. a core component of antimicrobial stewardship includes postprescriptive review with feedback to providers. 3 in this way, an asp skill set can theoretically assist with early identification of potential cases. this approach may be especially useful in situations in which the definition of a person under investigation is fluid because traditional epidemiologic efforts usually focus on identifying patients at the point of entry into health systems. asps often coordinate with microbiology laboratories for real-time interpretation and action involving upper respiratory pcr test results. they can support sars-cov-2/covid-19 evaluation efforts in this fashion as well. novel respiratory virus outbreaks associated with secondary bacterial pneumonias and acute respiratory distress syndrome (ards) provide an opportunity for asps to monitor compliance with guideline-concordant therapy; severe covid-19 cases have been treated with broadspectrum antibiotics. 4 additionally, asps can help in the development of local treatment protocols involving repurposed antivirals; they can monitor and manage drug shortages due to supply chain interruptions 5 ; and they can assist frontline providers with expanded access investigational new drug applications (einds) and local institutional review board procedures for investigational agents. asps are now mandated in the united states and are often multidisciplinary. the joint commission accreditation standard for asps includes, when available, an infectious diseases physician, pharmacist, infection preventionist, and other practitioners. 6 asp physician and pharmacy leaders often have specialized infectious diseases training. 3 leveraging these resources for planning and response efforts for emerging pathogens is critical and can strengthen and sustain collaborative relationships. we recommend that hospital epidemiology programs strongly consider integrating their asp colleagues into disaster preparedness plans as well as identify a more formal role for stewards in their operations beyond the current covid-19 outbreak. outbreak response and incident management: shea guidance and resources for healthcare epidemiologists in united states acute-care hospitals the role of the hospital epidemiologist in antibiotic stewardship essential resources and strategies for antibiotic stewardship programs in the acute care setting epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore covid-19) supply chain update. us food and drug administration website approved: new antimicrobial stewardship standard. the joint commission website acknowledgments.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-292736-698j35gp authors: keating, julie a.; mckinley, linda; safdar, nasia title: coronavirus disease 2019 (covid-19) and antibiotic stewardship: using a systems engineering approach to maintain patient safety date: 2020-10-12 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.1263 sha: doc_id: 292736 cord_uid: 698j35gp antibiotic stewardship (as) practices are critical during the covid-19 pandemic due to risks of antibiotic overuse on patient safety, including clostridioides difficile infection (cdi). a systems engineering approach can help teams evaluate and modify work system elements to support as and prevent cdi as part of their facility's covid-19 response. to the editor-in the absence of effective treatments for coronavirus disease 2019 (covid-19), many hospitalized covid-19 patients receive antibiotics. 1, 2 thus far, the literature does not indicate that antibiotics are effective in treating covid-19, and the incidence of bacterial coinfections appears low. 2 one analysis reported that while 8% of covid-19 patients experienced a bacterial or fungal coinfection, 72% of covid-19 patients received antibiotics. 2 clostridioides difficile infection (cdi) is associated with broad-spectrum antibiotics frequently used for covid-19; cdi is thus a significant concern for covid-19 patients. 3 patients at higher risk of severe covid-19 frequently also have risk factors for cdi such as advanced age and weakened immune systems. 3 covid-19 treatments themselves, which often involve extended hospital stays, can also increase a patient's risk of developing healthcare-associated cdi. 3 cdi has been identified in patients who received antibiotics as part of their covid-19 treatment. 4, 5 given the patient safety risks posed by cdi, effective antibiotic stewardship remains critical throughout the covid-19 pandemic. however, pandemic-related changes to healthcare delivery (eg, drug shortages, changing pharmacy workflows, and redeployed healthcare workers) have made antibiotic stewardship interventions even more challenging. we present a systems engineering approach to evaluate and modify antibiotic stewardship programs within the constraints of covid-19 responses, with the overall goal of reducing cdi. a framework to support antibiotic stewardship antibiotic stewardship initiatives can involve persuasive (eg, education or audit with feedback) and restrictive (eg, formulary restriction) approaches; these initiatives are used together with appropriate diagnostic and infection prevention measures. these strategies require complex behavioral changes and can involve significant resources such as real-time access to antibiotic stewardship staff for consultation. the covid-19 pandemic response has further increased the complexity of antibiotic stewardship. 6 prescribers and antibiotic stewardship team members are facing higher and more complex patient loads. the wide-ranging symptoms of covid-19 may mimic other infections, and a worsening of symptoms is frequently seen 1-2 weeks into the disease that can make it difficult to identify potential coinfections. the length of hospitalization for many patients increases risks of developing healthcare-acquired infections such as ventilator-associated pneumonia that may require additional antibiotic treatment. 7 these factors, combined with a lack of effective treatment options for severe covid-19, have resulted in high levels of antibiotic use among covid-19 inpatients. 1, 2 the structure and effectiveness of an antibiotic stewardship program is dependent on the individual work-system context, including characteristics of the patient population, organizational culture toward antibiotic stewardship, availability of infectious disease and pharmacy personnel, accessibility of clinical decision support tools, and existing policies to support antibiotic stewardship. a systems engineering approach can be used (1) to fully evaluate the roles that work-system elements play in complex antibiotic stewardship interventions and (2) to develop modifications to these elements to support the implementation of interventions. the systems engineering initiative for patient safety (seips) provides a framework for this approach. seips defines work-system elements: person(s), technology and tools, environment, tasks, and organization. the interaction of these elements influences care processes and outcomes. 8 given the urgent needs to ensure appropriate antibiotic use and reduce cdi risk in covid-19 patients, a systems engineering approach such as seips can be used to understand the various work-system factors that are involved in antibiotic stewardship and cdi prevention. the interaction of these elements drives antibiotic stewardship, covid-19 treatment, and cdi prevention processes in each work system; thus, they influence critical patient and organizational outcomes. this seips-based approach provides flexibility for teams to evaluate their own work-system-specific barriers and facilitators to antibiotic stewardship practices within their covid-19 response. 9 teams can then develop strategies to support antibiotic stewardship within the individual work system to optimize patient and organizational outcomes. work system-based elements can be modified to support antibiotic stewardship throughout covid-19 response table 1 lists strategies based on seips work-system elements to support antibiotic stewardship and cdi prevention through covid-19 responses. the seips framework is person centered: the covid-19 patient, prescribers, and antibiotic stewardship team members interact with all work-system elements. people use technology and tools (eg, antibiotic prescription decision support tools built into electronic medical records) to enact tasks (eg, choosing appropriate therapies for the patient, including postponing or de-escalating antibiotics). the organization's antibiotic stewardship and infection control infrastructure should continue activities such as reporting antibiotic usage, resistance, and cdi rates. within the work-system environment, visual cues reminding prescribers of best practices for antibiotic prescribing in covid-19 patients may be useful given the high and complex patient loads. existing cdi prevention practices (eg, environmental cleaning and appropriate diagnostic testing) should remain a priority. research is needed to understand whether, when, and how antibiotics should be used to treat covid-19 patients while minimizing adverse effects such as cdi. cdi in covid-19 patients should be investigated to identify risk factors such as use of specific antibiotics, previous cdi, and/or presentation of covid-19 gastrointestinal symptoms. research findings should be incorporated into comprehensive evidence-based antibiotic stewardship programs. in the meantime, the urgency of preventing cdi in covid-19 patients requires adjusting antibiotic stewardship interventions to fit within current covid-19 protocols. the seips-based approach presented here can help local antibiotic stewardship teams and decision makers adjust existing plans and develop new approaches to support antibiotic stewardship and reduce cdi during the covid-19 pandemic. financial support. this material is based upon work supported by the veterans' health administration, quality enhancement research initiative (grant no. hx003040). conflicts of interest. the authors report no potential conflicts of interest related to this article. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study bacterial and fungal coinfection in individuals with coronavirus: a rapid review to support covid-19 antimicrobial prescribing covid-19 and clostridioides difficile infection (cdi): possible implications for elderly patients clostridioides difficile in covid-19 patients severe clostridium difficile colitis as potential late complication associated with covid-19 covid-19: don't neglect antimicrobial stewardship principles! the challenge of ventilatorassociated pneumonia diagnosis in covid-19 patients seips 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients tackling antimicrobial resistance in the covid-19 pandemic involving antimicrobial stewardship programs in covid-19 response efforts: all hands on deck acknowledgments. the views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the department of veterans' affairs or the united states government. key: cord-332207-dmxbk7ad authors: sastry, sangeeta r.; pryor, rachel; raybould, jillian e.; reznicek, julie; cooper, kaila; patrick, amie; knowlson, shelley; bailey, pamela; godbout, emily; doll, michelle; stevens, michael p.; bearman, gonzalo title: universal screening for the sars-cov-2 virus on hospital admission in an area with low covid-19 prevalence date: 2020-07-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.358 sha: doc_id: 332207 cord_uid: dmxbk7ad nan (received 25 may 2020; accepted 18 july 2020) asymptomatic persons contribute to widespread transmission of the severe acute respiratory coronavirus virus 2 (sars-cov-2) and the coronavirus disease 2019 (covid-19) pandemic. 1 published reports from areas of high covid-19 incidence in the united states suggest that a significant percentage of asymptomatic persons are in healthcare systems. in 2 new york city (nyc) hospitals, 13.7% of asymptomatic pregnant women admitted for delivery tested positive for sars-cov-2 virus. 2 similarly, the nursing facility in washington state with the earliest death from covid-19 infection and the first healthcare worker infected in the united states, reported >50% positivity of their asymptomatic residents for the virus. 3 universal screening of healthcare populations may prevent in-hospital transmission of sars-cov-2 virus. however, testing resources and personal protective equipment (ppe) supplies to effectively isolate positive asymptomatic persons are currently limited, resulting in provider safety concerns. upon developing real-time reverse-transcriptase polymerase chain reaction (rrt-pcr) tests in-house with >98% sensitivity, as well as increasing the availability of ppe at our institution, we initiated universal screening of patients on hospital admission using nasopharyngeal swabs to identify and isolate asymptomatic positive patients to prevent in-hospital transmission of sars-cov-2. we report our experience with universal screening of asymptomatic hospitalized persons, including a comparison of demographics between symptomatic and asymptomatic populations. on april 27, 2020, our 1,000-bed academic center instituted universal sars-cov-2 testing of patients on hospital admission. clinicians performed covid-19 symptom screening using clinical criteria reported in the literature. 4 they designated patients as symptomatic or asymptomatic when ordering the test. an infectious diseases physician conducted chart review of asymptomatic positive patients to confirm accuracy of classification. asymptomatic patients were not isolated; test turnaround time was 6-24 hours. statistical analyses were performed with the fischer exact tests and paired t tests to compare asymptomatic and symptomatic positive patients using sas version 9.4 software (sas institute, cary, nc). between april 27, 2020, and may 18, 2020, when the hospital averaged at 60%-70% capacity, we performed 1,811 sars-cov-2 tests on nasopharyngeal specimens: 1,335 (74%) were asymptomatic, 420 (23%) were symptomatic, 56 (3%) were incorrectly ordered. of the 1,755 tests in this analysis, overall positivity for sar-cov-2 virus was 79 (4.5%). of 79 patients, 12 were asymptomatic (15%) and 67 were symptomatic (85%). of 1,335 asymptomatic patients, 12 tested positive, for a rate of~1%. of 420 symptomatic patients, 67 tested positive, for a rate of 16%. no test converted to positive among asymptomatic patients while hospitalized. a comparative analysis of patients with positive sars-cov2 tests is listed in table 1 . the mean age of asymptomatic patients was 37 years (sd, 19.71) versus a mean age of 59 years (sd, 13.08) among symptomatic patients (p = .0020). hispanic patients were more likely to be asymptomatic (7 of 12) than symptomatic (9 of 67) at the time of testing (58% vs 13%; p = .0017). we observed no difference in positivity rate on admission of asymptomatic versus symptomatic patients (p = .21). in addition, 5 asymptomatic positive women were pregnant (5 of 12, 42%); no symptomatic patients were pregnant (p ≤ .0001). a baby born to an asymptomatic sars-cov-2-positive mother tested positive at 48 hours of life, and 1 asymptomatic, sars-cov-2-positive, immunocompromised patient was receiving chemotherapy for breast cancer. one asymptomatic patient developed a fever during hospitalization, and another was readmitted within 14 days of testing positive, both of these events were not considered to be related to covid-19. universal screening for the detection of sars-cov-2 at our institution revealed that during the study period, the number of asymptomatic persons admitted to the hospital was relatively small. our health system had a relatively low number of confirmed sars-cov-2-positive covid-19 patients (n = 82) admitted during the observed 3-week interval, compared to 4,000 patients admitted to an nyc hospital reporting the use of convalescent serum for the treatment of covid-19 in a similar time frame. 5 although low prevalence of asymptomatic patients has limited generalizability to areas with higher rates of infection, it is valuable information for patients, healthcare workers, and epidemiology programs in similar areas of covid-19 prevalence. during our study period, 7.6% of all admitted patients were hispanic and 43.5% were african american, yet 11 of 12 (91.7%) asymptomatic patients who screened positive were african american or hispanic. a similar trend was observed in other studies. 6,7 furthermore, a higher proportion of pregnant women have asymptomatic infection, which supports screening of peripartum women. consistent with the literature, asymptomatic patients were younger than those who presented to our healthcare system with covid-19 symptoms. 8 the potential benefits of universal sars-cov-2 screening are many and are likely to increase with escalating covid-19 incidence. in hospitalized patients, detection of asymptomatic infection can guide hospital isolation practices, bed assignments, and the use of ppe. 2 for healthcare workers, it might improve workforce depletion by unnecessary quarantine, reduce transmission in asymptomatic cases, contain the virus in healthcare settings, and protect hospital staff from infection. in the community, mass testing can identify asymptomatic cases and assist in eliminating the sars-cov-2 virus, as reported in a village near venice, italy. 9 however, there are barriers to universal screening. current testing capacity and test turnaround time, staffing shortages, and availability of healthcare workers skilled to perform nasopharyngeal swabbing currently limit widespread feasibility. patient discomfort from nasopharyngeal sample collection is another potential barrier to universal screening. this study has several limitations. the sample size was small, and the study was conducted at a single center. in an area with high prevalence of covid-19 infection, asymptomatic screening would likely identify more asymptomatic cases. however, sensitivity of a test in asymptomatic persons cannot be precisely defined. we add to the body of literature on sars-cov-2 testing of asymptomatic patients at the time of hospital admission. more data on universal screening is necessary to evaluate the clinical impact on healthcare systems and to define optimal screening strategies of high-risk groups for asymptomatic covid-19 infection. note. sd, standard deviation. asymptomatic transmission, the achilles' heel of current strategies to control covid-19 universal screening for sars-cov-2 in women admitted for delivery presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility epidemiologic and clinical predictors of covid-19 convalescent plasma treatment of severe covid-19: a matched controlled study hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019-covid-net, 14 states evidence mounts on the disproportionate effect of covid-19 on ethnic minorities characteristics of asymptomatic patients with sars-cov-2 infection in jinan covid-19: identifying and isolating asymptomatic people helped eliminate virus in italian village acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-321933-cq0fa3hs authors: koff, alan g.; laurent-rolle, maudry; hsu, jack chun-chieh; malinis, maricar title: prolonged incubation of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in a patient on rituximab therapy date: 2020-10-07 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.1239 sha: doc_id: 321933 cord_uid: cq0fa3hs the incubation period of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is rarely >14 days. we report a patient with hypogammaglobulinemia who developed coronavirus disease 2019 (covid-19) with a confirmed incubation period of at least 21 days. these findings raise concern for a prolonged presymptomatic transmission phase, necessitating a longer quarantine duration in this patient population. severe acute respiratory syndrome coronavirus 2 (sars-cov-2) was discovered in wuhan, china, and has since become a global pandemic through person-to-person spread. sars-cov-2 exhibits presymptomatic transmission during the incubation period, where an individual is contagious prior to symptom onset. 1 defining the incubation period, therefore, has infection control and public health implications because a longer incubation necessitates a longer quarantine duration after an exposure. mean incubation periods range from 5.0 to 7.2 days, and a median incubation period of 5.1 days has been reported. [2] [3] [4] [5] [6] in 2 studies, the 95th percentiles of the distribution were reported as 12.5 days and 13 days, and another 3 studies reported the 99th percentile as 11.9 days, 14 days, and 14.9 days, respectively. [2] [3] [4] 6, 7 in the vast majority of cases, the incubation period is far less than 14 days, which has helped to inform the centers for disease control and prevention (cdc) recommendations for a 14-day quarantine period after a known coronavirus disease 2019 (covid-19) exposure. 8 however, these cases represent the general population and do not provide detailed information on subpopulations in whom the incubation period may differ. herein, we present a case with objectively confirmed covid-19 with a prolonged incubation period proven through viral culture. a 71-year-old female on rituximab for granulomatosis with polyangiitis presented with shortness of breath and nonproductive cough. six weeks prior to admission, several family members had been diagnosed with covid-19 infection, prompting her to undergo testing despite being asymptomatic. her nasopharyngeal (np) swab polymerase chain reaction (pcr) test for sars-cov-2 was positive. she was self-isolating, and her only contact was a family member who had recovered from mild covid-19 illness and had since been asymptomatic. repeat np pcr testing 13 days later was also positive. on day 21 after the first test, the patient developed progressive dyspnea on exertion, a minimally productive cough, significant fatigue, and nonbloody diarrhea. she was admitted to hospital on day 36 after her first test. she was febrile to 38.8°c and her oxygen saturation was 93% on room air. she was placed on 2 l/minute of supplemental oxygen. computed tomography (ct) of the chest demonstrated bilateral peribronchovascular ground-glass opacities ( supplementary fig. 1 online) . relative to the day of her first test, she had repeat sars-cov-2 np pcr tests on days 36, 37, and 40, which were negative. serology for sars-cov-2 was negative. flow cytometry of peripheral blood demonstrated no circulating b-cells, and an immunoglobulin panel demonstrated low levels of igm, igg, and iga consistent with a history of receiving rituximab. bronchoalveolar lavage (bal) on hospital day 5 revealed a positive sars-cov-2 pcr with n1 and n2 cycle thresholds of 29 and 28, respectively. the patient was weaned off supplemental oxygen and was discharged on hospital day 9. the patient's bal fluid was stored at −80°c then thawed and inoculated into vero e6 cell culture. viral supernatant was harvested on day 4 after inoculation for plaque assay demonstrating infectious virus with a titer of 1.3 × 10 3 pfu/ml on passage 1 ( fig. 1a and 1b) . nucleic acid extraction from the cell lysate confirmed the presence of sars-cov-2 by reverse-transcription realtime pcr and by polyacrylamide gel (fig. 1c) . isolate from the first passage of the bal specimen was used to infect vero e6 cells for 48 hours. cell lysates were probed for protein analysis using an antibody raised against sars-cov 3a antibody which demonstrated bands consistent with sars-cov-2 3a protein (fig. 1d) . these studies indicate that infectious sars-cov-2 virus was isolated from the patient's bal. this case demonstrates an objectively confirmed asymptomatic sars-cov-2 infection with symptom onset 21 days after her positive test. furthermore, since an np pcr can be falsely negative on the first day of infection, her incubation period may have been even greater. 9 lower respiratory tract sampling demonstrated viable sars-cov-2 virus, though the np pcr was negative. a prior study demonstrated that np pcr had a false negative rate of 66% by day 21, which may explain our observation. 9 reports of incubation periods >21 days are very rare. a patient with an incubation period of 24 days was reported; however, the incubation period was defined as the time between the earliest potential date of exposure to the first day of symptom onset, potentially leading to overestimation. 6 a case report described a patient with an incubation period of at least 38 days based on a social history of limited contact with others after an exposure. 10 whether our patient's absence of circulating b cells with subsequent hypogammaglobulinemia predisposed her to a prolonged incubation period is not known. her negative serology suggests a poor humoral response to infection. this report has significant implications for preventing the spread of sars-cov-2. for patients with known humoral immune deficits, until further data are available, one should exercise caution using a 14-day quarantine window based on the assumption of 14 days being the upper bound of the incubation period. it remains possible that this patient was shedding viable virus from the date of her initial positive test to beyond the date of her bronchoscopy 41 days later. this patient's presymptomatic transmission window may have therefore been substantially greater than the estimated mean presymptomatic transmission window of 2.3 days in the general population. 1 whether prolonged incubation periods may occur in other immunosuppressing conditions remains to be evaluated, and further data in this area are needed to better define the appropriate quarantine period in this population. temporal dynamics in viral shedding and transmissibility of covid-19 early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application incubation period of 2019 novel coronavirus (2019-ncov) infections among travellers from wuhan, china the difference in the incubation period of 2019 novel coronavirus (sars-cov-2) infection between travelers to hubei and nontravelers: the need for a longer quarantine period epidemiological characteristics and incubation period of 7,015 confirmed cases with coronavirus disease 2019 outside hubei province in china incubation period and other epidemiological characteristics of 2019 novel coronavirus infections with right truncation: a statistical analysis of publicly available case data covid-19) quarantine and isolation variation in false-negative rate of reverse transcriptase polymerase chain reaction-based sars-cov-2 tests by time since exposure a case of covid-19 with ultra-long incubation period acknowledgments. the antibody generated against sars-cov 3a protein was a kind gift from carolyn machamer, department of cell biology, johns hopkins university school of medicine. key: cord-323596-dh7oh54z authors: advani, sonali d.; baker, esther; cromer, andrea; wood, brittain; crawford, kathryn l.; crane, linda; adcock, linda; roach, linda; padgette, polly; anderson, deverick j.; sexton, daniel j. title: assessing severe acute respiratory coronavirus virus 2 (sars-cov-2) preparedness in us community hospitals: a forgotten entity date: 2020-10-07 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.1238 sha: doc_id: 323596 cord_uid: dh7oh54z we performed a cross-sectional survey of infection preventionists in 60 us community hospitals between april 22 and may 8, 2020. several differences in hospital preparedness for sars-cov-2 emerged with respect to personal protective equipment conservation strategies, protocols related to testing, universal masking, and restarting elective procedures. novel coronavirus (sars-cov-2) has been associated with the largest recorded coronavirus outbreak to date. in the united states, there have been >2.2 million cases with >119,000 deaths (as of june 21, 2020). 1 this pandemic has placed a tremendous strain on the us healthcare system leading to personal protective equipment (ppe) and resource shortages. 2 most hospitals have implemented contingency and crisis capacity strategies to optimize the use of resources. 3 although public health agencies like the centers for disease control and prevention (cdc) have provided interim guidance on infection prevention and control in us hospitals, 4 the current state of community hospital preparedness is unknown. assessing preparedness of community hospitals is crucial to risk assessments and outbreak control activities in these settings. hence, we conducted a cross-sectional survey of sars-cov-2 preparedness among community hospitals in southeastern united states. we performed a cross-sectional survey of 60 community hospitals within the duke infection control outreach network (dicon). dicon provides infection control services to 60 community hospitals and surgery centers in 6 states (north carolina, south carolina, virginia, florida, georgia, and west virginia). 5 these hospitals range in size from 30 to 685 beds, with a median size of 162 beds. also, 77% of these hospitals have maternity and pediatric wards. this study was deemed exempt from institutional review board review by the duke university health system (no. pro00105818). the survey (provided in the supplementary data online) was conducted between april 22 and may 5, 2020, using qualtrics (qualtrics, provo, ut); it was distributed electronically to infection preventionists at community hospitals. participation was voluntary, anonymous, and without compensation. the survey included 13 questions related to ppe availability, crisis capacity strategies to extend and reuse ppe, policies related to restarting surgeries, testing prior to elective surgery and prior to transfer to extended care facilities, universal masking, and daily screening of hospital staff. extended use was defined as using the same single-use ppe for encounters with multiple patients without removing it between encounters. reuse was defined as using the same ppe for multiple encounters but doffing it after each encounter and donning it prior to the next encounter. survey responses were analyzed using descriptive statistics. of 60 hospitals, 50 (83%) responded to our survey. these hospitals reported varying degrees of ppe shortages (fig. 1) . overall, 20 hospitals (40%) reported "no supply" or "few days supply" of powered air-purifying respirators (paprs), environmental disinfectant, and gowns. almost 30% of facilities reported an insufficient supply of face masks and n95 respirators, and 16% reported an insufficient supply of face shields. more than 80% of community hospitals were implementing strategies to reuse n95 respirators, face shields, and goggles. only 6 hospitals (12%) were reusing gowns at the time of this survey. similarly, at least 80% of hospitals were extending the use of n95 respirators, face shields, and surgical masks (table 1) . furthermore, 36 community hospitals (72%) reported reprocessing n95 respirators, mostly using hydrogen peroxide plasma (29.8%), ultraviolet radiation (21%), and/or hydrogen peroxide vapor (12%). most community hospitals had implemented universal masking policies: 38 (76%) required masking of patients, visitors and healthcare personnel (hcps), 7 (14%) required masking of hcps and visitors; and 4 (8%) required universal masking of hcps only. also, 90% of hospitals were performing daily employee screening at point of entry. additionally, 7 (14%) hospitals had restarted tier 1 elective surgical procedures at the time of this survey; 16 (32%) restarted tier 2 nonurgent surgical procedures; and 43 (86%) were performing only tier 3 emergent surgical procedures. only 43 facilities (86%) reported performing preoperative testing for sars-cov-2. moreover, 17 facilities (34%) performed 1 sars-cov-2 pcr test before discharging an asymptomatic patient to skilled nursing facilities, and 20 facilities (40%) performed 2 tests prior to discharge to these facilities. the community hospitals in our network reported a wide variety of laboratories used for sars-cov-2 testing, with most using in-house testing (n = 34, 68%), followed by testing by labcorp (n = 21, 42%), quest diagnostics (n = 13, 42%), department of health (n = 13, 26%), and others. only 4% of hospitals performed antibody testing for sars-cov-2 at the time of this survey. the results of this survey reveal gaps and differences in sars-cov-2 preparedness among community hospitals in the southeastern united states. a recent survey of hospitals in the society for healthcare epidemiology of america research network highlighted similar shortages in academic hospitals and large medical centers, 6 but our survey is the first report, to our knowledge, focusing on the state of smaller community hospitals during the covid-19 pandemic. almost half of the community hospitals reported shortages in their supplies of paprs, environmental disinfectants, and gowns. in addition, 80% of hospitals reported an adequate supply of n95 respirators, face shields, and googles, likely due to use of crisis capacity strategies to extend, reuse, and reprocess these ppe. our report is different from a recently reported survey of hospitals in idaho that reported shortages of face shields. 7 our survey highlights that face shields are less prone to shortages due to their simpler design, reuse potential, and durability. 8 more than half of the community hospitals in our network had employed strategies to extend the use of face masks, n95 respirators, gowns, face shields, and googles. currently, to our knowledge, no data are available on the safety of extended use ppe or time limits for safely extending the use. similarly, most hospitals were employing strategies to reuse n95 respirators, paprs, face shields, goggles, and masks. although some data exist on the safety of reprocessed n95 respirators, safety data on reuse of other single use ppe are scarce. 9 shortages of disinfectants and sanitizers may lead to the introduction of new agents with a potential decrease in cleaning efficiency, variation in equipment compatibility, an increase in staff dissatisfaction, and occupational safety hazards. 9 our survey also demonstrates that most of our community hospitals had implemented policies related to employee screening at the point of hospital entry. although most hospitals had developed policies related to universal masking, the content of these policies varied widely. there was significant variation in policies related to testing for active infection with sars-cov-2 infection, with respect to the laboratory used, testing before surgical procedures, and testing prior to discharge to skilled nursing facilities. our study has several limitations. it was a cross-sectional study and relied on self-reported data from infection preventionists. we did not include other healthcare facilities such as nursing homes. however, this survey provided valuable information on differences in outbreak readiness among community hospitals that may help identify factors influencing preparedness. we found several differences in community hospital preparedness for sars-cov-2 with respect to type of conservation strategies used to preserve ppe, protocols related to testing, masking, and restarting elective procedures. we believe that this lack of standardization in approaches was due to differences in state guidelines, the decentralized federal approach to sars-cov-2 preparedness, and a lack of confidence in public health guidelines. these differences also highlight the challenges with implementing guidelines related to sars-cov-2 in community hospitals because of ppe and personnel shortages, financial constraints, and uncertainty regarding how and when to implement policies such as universal masking, preoperative testing, and predischarge testing. this study also offers a starting point for future assessments of pandemic preparedness among community hospitals in the united states. ? cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2f2019-ncov%2fcases-in-us.html. published conserving supply of personal protective equipment-a call for ideas challenges and solutions for addressing critical shortage of supply chain for personal and protective equipment (ppe) arising from coronavirus disease (covid19) pandemic-case study from the republic of ireland interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings duke infection control outreach network website policies and practices of shea research network hospitals during the covid-19 pandemic a survey of covid-19 preparedness among hospitals in idaho universal masking in hospitals in the covid-19 era: is it time to consider shielding? hand sanitisers amid covid-19: a critical review of alcohol-based products on the market and formulation approaches to respond to increasing demand acknowledgments. we thank the community hospitals in our network for participating in this survey.financial support. this work was funded by the centers for disease control and prevention (grant no. 6u54ck000483).conflicts of interest. dr advani reports grants from the cdc. dr anderson reports grants from the ahrq, the cdc, and the niaid, as well as personal fees from uptodate, outside the submitted work. all other authors report no conflicts of interest or disclosures relevant to this article. key: cord-252714-idlyl4ga authors: islam, m. saiful; rahman, kazi m.; sun, yanni; qureshi, mohammed o.; abdi, ikram; chughtai, abrar a.; seale, holly title: current knowledge of covid-19 and infection prevention and control strategies in healthcare settings: a global analysis date: 2020-05-15 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.237 sha: doc_id: 252714 cord_uid: idlyl4ga objective: in the current absence of a vaccine for covid-19, public health responses aim to break the chain of infection by focusing on the mode of transmission. we reviewed the current evidence on the transmission dynamics and on pathogenic and clinical features of covid-19 to critically identify any gaps in the current infection prevention and control (ipc) guidelines. methods: in this study, we reviewed global covid-19 ipc guidelines by organizations such as the world health organization (who), the us centers for disease control and prevention (cdc), and the european centre for disease prevention and control (ecdc). guidelines from 2 high-income countries (australia and united kingdom) and from 1 middle-income country (china) were also reviewed. we searched publications in english on ‘pubmed’ and google scholar. we extracted information related to covid-19 transmission dynamics, clinical presentations, and exposures that may facilitate transmission. we then compared these findings with the recommended ipc measures. results: nosocomial transmission of sars-cov-2 in healthcare settings occurs through droplets, aerosols, and the oral–fecal or fecal–droplet route. however, the ipc guidelines fail to cover all transmission modes, and the recommendations also conflict with each other. most guidelines recommend surgical masks for healthcare providers during routine care and n95 respirators for aerosol-generating procedures. however, recommendations regarding the type of face mask varied, and the cdc recommends cloth masks when surgical masks are unavailable. conclusion: ipc strategies should consider all the possible routes of transmission and should target all patient care activities involving risk of person-to-person transmission. this review may assist international health agencies in updating their guidelines. the global outbreak of coronavirus disease is caused by the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2). during the last 20 years, 2 other coronavirus epidemics, sars-cov and middle east respiratory syndrome (mers)-cov, have resulted in a considerable burden of cases across multiple countries. 1,2 outbreaks of newly emerging or remerging infectious diseases present a unique challenge and a threat to healthcare providers (hcps) and other frontline responders due to limited understanding of the emerging threat and reliance on infection prevention and control (ipc) measures that may not consider all transmission dynamics of the emerging pathogens. furthermore, hcp understanding and skills around the use of personal protective equipment (ppe) vary widely. during the outbreaks of both sars-cov and mers-cov, patient-to-patient and patient-to-hcp transmission occurred in healthcare settings. 3, 4 although the level of risk of transmission across hospital occupants (to hcps and others) falls on a spectrum, all of these groups pose unique challenges when it comes to reducing transmission. in hospital settings, performing aerosolgenerating procedures (agps, eg intubation, suction, bronchoscopy, cardiopulmonary resuscitation) or using a nebulizer on a sars patient facilitated patient-to-hcp transmission. 3, 5, 6 overcrowding in emergency rooms, poor compliance with ipc measures, and contamination of the environment also contribute to viral spread. [7] [8] [9] [10] [11] in healthcare settings, the most common pathway of human-tohuman transmission has been the contact of the mucosae with infectious respiratory droplets or fomites. 12 however, prior studies have also detected coronaviruses in sputum, nasal or nasopharyngeal secretions, endotracheal aspirate, bronchoalveolar lavage, urine, feces, tears, conjunctival secretions, and blood and lung tissues. [13] [14] [15] [16] other research has also shown that sars-cov can survive in sputum, serum, and feces for at least 96 hours and in urine for 72 hours, 17 and it can survive on surfaces up to 9 days. 18 thus, the recommended mitigation strategies may need to be sufficiently broad to control these transmission modes. the covid19 ipc guidelines have been adopted and or developed based on the knowledge gained from experience during responding mers-cov or sars-cov outbreaks. [19] [20] [21] [22] however, the available published literature to date have indicated that sars-cov-2 is genetically similar to, but distinct from, sars-cov [22] [23] [24] in terms of transmissibility, viral shedding, and other characteristics. [25] [26] [27] [28] therefore, a critical review of the available literature related to the covid-19 outbreak is essential as part of informing and updating ipc guidelines. in this study, we examined the current recommendations for ipc in light of what is known to date about covid-19. we reviewed global covid-19 ipc guidelines from the world health organization (who), the us centers for disease control and prevention (cdc), and the european centre for disease prevention and control (ecdc). we selected these international guidelines because they are commonly used as a reference globally. 29, 30 guidelines from 2 high-income countries (australia and the united kingdom) and 1 middle-income country were also selected. we searched publications in english on 'pubmed' and google scholar for the period between january 1 and april 27, 2020, using the following search terms: "2019-ncov" or "covid-19" or "2019 novel coronavirus" or "sars-cov-2." to identify covid-19 ipc guidelines, we visited the websites of the international public health agencies such as cdc, ecdc, who, as well as the australian government department of health, the bureau of disease prevention and control of the national health commission of the people's republic of china, and public health england. using the aforementioned terms, we also undertook a google search for newspaper articles, reports, and updates related to the disease. we extracted information related to covid-19 transmission dynamics, clinical presentations, and exposures that may facilitate the transmission while reviewing the literature. for guidelines, we extracted title, country or organization, department, target audience, and the different control measures recommended to control covid-19. the lead author extracted the information from the guidelines, and all coauthors reviewed and validated it. we performed a content analysis of all data and summarized it under certain themes, and we then compared and contrasted our findings as they related to covid-19 ipc measures. 31 the sars-cov-2 is a zoonotic virus, and bats are assumed to be the reservoir. 23, 32 the suspected mode of covid-19 transmission in wuhan is from bats to humans; this animal served as an intermediate host that facilitated the transfer of this virus to humans. 23 sars-cov-2 can be spread via droplets and aerosols (in a closed environment with high concentration of aerosols) transmitted from human to human through everyday interactions and by contact (eg, a person touches the patient or object contaminated with the virus). 21,22,33-43 van doremalen et al 44 found that sars-cov-2 may remain viable in aerosols for up to 3 hours and on surfaces for up to several days. 44, 45 public health england classified covid-19 as an airborne, high-consequence, infectious disease in the united kingdom. 21 transmission may occur presymptomatically, during the incubation period, or even after recovery. 46, 48 like influenza and other respiratory pathogens, sars-cov-2 may also be transmitted through respiratory droplets through coughing and sneezing. 49 the cdc team reasoned that when an infected person coughs or sneezes, the large respiratory droplets expressed from the patients' mouth and nose are likely to transmit the virus from the infected patient to a healthy person. 50 the propelled droplets can land directly on the mucous membrane of the mouth, nose, or eyes of a nearby person or on the surface of objects. 49 these droplets may travel up to~4 m 51 and may increase the risk of infection to hcps. 52 guo et al 51 also identified sars-cov-2 on shoe soles of hcps working in intensive care units (icus); therefore, shoes can carry the virus. in an experimental study conducted by van doremalen et al, 44 sars-cov-2 remained viable on plastic and stainless-steel surfaces for up to 3 days. moreover, sars-cov-2 rna was identified on a cruise ship 17 days after the ship was vacated. 45 agps, such as bronchoscopy, bronchial suction, tracheal intubation, and sputum induction, may generate aerosols containing the virus and increase the risk of transmission. 19, 42 these modes of transmission may contribute to spreading the virus in healthcare settings, including superspreading events, 53 and they inform guidance for ipc in healthcare settings. the incubation period of covid-19 is 2-14 days. 64 backer et al 65 estimated the mean incubation period to be 6.4 days (95% confidence interval [ci], 5.6-7.7). the available findings showed that transmission of sars-cov-2 may occur before and after symptom onset. 45 zou et al 27 found modest viral loads on nasal and throat swabs early in the illness, with viral loads peaking~5 days after symptom onset. the virus can be detected until 15 days from onset of illness and can be transmitted throughout the illness episode. 27 sharing a toilet in healthcare settings can also be a source of infection; the sars-cov-2 has been detected in toilet bowls and sinks. 66, 67 inappropriate selection of ppe may also put hcps at risk of infection. 68 exposure to agps was identified as a risk factor for acquiring covid-19, 42 but the others drivers of transmission and the exact mode of transmission remain uncertain. for example, blood, saliva, and stool, of covid-19 patients have been tested positive for sars-cov-2, 60,63,69 but the precise role these body fluids play in disease transmission in healthcare settings and the ways in which they may be transferred remain uncertain. as of april 8, 2020, >22,000 hcps have been infected with covid-19 in 55 countries. 70 hcps comprise~11% of all reported covid-19 cases in italy, 70 13 .6% in spain, 71~1 4% in the united kingdom, 72,73 and 3.8% in china. 70 one of the largest known outbreaks of hospital-acquired covid-19 was reported in china among 17 (12.3%) of 138 patients and 40 (29%) of 138 hcps in 1 hospital. 54 of the infected hcps, 77.5% worked in general wards, 17.5% worked in the emergency department, and 5% worked in intensive care units. 54 li et al 74 reported that no cases of covid-19 occurred in hcps before january 1, 2020. 74 from january 1 to 11, 7 (3%) of 248 hcps were infected, and from january 12 to 22, 7% (8/122) hcps were infected, showing that healthcare-associated infections were increasing. 74 a more recent study in a hospital in the united kingdom showed ongoing transmission of covid-19 among hcps. 75 the department of health, australia, the bureau of disease prevention and control of the national health commission of the people's republic of china, the cdc, the ecdc, public health england, and the who have published covid-19 ipc guidelines that have targeted health administrators, hcps, or public health units to implement ipc measures. 22, [78] [79] [80] [81] [82] currently, the following ipc measures are in practice: suspected source control, use of personal protective equipment, rapid diagnosis, physical distancing, isolation, investigation, and follow-up of close contacts. 54 all guidelines include administrative control, environmental control, and ppe, and the guidelines of australia, the who, and the cdc also include engineering control. a comparison of the recommendations made in the guidelines is presented in tables 1-3. all guidelines recommend early diagnosis and isolation of covid-19 patients in a single room, if available. in settings where single-room isolation facilities are limited, all of the guidelines recommend cohorting or group zoning of suspected covid-19 patients in a well-ventilated room. the guidelines prioritize source control and recommend providing face masks to patients. the guidelines also recommend training for all hcps regarding ipc measures. however, there are discrepancies in the guidelines regarding ipc measures. for example, the who recommends at least 1 meter distance between patients or between patients and hcps when patients are cohorted in a large room, whereas australia recommends 1.5 m of distance and the cdc recom-mends~2 m (~6 ft) between patients. moreover, 4 guidelines recommend patient education, and 3 guidelines suggest establishing surveillance in the hospital to monitor cross infection in patients and hcps. all of the guidelines highlight visitor controls in the hospitals. however, only china and the who discuss family members giving care in healthcare settings; they recommend that family caregivers use contact and droplet precautions while attending family members in the hospital. in addition, the ecdc guidelines recommend ppe for social workers when they provide care in healthcare settings. all of the guidelines recommend that agps must be prioritized in a negative-pressure isolation room or in a well-ventilated room and that contact and airborne precautions should be followed during the agp. to reduce room contamination in hospital settings, all of the guidelines recommend routine cleaning and disinfection of surfaces using disinfectants. the chinese guideline also recommends air disinfectants using an air sterilizer and pressure steam sterilization. incinerating or sterilizing patients' clothing, bedding, and utensils are included in the guidelines from australia, china, and the united kingdom. although the fecaloral route of covid-19 transmission has not yet been confirmed, the chinese guidelines recommend disinfecting septic tanks. the cdc, ecdc, and uk guidelines recommended separate toilets for each patient. although all of the guidelines recommend precautions during patient transfer, only the chinese, ecdc, and uk guidelines emphasize decontaminating transportation means and trollies used by confirmed covid-19 patients. due to the global supply shortages of ppe, almost all of the guidelines revised their initial recommendations related to ppe use. of the 6 guidelines, 5 now recommend reuse of ppe following the manufacturers' instructions. considering the global scarcity of ppe supplies, the who, cdc, ecdc, australian, and uk updated guidelines recommend surgical masks as an acceptable alternative to n95 respirators for hcps during routine care, and n95 or equivalent respirators have been prioritized during agps. however, the recommendations around the type of face mask vary; for example, some guidelines recommend fluidrepellent surgical face masks, whereas others recommend general surgical masks. 82 the cdc also recommends homemade cloth masks or homemade masks when a face mask is totally unavailable. 81 as contact and droplet precautions, ppe measures, including wearing a surgical mask, and a gown, gloves, face shield, goggles and/or visors, and hand hygiene, have been recommended upon entering the patient's room as well as removal of ppe upon leaving (table 1 ). in all guidelines, alcohol-based hand sanitizers have been prioritized whenever available (table 1) . fit testing and seal checks are an essential part of respirator use, but fit testing is recommended in 5 guidelines and a seal check is recommended in 3 guidelines. precautions during donning and doffing are recommended in all guidelines. if an autopsy is required for a patient, the who, cdc, ecdc, and uk guidelines recommend the use of contact and airborne precautions during the autopsy. however, the who recommends performing autopsies in an adequately ventilated room, whereas the cdc recommends performing this procedure in airborne infection isolation room 85, 86 engineering control physical separation is efficient in reducing transmission of respiratory virus in hospital settings. the australian, cdc, and who guidelines emphasize engineering control as an ipc measure. these guidelines recommend the following engineering control measures: spatial barriers or partitions to manage patients in triage areas, curtains around each bed in inpatient wards, closed suctioning systems for airway suctioning in intubated patients, and airflow management. the cdc guidelines also recommend installing physical barriers using glass or plastic windows in the hospital reception area. all of the guidelines recommend standard precautions while handling dead bodies. only the australian, chinese, and uk guidelines recommend the use of body bags. the chinese guideline recommends putting cotton balls or gauze in the mouth, nose, ears, and anus, as well as any tracheotomy or open wound of the deceased body. 22 all of the guidelines also state that a burial ritual may be allowed with standard precautions. a dedicated vehicle is recommended for postmortem transport. in this review, we identified the transmission model and risk exposures of the covid-19 pandemic. the identified signs and symptoms of the case patients suggest that sars-cov-2 can be transmitted through cough, sneeze, saliva, nasal secretion, stool, and vomit via droplet, aerosol, fecal-oral, or fecal-droplet transmission. 42, 69 however, currently discrepancies exist among the guidelines; not all documents acknowledge the 3 routes of transmission. to reduce exposures to sars-cov-2, all of the guidelines recommend early diagnosis and rapid isolation of covid-19 patients. however, studies to date have indicated that rapid diagnosis of patients is challenging 87 because the signs and symptoms of covid-19 are nonspecific and may be confused with all microbial causes of respiratory tract infection. 87 the nonspecific nature of the virus, as well as asymptomatic patients, may affect the ipc measures. the recommendations regarding spatial separation between patients or between patients and hcps are inadequate for droplet precautions in hospital settings. the recommendation of physical distance in the guidelines varies between 1 m and 2 m; however, a recent study has reported that the sars-cov-2 may travel >4 m. 51 moreover, environmental factors, such as air flow, humidity, and use of air conditioners or air mixing fans, may also influence the horizontal travel of droplets. an outbreak of covid-19 linked to air conditioning has been reported in china. 88 these reports indicate that revision of the spatial separation recommendation is warranted. although evidence that sars-cov-2 can be airborne is very limited, all of the guidelines recommend placing patients in a single room, if available. the exponentially large number of patients in several countries made the implementation of this isolation recommendation impossible due to the shortages of single isolation rooms. 89, 90 therefore, cohorting patients in large shared rooms has become a practical alternative that is recommended in most updated guidelines. all of the international guidelines should make specific recommendations for hospitals that treat several patients in a large shared room. in addition, bed sheets and bed rails can be an important source of droplet and fomite transmission. 18 none of the guidelines provided proper instruction on how to handle the bedding and clothing of covid-19 patients. because sars-cov-2 may remain viable on surfaces for days, a recommendation is needed for safe handling these items. the presence of virus in stool samples indicates that the virus may also be transmitted through fecal-oral or fecal-droplet routes. 63, 67, 69 prior evidence of sars coronavirus transmission through feces supports the likelihood of covid-19 transmission via an oral-fecal or fecal-droplet route. 91 in recent studies, investigators have detected sars-cov-2 in toilet bowls, sinks, and air. 66, 92 toilet flushing may generate bioaerosols contaminated with pathogens. one study detected pathogenic microorganisms in air samples collected from hospital toilets, and the pathogen may remain viable in the air for at least 30 minutes after flushing suggest the possibility of fecal-droplet transmission. 93 specific recommendations are needed regarding the prevention of fecal-oral or fecal-droplet transmission in hospital settings. shortages of ppe are expected during pandemics due to high demand, and they have occurred in past epidemics as well. 94 due to the shortage of ppe, all guidelines recommend that hcps should wear surgical mask as a droplet precaution and during specimen collection. 19, 22 the use of n95 or equivalent respirators is recommended only during agps in all guidelines. 19 the virus may be transmitted through aerosols, 42, 92 and it can remain viable in aerosols for several hours. 44, 92 therefore, face masks may not provide sufficient protection to hcps due to their long and repeated exposure in confined spaces. 77 in addition, the transmission dynamics of covid-19 seems more like that of influenza than sars-cov. 27 a randomized control study among hcps exposed to influenza patients found that surgical masks may provide some protection to the wearers, probably by minimizing the frequency of times a person touches their nose and mouth 95 ; however, surgical masks may not provide fully effective protection from respiratory pathogens because of leakage due to the loose fit of surgical masks. 96 considering the shortage of hcps globally, 97 the international guidelines should recommend optimal protection and ipc standards to protect frontline hcps. already, >22,000 hcps have been infected, and many countries have reported ongoing nosocomial transmission of sar-cov-2 among hcps. 70, 72, 98, 99 the role of face masks in protecting hcps from sar-cov-2 has been questioned. 100 we understand that a global shortage of n95 or equivalent respirators might have prompted the who, the uk, the ecdc, australia, and the cdc to loosen their recommendations regarding face protection, but frontline hcps should not be put at risk of infection. the face mask recommendation should be changed to n95 or equivalent respirators for all hcps in all guidelines. the guidelines should include a strong statement against the use of cloth or material masks, and hcps should be encouraged not to wear 2 products simultaneously. although 4 guidelines recommend the reuse of ppe or extended wear, no current guidelines address this behavior, and strict hand hygiene and donning/doffing procedures should be followed. for example, the uk guideline recommends that ppe be used between 2 and 6 hours, whereas the ecdc guidelines recommend wearing ppe for up to 4-6 hours. [80] [81] [82] if countries resort to these strategies, it would be useful for the wider international community that observations studies be undertaken so that the results can be applied to future guidelines. lastly, the who guidelines lack a recommendation on fit testing. it cannot be assumed that staff members have been fit tested for their respirators, so hospitals should be encouraged to fit test or at least fit check members of staff, including ancillary staff (ie, cleaning and support staff) and pharmacists who frequent the wards. the recommendations should be updated regarding the disposition of patients after recovery and the use of standard precautions. although all the guidelines make specific recommendations on this topic, some of the recommendations do not match our findings. for example, the who guideline recommends continuing standard precautions until a patient is asymptomatic. however, one study identified prolonged shedding of sars-cov-2 after recovery, 46 and, therefore, special attention must be given to changing this recommendation. the discord in the recommendations on corpse handling may result in an increase in the risk of infection among the exposed. corpse-to-human transmission of ebola and nipah viruses has been documented, 101, 102 and mers-cov was detected in the nasal secretions of a deceased human. 103 sars-cov-2 has been detected in respiratory secretions, saliva and stool, and the virus may remain active in secretions and excreta from deceased bodies at least a few hours after death. 27, 74, [104] [105] [106] [107] [108] direct physical contact with bodies infected with the virus may increase the risk of infection. all of the guidelines should include recommendations on how to handle corpses and their management in hospitals. the increasing numbers of covid-19 cases among hcps along with evidence of ongoing transmission in some hospitals suggest some that gaps in ipc measures should be revisited in the guidelines. low-and middle-income countries often adopt international ipc guidelines as they stand or with modifications for the local context. therefore, we recommend international guidelines consider the global context while recommending ipc measures. in conclusion, sars-cov-2 may spread faster than the previous sars-cov. ipc measures should consider sars-cov-2 to spread as a droplet, an aerosol, and through the oral-fecal route. all of the guidelines should target these modes of transmission while recommending control measures. because no drug or vaccine is publicly available for sars-cov-2, hcps and other frontline outbreak responders must rely on ipc measures for safety. in addition, gaps always occur between the development of ipc guidelines, their introduction to target audience, and their implementation. during a public health emergency, international agencies may use an online platform to introduce ipc guidelines to hcps in a shorter time. national authorities should provide training on the ipc 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risk in the uk. in the latest number of coronavirus (covid-19) cases and risk level in the united kingdom early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia first experience of covid-19 screening of health-care workers in england healthcare workers worry about coronavirus protection. the washington post exploring the reasons for healthcare workers infected with novel coronavirus disease 2019 (covid-19) in china publications-detail/infection-prevention-and-control-during-healthcare-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125 canberra: cdna; 2020. 80. infection prevention and control for the care of patients with 2019-ncov in healthcare settings. ecdc technical report. european centre for disease prevention and control website interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings guidance on infection prevention and control for 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in a hospital-based patient care setting policies on the use of respiratory protection for hospital health workers to protect from coronavirus disease (covid-19) n95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial frequently asked questions about respirators and their use a universal truth: no health without a workforce christopher's doctor infected with covid-19; icu closed to new patients. 6 abc action news battling coronavirus, iran's health workers complain of severe shortages protecting healthcare workers from subclinical coronavirus infection nipah virus infection outbreak with nosocomial and corpse-to-human transmission ebola virus shedding and transmission: review of current evidence case report: detection of the middle east respiratory syndrome corona virus (mers-cov) in nasal secretions of a dead human consistent detection of 2019 novel coronavirus in saliva first case of 2019 novel coronavirus in the united 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examining the inclusion of patients and their family members in infection prevention and control policies and guidelines across bangladesh, indonesia, and south korea acknowledgments. we appreciate a colleague for providing us the latest guidelines from china. we are also grateful to univesity of new south wales, sydney, australia, for providing scholarships to the primary author. we are grateful to the governments of bangladesh, canada, sweden, and the united kingdom for providing core, unrestricted support to the international centre for diarrhoeal disease research, bangladesh (icddr,b), the home institution of the primary author.financial support. this research did not receive any funding from donor agencies.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-327920-51s4figy authors: kohler, philipp p.; kahlert, christian r.; sumer, johannes; flury, domenica; güsewell, sabine; leal-neto, onicio b.; notter, julia; albrich, werner c.; babouee flury, baharak; mcgeer, allison; kuster, stefan; risch, lorenz; schlegel, matthias; vernazza, pietro title: prevalence of sars-cov-2 antibodies among swiss hospital workers: results of a prospective cohort study date: 2020-10-08 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.1244 sha: doc_id: 327920 cord_uid: 51s4figy in this prospective cohort of 1,012 swiss hospital employees, 3 different assays were used to screen serum for sars-cov-2 antibodies. seropositivity was 1%; the positive predictive values of the lateral-flow immunoassay were 64% (igg) and 13% (igm). history of fever and myalgia most effectively differentiated seropositive and seronegative participants. (received 8 july 2020; accepted 23 september 2020) coronavirus disease 2019 (covid-19) is currently threatening global health. evidence from various countries indicates that healthcare workers (hcws) are at increased risk for covid-19. 1, 2 many previous studies have focused on the molecular testing of symptomatic hcws, ignoring the fact that a significant proportion of infected people might not exhibit any symptoms and that falsenegative pcr results are not uncommon. 3, 4 although available serologic tests have somewhat uncertain performance characteristics, assessment of antibodies to severe acute respiratory virus-2 (sars-cov-2) provides a better estimate of the true prevalence and has therefore been recommended by leading healthcare experts. 5 the aims of this prospective cohort study were to assess seropositivity for sars-cov-2, to identify risk exposures, and to describe the spectrum of covid-19 symptoms among hospital workers. between march 19 and april 3, 2020, hospital workers (≥16 years) from 2 tertiary-care hospitals (cantonal hospital st gallen and the children's hospital of eastern switzerland) were invited to participate. covid-19 cases in this region peaked between march 23 and march 30 (53 cases per 100,000 population per week). hospital admissions were highest in the second week of april. participants' sera were analyzed for sars-cov-2 antibodies using 3 different tests: a lateral flow immunochromatographic assay (lfia, sugentech, yuseong-gu, daejeon, republic of korea), a chemiluminescence microparticle immunoassay (cmia, abbott diagnostics, lake bluff, il), and an electro-chemiluminescence immunoassay (eclia, roche diagnostics, basel, switzerland). participants with a positive signal in any test provided a second sample 4 weeks later (all tests performed again). true seropositivity was assumed in cases of positive igg in lfia and either cmia or eclia (at the same time). this procedure corresponds to an orthogonal testing algorithm in which an independent second test confirms the positive result of the first test (https://www.cdc.gov/ coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html). samples with positive igg in lfia only were additionally tested with a chemiluminescence immunoassay (clia) directed at the spike proteins s1/s2 (diasorin, italy). pcr was not routinely performed. participants filled in a web-based questionnaire asking about respiratory and general symptoms and covid-19 exposures (3 weeks prior to baseline testing). the intensity of patient contact was stratified as follows: hcws caring for confirmed covid-19 patients; hcws exposed to patients without known covid-19; and others. we included 1,012 hospital workers with a median age of 38.3 years (range, 16.9-64.8); 761 (75%) were women. most were nurses (n = 398, 39%) or physicians (n = 268, 27%) ( table 1) . at the baseline, 58 of 1,012 participants (5.7%) showed a positive signal in at least 1 test. in the lfia, 13 participants had igg (8 confirmed by eclia/cmia) and 45 had igm only. at followup, 2 participants showed a positive lfia (igg) and eclia/ cmia result in addition to the 8 samples confirmed at baseline, resulting in 10 of 1,012 true seropositives (1.0%) and 48 of 1,012 false seropositives (4.7%) (fig. 1) . also, 5 participants had isolated lfia igg at baseline and follow-up and remained negative with anti-s1/s2 clia (diasorin). overall, the ppv of the lfia was 64% (18 true positive of 28 positive results) for igg and 13% (12 true positive of 96 positive results) for igm. eclia and cmia results were consistent except for 1 participant (eclia negative and cmia positive). seropositive participants more frequently reported fever or feverishness and limb or muscle pain than seronegative participants. respiratory symptoms were reported by 73% of seropositive and 54% of seronegative participants (p = .36). similar differences were detected between participants with true-positive and falsepositive serology results (supplementary figs. s1 and s2). of the 10 seropositive patients, 2 (20%) denied any symptoms. all positive participants worked in adult care (p = .77); 2 of 20 (10%) reported unprotected contact with confirmed covid-19 cases outside work and household versus 30 of 972 (3%) among seronegative workers (p = .04). the intensity of patient contact was not associated with seropositivity (p = .20), although all seropositive participants reported some form of patient contact. among those with patient contact, hcws who wear masks were less likely to test positive (2 of 370, 0.5%) than those who did not wear masks (8 of 642, 1.2%) (p = .009) ( table 1 ). in this prospective hospital worker cohort, 1% had sars-cov-2 antibodies detected at baseline. the high proportion of falsepositive lfia results (particularly igm) underscores the low ppv of these tests when prevalence is low. fever or feverishness and muscle or limb pain were most useful in discriminating patients with positive and negative serologies. the strengths of the study are the use of 3 different tests and our analysis of a followup sample in case of a positive signal at baseline. given the covid-19 peak in the region around collection of baseline samples, and considering a latency between infection and igg detection of 2-3 weeks, these data represent an early phase of the local epidemic. this explains the low positivity rate and the low ppv of 64% (igg) and 13% (igm) for the lfia. data suggest cross reactions between endemic coronaviruses and sarscov-2, particularly for assays targeting the nucleocapsid protein. 6 however, despite being directed against nucleocapsid, the cmia and eclia used in this study have previously demonstrated excellent specificity (>99%) and acceptable sensitivities (93.9 and 87.7%, respectively). 7 the concordant results between cmia and eclia, as well as between cmia/eclia and clia (directed at s1/s2 proteins), further strengthen our confidence in the specificity of the tests. regarding sensitivity, recent evidence shows that a humoral immune response is mounted less frequently in patients with mild covid-19. 8 indeed, the reported sensitivities of the cmia and eclia are 93.9 and 87%, which might have underestimated our seroprevalence. 7 notably, lfia screening identified 2 patients by positive igm but negative cmia and eclia at baseline, who eventually had igg seroconversion in all tests. this finding is in line with data from the infectious diseases society of america (idsa) guideline on sars-cov serology testing showing a lower sensitivity of cmia igg compared to lfia igm early after infection. 9 although limited by the small case number, constitutional symptoms were more useful than respiratory symptoms in discriminating between seropositive and seronegative participants. although covid-19 may be a mild illness, it appears that illness caused by other respiratory viruses were more likely to cause isolated respiratory symptoms without constitutional symptoms than covid-19. furthermore, 20% of sars-cov-2-positive patients denied any symptoms, which is in line with current estimates. 3 serologically positive participants more likely reported exposure to covid-19 cases outside work, whereas the intensity of patient contact did not differ compared to seronegative participants. despite being compatible with data showing no increased seroprevalence of hcws working in high-risk settings, 10 these results should be interpreted with caution. because of the early time point of baseline collection in relation to the local epidemic, providers might have had too little exposure to hospitalized covid-19 patients to detect an exposure effect. the apparent protective effect of masks may reflect a reduction in undetected, unprotected exposure to other hcw or patients, or be an epi-phenomenon associated with adherence to other preventive practices. in conclusion, seroprevalence was 1% at baseline in this prospective hcw cohort from switzerland. using 3 different tests, we challenge the usefulness of serology tests with limited specificity when prevalence is low. a prospective analysis of cohort data will allow us to better study the spectrum of symptoms and risk exposures associated with covid-19. supporting the health care workforce during the covid-19 global epidemic covid-19: protecting healthcare workers is a priority estimating the asymptomatic proportion of coronavirus disease 2019 (covid-19) cases on board the diamond princess cruise ship false negative tests for sars-cov-2 infection-challenges and implications waiting for certainty on covid-19 antibody tests-at what cost? interpreting diagnostic tests for sars-cov-2 covid-19: two antibody tests are "highly specific" but vary in sensitivity, evaluations find systemic and mucosal antibody secretion specific to sars-cov-2 during mild versus severe covid-19 infectious diseases society of america guidelines on the diagnosis of covid-19: serologic testing hospitalwide sars-cov-2 antibody screening in 3,056 staff in a tertiary center in belgium acknowledgments.financial support. the study was funded by the swiss national sciences foundation and the federal office of public health. pk is financially supported by an ambizione grant of the swiss national sciences foundation.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-286885-eih8a6ul authors: ali, sheikh muhammad ebad title: one-house one-person testing: strategical plan to limit covid-19 spread in stage three in the developing world date: 2020-05-06 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.200 sha: doc_id: 286885 cord_uid: eih8a6ul nan to the editor-coronavirus disease 2019 (covid-19) is a respiratory viral disease discovered in wuhan province of china in november 2019, but soon the sars-cov-2 virus has spread across the entire world, and the world health organization (who) declared covid-19 a pandemic in march 2020. in the hour of crisis, the only preventive measures were strict quarantine; hygiene maintenance with regular handwashing; covering mouth, nose, eyes, and ears; risk screening at airports and railways 1 ; and social distancing. a strategy was proposed after the advent of a virus-specific molecular polymerase chain reaction (pcr) test called "mass screening" that involved testing nasal and throat swabs from the random population to assess viral spread and to isolate those infected from the healthy population. 2 the strategy gained widespread approval in developed countries, and huge random populations were screened. however, the cost of testing was an obstacle for developing nations; governments intended to adopt this strategy but could not due to the overwhelming expense. consequently, covid-19 outbreaks across the globe have continued to occur, with less pcr testing of the population because of overburdened healthcare system and economic limitations under strict lockdowns. as of april 23, 2020, 2,630,516 confirmed covid-19 cases, along with 183,924 covid-19 deaths and 58,139 covid-19 patients in critical condition have been reported. 3 most of the cases reported have been attributed to local transmission through respiratory droplets. most countries have implemented strict lockdowns, but the results have not been satisfactory in terms of local transmission control and adverse economic effects. i propose a method of screening that can be used in remote areas and developing nations during stage 3 of the covid-19 pandemic; it is cost efficient and has a high probability of isolating asymptomatic cases. theoretically, the strategy could also ease the lockdowns rapidly and thus help mitigate the global economic crisis during stage 3 of this pandemic. this technique may be highly useful in overcrowded and slum areas that show higher levels of local transmission from asymptomatic cases. as reported in previous studies, covid-19 spreads rapidly through droplets, and the probability of infection is increased if a person comes in contact with any infected patient. however, asymptomatic cases, which may be as high as 84% of all cases, may have similar transmission risks as symptomatic patients. for those quarantined in their homes, the most vulnerable victims can be close family members of infected patients living in the same house, which is termed a family cluster (table 1 ). in the strategy i propose, instead of random sampling, areas under lockdown should be allocated within boundaries, and a single person from each household should be tested using swabs collected door to door. the pcr results are available within 48 hours. if a person from 1 house is positive, the whole family should be either screened or isolated for the following 14 days. if the person is negative, then the whole family can be considered negative (fig. 1) . for example, india, with a population of 1.353 billion, cannot test each citizen, and there is a high probability of missing covid-19 cases in random sampling, which might worsen the situation once lockdown is lifted. however, india has some of the largest slum areas in the world, where 10-20 people reside per 27.9 m 2 (~300 square feet), producing a very high risk of spread. hence, if 1 person from the slum gets tested, there is a high probability that the test results reflect the status of those nearby. rather than testing the whole slum, 1 person from every hut in each slum could be tested. this approach would reduce the number of tests and help to end the lockdowns within 4-5 days. although this strategy is not comparable with mass screening, it may offer a substantial decrease in the burden of disease, especially in countries with larger populations and limited resources. i request that researchers conduct cross-sectional studies to execute this plan, which could save lives by preventing local transmission from asymptomatic covid-19 cases. effectiveness of airport screening at detecting travellers infected with novel coronavirus covid-19 mass testing facilities could end the epidemic rapidly international cases details. internet transmission potential of asymptomatic and paucisymptomatic sars-cov-2 infections: a three-family cluster study in china delivery of infection from asymptomatic carriers of covid-19 in a familial cluster familial cluster of covid-19 infection from an asymptomatic a covid-19 transmission within a family cluster by presymptomatic infectors in china transmission of covid-19 in the terminal stage of incubation period: a familial cluster epidemiological investigation of a family clustering of covid-19 acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-331455-dfnn9mrf authors: shah, aditya s.; walkoff, lara a.; kuzo, ronald s.; callstrom, matthew r.; brown, michael j.; kendrick, michael l.; narr, bradly j.; berbari, elie title: the utility of chest computed tomography (ct) and rt-pcr screening of asymptomatic patients for sars-cov-2 prior to semiurgent or urgent hospital procedures date: 2020-07-16 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.331 sha: doc_id: 331455 cord_uid: dfnn9mrf objective: presently, evidence guiding clinicians on the optimal approach to safely screen patients for coronavirus disease 2019 (covid-19) to a nonemergent hospital procedure is scarce. in this report, we describe our experience in screening for sars-cov-2 prior to semiurgent and urgent hospital procedures. design: retrospective case series. setting: a single tertiary-care medical center. participants: our study cohort included patients ≥18 years of age who had semiurgent or urgent hospital procedures or surgeries. methods: overall, 625 patients were screened for sars-cov-2 using a combination of phone questionnaire (7 days prior to the anticipated procedure), rt-pcr and chest computed tomography (ct) between march 1, 2020, and april 30, 2020. results: of the 625 patients, 520 scans (83.2%) were interpreted as normal; 1 (0.16%) had typical features of covid-19; 18 scans (2.88%) had indeterminate features of covid-19; and 86 (13.76%) had atypical features of covid-19. in total, 640 rt-pcrs were performed, with 1 positive result (0.15%) in a patient with a ct scan that yielded an atypical finding. of the 18 patients with chest cts categorized as indeterminate, 5 underwent repeat negative rt-pcr nasopharyngeal swab 1 week after their initial swab. also, 1 patient with a chest ct categorized as typical had a follow-up repeat negative rt-pcr, indicating that the chest ct was likely a false positive. after surgery, none of the patients developed signs or symptoms suspicious of covid-19 that would indicate the need for a repeated rt-pcr or ct scan. conclusion: in our experience, chest ct scanning did not prove provide valuable information in detecting asymptomatic cases of sars-cov-2 (covid-19) in our low-prevalence population. (received 19 may 2020; accepted 1 july 2020) coronavirus disease 2019 (covid-19), caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), was first described in wuhan, china, in december 2019 and was subsequently declared a global pandemic by the who on march 11, 2020. [1] [2] [3] unprecedented measures have been implemented worldwide in an effort to flatten the curve of this pandemic. a key measure, early in the pandemic, relied on postponing and cancelling elective hospital procedures to limit the spread of covid-19 and to preserve much needed healthcare resources. this delay of elective procedures, if protracted, may adversely affect the clinical care and outcome of patients without covid-19. patients with undiagnosed or asymptomatic covid-19 pose a risk to both health care workers and other patients. therefore, measures aimed at detecting patients with asymptomatic covid-19 infection before a planned procedure or surgery should be implemented. although more data are needed regarding the sensitivity of reverse-transcriptase polymerase chain reaction (rt-pcr), the definitive test for covid-19 infection, reports available currently and reported in the infectious disease society of america (idsa) guidelines for diagnosis of covid-19, estimate it to be between 75% and 95%. 4 the reported sensitivity of chest computed tomography scans (cts) for patients with covid-19 pneumonia varies but has been reported to be as high as 98%. 5 given the potential for false-negative rt-pcr tests, we sought to determine whether the addition of a second test with high sensitivity, such as chest ct, could enhance the detection of patients with asymptomatic covid-19. safely managing patients in need of elective hospital procedures will continue to be relevant during this pandemic and beyond. here, we describe our experience and the results of implementing this safety project of screening and testing patients for sars-cov-2 (covid-19) prior to semiurgent or urgent hospital procedures using both ct chest imaging and rt-pcr testing. our institution screened surgical patients preoperatively using a 3-pronged approach: patient phone interview, ct imaging of the chest, and sars-cov-2 nasopharyngeal swab testing by rt-pcr. 7 days prior to the anticipated procedure, patients were contacted by phone. using a standardized questionnaire, they were evaluated for symptoms of fever, cough, shortness of breath, difficulty in breathing, sore throat, diarrhea, chills, or myalgia, and for exposures to covid-19 infection such as high-risk travel or contact. an affirmative response to any of these questions would result in deferral of the surgical procedure, if feasible. a clinical team would then contact the patient to formulate a treatment plan. if the phone-screening questionnaire was entirely negative, the patient would undergo a sars-cov-2 nasopharyngeal swab pcr 48 hours prior to the elective hospital procedure as well as ct imaging of the chest the day before the procedure. our initial plan was to swab patients 5 days and 2 days prior to planned procedure; however, this procedure changed to just 2 days (48 hours) prior to the procedure due to limited testing availability and significant logistical difficulties. in the large majority of cases, chest ct was performed using a low radiation dose protocol without intravenous (iv) contrast material. exceptions were made in several instances in which concurrent staging for malignancy was requested in addition to screening for sars-cov-2, in which case standard-dose chest ct imaging was performed with or without iv contrast. in all cases, the radiologist was provided with 0.75-mm-thick contiguous axial slices reconstructed at 0.5-mm intervals and 3-mm-thick contiguous axial, coronal, and sagittal series. the ct chest study was interpreted as typical, indeterminate, atypical, or normal using the criteria set forth in the publication "radiological society of north america expert consensus statement on reporting chest ct findings related to covid-19, endorsed by the society of thoracic radiology, the american college of radiology, and rsna" and the corresponding "suggested reporting language" accompanied each category in the impression of the ct report. 6 typical ct features were defined as those reported in literature as associated with covid-19 pneumonia, including peripheral bilateral ground glass opacities (ggos) or multifocal ggos of a rounded morphology (with or without consolidation or intralobular lines), or findings of organizing pneumonia. an indeterminate study was defined as the absence of typical features and the presence of "multifocal, diffuse, perihilar, or unilateral ggo with or without consolidation lacking a specific distribution and are non-rounded or non-peripheral" or "few very small ggos with a non-rounded and non-peripheral distribution." an atypical appearance was defined as the absence of typical or indeterminate features and having isolated lobar or segmental consolidation without ggos, discrete small nodules, cavitation, or smooth interlobular septal thickening with a pleural effusion. a normal study was defined as one without features to suggest pneumonia. [6] [7] [8] comparison to prior chest cts was made, if available. if the sars-cov-2 pcr was negative and the chest ct was interpreted as either normal or atypical for covid-19, the patient underwent their planned procedure. in the setting of either a positive sars-cov-2 pcr or a chest ct with typical findings for covid-19, the procedure was deferred. when indeterminate chest ct findings were present and sars-cov-2 pcr was negative, management was determined on an individual patient basis. in total, 625 patients underwent imaging and rt-pcr testing. results are summarized in table 1 . our cohort of 625 patients had chest cts performed with rt-pcr testing (640 rt-pcr tests). of the 625 patients, 520 scans (83.2%) were interpreted as normal; 1 (0.16%) had typical features; 18 scans (2.88%) had indeterminate features; and 86 (13.76%) had atypical features of covid-19. only 1 of the 625 screening chest cts was performed on a patient with a positive rt-pcr result. in total, 640 rt-pcrs were performed, with 1 positive result (0.15%). this positive result was in a patient with ct scan interpreted as atypical. of the 18 patients with chest cts categorized as indeterminate, 5 underwent repeat rt-pcr nasopharyngeal swab 1 week after their initial negative swab; all results remained negative. also, 1 patient with chest ct categorized as typical had a follow-up repeat rt-pcr which was negative, indicating that the chest ct was likely a false positive. after surgery, none of the patients developed signs or symptoms suspicious of covid-19, needing repeat rt-pcr or ct scan. our results demonstrate that while feasible, screening chest ct provided little additional value for the detection of sars-cov-2 in asymptomatic individuals when performed in conjunction with a screening questionnaire and rt-pcr in our population, where there is a low presence of covid-19 (~20 cases per 100,000 population). 9 several studies examining the utility of chest ct in the diagnosis of covid-19 pneumonia have recently been performed. multiple studies have demonstrated the presence of bilateral peripheral ggos with a lower-lung predominance as one of the typical features of rt-pcr diagnosed covid-19 pneumonia 10,11 ; however, "typical" chest ct findings for covid-19 can also be seen in other entities including infectious processes, organizing pneumonia, and connective-tissue diseases. 6 current studies have demonstrated that chest ct is able to discern pulmonary findings in patients with microbiologically diagnosed covid-19 pneumonia with a sensitivities up to 90% and specificities up to 96%. 12, 13 several reports in the literature advocate the use of chest ct as a reliable alternative to rt-pcr. 14 notably, however, these studies were performed on largely symptomatic groups of patients in regions with a high population prevalence of sars-cov-2, [12] [13] [14] [15] which contrasts with our entirely asymptomatic cohort living in a low-prevalence region. a recent meta-analysis evaluating the performance of ct and rt-pcr in the diagnosis of covid-19 showed an overall pooled sensitivity of 94% and specificity of 37% for chest ct with a pooled sensitivity of rt-pcr being 89%; it concluded that in regions with low disease prevalence, the positive predictive value of rt-pcr was~10 times that of a ct. 16 another study revealed that 56% of patients with covid-19 had negative chest cts within the first 2 days of symptom onset. 17 among asymptomatic patients on the diamond princess cruise ship who tested positive for sars-cov-2 by rt-pcr, cts scan were negative for pulmonary opacities in 46% of cases, 18 although the prevalence of disease was relatively high in this cohort (~26%). with regard to rt-pcr, initial reports indicate a sensitivity of between 75% and 95% in patients with symptoms of the disease. 4 in many cases, the patient's underlying condition may have predisposed them to having lung findings, appears similar to covid-19 pneumonia. the patient with ct findings interpreted as being typical for covid-19 had a history of systemic lupus erythematosus, which may have produced the lung parenchymal abnormalities. many of the patients had a history of malignancy that had been treated with chemotherapy and radiation before the planned surgical procedure. the high prevalence of nonspecific lung findings, which were likely due to other causes, made it difficult to completely exclude covid pneumonia and resulted in false-positive ct interpretations. thus, cts might perform better when used in an otherwise healthy population. one of the strengths of this study is the large number of patients involved in the screening process. our hope is that our findings help guide other healthcare systems as they begin to resume routine clinical operations. the low prevalence of sars-cov-2 (covid-19) in our local community could be a potential limitation of this study because the positive predictive value of our approach might be hampered by low community prevalence. however, our findings would be applicable to other regions with a similar community prevalence of sars-cov-2 (covid-19). our findings have the potential to save patients from unnecessary testing, expense, and potential delays in elective hospital procedures. in this evolving global pandemic of covid-19, safe resumption of surgical and interventional procedures is critical for patient care and health care, both of which have been drastically adversely impacted. with the goal of resuming semiurgent and urgent procedural care at our institution, we took a conservative approach to minimize the risks to both patients and providers, using questionnaires and rt-pcr in combination with screening chest ct. in our experience, chest ct scanning did not prove provide valuable information in detecting asymptomatic cases of covid-19 in our low-prevalence population. our findings are in keeping with statements by multiple organizations, including the center for disease control and prevention (cdc) and the society of thoracic radiology, which do not recommend routine ct for the diagnosis of patients under investigation for covid-19. clinical features of patients infected with 2019 novel coronavirus in wuhan, china world health organization website guide to understanding the 2019 novel coronavirus infectious diseases society of america guidelines on the diagnosis of covid-19. infectious diseases society of america website chest ct for detecting covid-19: a systematic review and meta-analysis of diagnostic accuracy radiological society of north america expert consensus statement on reporting chest ct findings related to covid-19. endorsed by the society of thoracic radiology, the american college of radiology, and rsna performance of radiologists in differentiating covid-19 from viral pneumonia on chest ct coronavirus disease 2019 (covid-19): a systematic review of imaging findings in 919 patients geographic differences in covid-19 cases, deaths, and incidence-united states epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumo the clinical and chest ct features associated with severe and critical covid-19 pneumonia artificial intelligence distinguishes covid-19 from community acquired pneumonia on chest ct chest ct in patients suspected of covid-19 infection: a reliable alternative for rt-pcr imaging and clinical features of patients with 2019 novel coronavirus sars-cov-2 diagnostic performance of ct and reverse transcriptase-polymerase chain reaction for coronavirus disease 2019: a metaanalysis chest ct findings in coronavirus disease-19 (covid-19): relationship to duration of infection chest ct findings in cases from the cruise ship "diamond princess" with coronavirus disease 2019 (covid-19). radiol cardiothor imag acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-310285-ua894psi authors: khatri, anadi; kharel, muna; chaurasiya, babu dhanendra; k.c., ashma; khatri, bal kumar title: covid-19 and ophthalmology: an underappreciated occupational hazard date: 2020-07-20 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.344 sha: doc_id: 310285 cord_uid: ua894psi nan letter to the editor-we read the article "covid-19 and ophthalmology: an underappreciated occupational hazard" by kuo and o'brien 1 with great interest. they have described the challenges faced by eye care personnel during this pandemic very well in a systematic manner. we would like to add few of our own experiences. personal protective equipment (ppe) has become the gold standard during the covid-19 pandemic for prevention of infection. although it has its advantages, many problems may arise in terms of comfort and ease in certain circumstances. currently, with much of the primary focus on infection prevention, these may often be overlooked. in the long term, these difficulties may hamper the performance of healthcare workers like ophthalmologists, whose work demands high precision. as lockdowns are easing and services are resuming, we present our report from a pilot study we conducted in nepal among ophthalmologists on this matter. we conducted a small survey among 24 ophthalmologists who had recently (<1 week) returned to work using ppe. they were asked to describe issues related to discomfort or difficulty in performing regular tasks when using ppe. they were also asked to grade on a likert scale of 1 to 5 (1 least likely to 5 most likely) the issues they considered were most troubling (table 1) . returning to work after weeks of furlough only to suddenly and be enshrouded in ppe is a new challenge for many of us. although it has become a norm, the evidence is already clear that many ophthalmologists and eye care professionals are having difficulties related to ppe use. 2 although the evidence is concrete on infection prevention with its use, 3 our results suggest that ppe may need to be redesigned and customized to best fit the activity or the demands of individual workers. problems like fogging, sweating, and difficulty focusing are unacceptable not only in ophthalmological but many other faculties related to high-precision procedures. with more evidence that covid-19 is here to stay, 4 these problems will continue to hinder efforts to restart or continue services. physical distancing often tops the list and is the most prioritized advise during this pandemic. however, due to the nature of examination, it is practically impossible for eye care professionals to adopt it. 1, 5 in addition to ppe, improvised, low-tech, "do it yourself" (diy) protective devices are also being widely used. 6 although this may be an advantage because much of the "design for the greatest ease of use" would have already been already improvised, many such diy efforts remain unproven in terms of the actual protection they provide. until tested for its "quantifiable" protection value, physicians may fall into the trap of "pseudo" protection and confidence in their use. collaboration of physicians with the manufacturers, laboratories, and testing facilities are of utmost importance to devise such protective devices. efforts focused on extensive testing of these materials and designs to make them more protective and comfortable are necessary immediately if we are to continue serving with confidence in this era of "the new normal." covid-19 and ophthalmology: an underappreciated occupational hazard survey of ophthalmology practitioners in a&e on current covid-19 guidance at three major uk eye hospitals personal protective equipment and covid-19 challenges of "return to work" in an ongoing pandemic covid-19: limiting the risks for eye care professionals safety testing improvised covid-19 personal protective equipment based on a modified full-face snorkel mask acknowledgments.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-338946-j8xdz15a authors: luo, yuying; grinspan, lauren t.; fu, yichun; adams-sommer, victoria; willey, d. kyle; patel, gopi; grinspan, ari m. title: hospital-onset clostridioides difficile infections during the covid-19 pandemic date: 2020-09-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.1223 sha: doc_id: 338946 cord_uid: j8xdz15a nan to the editor-clostridioides difficile infection (cdi) is the most common healthcare-associated infection in the united states. 1 cdi affects 13 in every 1,000 patients, and~75% of cases are classified as hospital onset. antimicrobial stewardship and compliance with hand hygiene and personal protective equipment (ppe) protocols are paramount in efforts to reduce horizontal cdi transmission. 2 as an epicenter of the coronavirus disease 2019 (covid-19) caused by severe acute respiratory syndrome coronavirus-2 (sars-cov-2), new york city hospitals saw a dramatic increase in admissions and icu utilization. 3 to understand the impact of covid-19 on hospital-onset cdi, we examined antibiotic prescribing patterns, standardized infection ratios (sirs), and baseline variables in hospitalized adult patients prior to and during the covid-19 pandemic. we hypothesized that increased antibiotics exposure during the covid-19 pandemic would lead to a higher incidence of cdi in hospitalized patients. we conducted a retrospective cohort analysis at a high-volume tertiary-care center comparing a pre-covid-19 cohort (february-june 2019) of all adult patients who were diagnosed with cdi on admission or during their hospitalization with a cohort during the covid-19 pandemic (february-june 2020). baseline categorical variables were compared using χ 2 tests and continuous variables were compared using the student t test and mann-whitney-wilcoxon test. all analysis was performed in sas version 9.4 software (sas institute, cary, nc). primary outcomes of interest included rates of hospital-onset cdi (ho-cdi, defined as a positive c. difficile test over 3 days after admission), 4 antibiotic prescribing and length of stay. ho-cdi incidence was described by the standardized infection ratios (sir), which adjusts for facility and patient-level factors that contribute to hospitalonset infection risk within each facility. antibiotic prescriptions were measured by antibiotic days per 1,000 days present. the study was approved by the institutional review board of the icahn school of medicine at mount sinai. overall, ho-cdi sir 5 was not statistically different during the covid-19 period than during the 2019 period (p = 0.69) (fig. 1a) . for all months, our sir remained <1, indicating that the number of observed infections was fewer than the number of predicted infections. compared to the same period in 2019, there were fewer c. difficile tests sent during the covid-19 period, but this was not significant (p = .86) (fig. 1b) . interestingly, we detected a trend toward a higher percentage of positive tests (p = .15) during the pandemic than in the pre-covid-19 time period. we detected a trend toward increased length of stay during the covid-19 period (fig. 1c) and increased rate of high-risk antibiotic prescriptions predisposing to cdi, including clindamycin, fluoroquinolones, and thirdgeneration cephalosporins (p = .06) (fig. 1d) . there was no difference in mean age at cdi diagnosis, sex, and location at time of cdi diagnosis (eg, intensive care units or stepdown settings versus medical and surgical wards) between the covid-19 and the pre-covid-19 cohorts. at a high-volume, academic, tertiary-care center in an epicenter of the covid-19 pandemic, we did not find a difference in hospital-onset cdi rate despite a trend toward increased high-risk antibiotic exposures. although there is growing concern over the increased use of broad-spectrum antibiotics for patients during the pandemic, our data suggest that the rate of cdi was not affected. 6 we detected a trend toward increased length of stay, especially during our peak covid-19 census in april, which may predispose patients to hospital-acquired infections, including cdi. we detected a trend toward decreased c. difficile testing volume during the covid-19 period, but a higher percentage of tests returned positive. patients who presented with diarrhea during the pandemic may have had their diarrheal symptoms attributed to sars-cov-2, and c. difficile testing may not have been sent in that setting. although diarrhea can be a symptom of covid-19, clinicians must be cognizant that these patients remain at high risk for cdi. our data underscore the continued incidence of ho-cdi in hospitals. the limitations of our study include lack of patient-level data; individual risk factors for developing ho-cdi (eg, a patient's immunocompromised status) may have differed between our pre-covid-19 and covid-19 cohort. whether covid-19 itself increases an individual's risk for cdi remains unclear. multiple contributing factors drive cdi incidence, severity, and recurrence. although ppe use including gowns and gloves during covid-19 increased, efforts to curb cdi transmission in the hospital setting should continue to emphasize the importance of antimicrobial stewardship, especially as this pandemic re-emerges globally. reassuringly, cdi rates do not appear to significantly increase during the covid-19 pandemic. clostridium difficile infection in acute-care hospitals: systematic review and best practices for prevention clinical practice guidelines for clostridium difficile infection in adults and children: 2017 update by the infectious diseases society of america (idsa) and society for healthcare epidemiology of america (shea) new york city department of health and mental hygiene website national health care safety network (nhsn) faq: multidrug-resistant organism and clostridioides difficile infection the nhsn standardized infection ratio. centers for disease control and prevention website alarming antimicrobial resistance trends emerge globally acknowledgments.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-331227-s7lrzu99 authors: su, ke; ma, yiqiong; wang, yujuan; song, yuan; lv, xifen; wei, zhongping; shi, ming; ding, guohua; shen, bo; wang, huiming title: how we mitigated and contained the covid-19 outbreak in a hemodialysis center: lessons and experience date: 2020-04-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.161 sha: doc_id: 331227 cord_uid: s7lrzu99 nan to the editor-covid-19 has become a worldwide pandemic. after 2 months of strict control and prevention measures, the covid-19 epidemic has been contained successfully in wuhan. we have summarized lessons and experiences related to the reduction of nosocomial covid-19 in the hemodialysis center for the benefit of healthcare providers and administrations outside china who are facing the challenges of the covid-19 pandemic. hemodialysis patients are particularly vulnerable to infection and may exhibit greater variations in clinical symptoms and infectivity. hemodialysis patients are susceptible to infection for the following reasons: (1) hemodialysis patients require frequent transportation to and from the hospital and their residence to receive dialysis 2 to 3 times per week, which increases the risk of covid-19 transmission. (2) hemodialysis patients often require care from family members or caregivers, and if a caregiver is infected, they can transmit the virus to all close contacts, including the hemodialysis patient. (3) the hemodialysis center is a relatively open space with personnel (eg, medical staff and facility workers), patients, and their family members. thus, many people gather in hemodialysis centers, posing a risk for a virus transmission cluster. (4) hemodialysis patients infected with covid-19 may lack typical clinical symptoms (eg, fever, cough, or other respiratory symptoms, or the typical ground-glass image computed tomography (ct) scan of the lungs); they may appear asymptomatic or may have mild symptoms. chest ct images of hemodialysis patients often show acute exudative lesions, lung consolidation, or interstitial changes. these factors increase the difficulty medical workers face in identifying and diagnosing covid-19 in hemodialysis patients. for these reasons, sars-cov-2 spreads quickly in hemodialysis centers. to prevent the spread of sars-cov-2 in our hemodialysis center, the people's hospital of wuhan university, we consulted with the hubei province public health authorities to develop a series of key strategies to help prevent and mitigate the spread of sars-cov-2. here, we describe the control measures that were implemented. to maximize the safety of hemodialysis patients and staff, we continually monitored all persons in our hemodialysis center, including hemodialysis patients and their family members (or caregivers), healthcare workers, and facility workers. we recommend monitoring body temperature and respiratory symptoms, conducting routine blood routine tests, conducting nasopharyngeal or pharyngeal swab sars-cov-2 nucleic acid tests, and performing chest ct scans to screening for covid-19. 1 testing for sars-cov-2 igg and igm antibodies in serum is also recommended. 2 chest ct scans are very important in screening hemodialysis patients for covid-19. we repeated ct scans every 2 weeks to recognize and isolated patients as early as possible in the incubation period. based on screening results and the guidelines of the china national health commission (6th and 7th editions), personnel in our hemodialysis center can be classified into 5 groups: (1) confirmed cases: a person with laboratory confirmation of covid-19 infection (covid-19 nucleic acid testing positive), irrespective of clinical signs and symptoms; (2) suspected cases: patients who satisfy epidemiological and clinical criteria (fever or respiratory symptoms and typical ct imaging features) but without laboratory confirmation; (3) patients with clinical manifestations but who cannot be excluded from covid-19 through ct imaging; (4) those who have had close contact with a confirmed case; and (5) non-covid-19 patients. we distributed hemodialysis patients to different hemodialysis centers or hospitals according to the screening results as follows ( fig. 1): (1) hemodialysis patients with confirmed or suspected covid-19 infection were required to be admitted to a negative pressure isolation ward of specified hospitals where only hemodialysis patients with covid-19 were cared for. if the capacity of the isolation facility was overloaded, the "fixed dialysis care model" outlined below was followed. 3 author for correspondence: huiming wang, e-mail: rm000301@whu.edu.cn. could not be excluded from covid-19 through ct imaging and who had had due to close contact with a confirmed case remained hospitalized in a quarantined ward and received continuous renal replacement therapy (crrt). dialysis shifts, dialysis units, and caregiver staff were not be changed to prevent cross contamination and infection. contact with relatives was minimized. these quarantine hemodialysis patients underwent the testing outlined previously during the 14-day quarantine period. once a hemodialysis patient converted to a confirmed case, the patient was treated under confirmed case management protocols. screening for patients only once was not enough; repeated screening was needed to identify probable cases. (4) when hemodialysis patients with covid-19 recovered, they were transferred to a quarantine ward for recovered patients for 14 days of observation. after 2 negative nucleic acid tests, the patient could be transferred to the uncontaminated hemodialysis center. if any healthcare personnel were confirmed with covid-19 or had a probable case, they were also quarantined. 4 these measures have proven effective. after the beginning of outbreak, there were 37 covid-19 cases among 230 hemodialysis patients (16.09%) and 4 cases among 33 staff (12.12%) who were suspected cases. furthermore, 7 confirmed and suspected hemodialysis patients died between february 4 and february 13, 2020. 5 also, 5 confirmed patients and no healthcare workers or facility workers were infected between february 14 and march 1, 2020. collectively, these strategies can effectively minimize clusters of infection while providing timely treatment for hemodialysis patients. guideline for diagnosis and treatment of novel coronavirus disease (version 6) the national health commission of prc website the novel coronavirus 2019 epidemic and kidneys interim additional guidance for infection prevention and control recommendations for patients with suspected or confirmed covid-19 in outpatient hemodialysis facilities novel coronavirus disease in hemodialysis (hd) patients: report from one hd center in fig. 1. personnel cohort in our hemodialysis center and distribution to a different ward acknowledgments.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-319427-jkxioc1j authors: mughal, mohsin sheraz; kaur, ikwinder preet; patton, chandler d.; mikhail, nagy h.; vareechon, chairut; granet, kenneth m. title: the prevalence of severe acute respiratory coronavirus virus 2 (sars-cov-2) igg antibodies in intensive care unit (icu) healthcare personnel (hcp) and its implications—a single-center, prospective, pilot study date: 2020-06-12 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.298 sha: doc_id: 319427 cord_uid: jkxioc1j nan to the editor-healthcare personnel (hcp), including practitioners, nursing staff, respiratory therapists, and the pronepositioning team caring for coronavirus disease 2019 (covid-19) patients in the intensive care unit (icu) are considered to have a high risk of exposure to severe acute respiratory syndrome coronavirus 2 (sars-cov-2). most patients admitted to the icu are severely sick and need to be intubated. high-risk procedures for droplet dispersion, including tracheal intubation and tracheostomy tube placement, can be performed in the icu. 1 in a community seroprevalence study in los angeles county, the prevalence of antibodies to sars-cov-2 was 4.65%. 2 to our knowledge, no other study has addressed the prevalence of subclinical seroconversion of sars-cov-2 among hcp in the icu setting. in this study, we investigated the seroconversion of asymptomatic sars-cov-2 infection in icu hcp exposed to critically ill covid-19 patients. this single-center, prospective, pilot study was performed in an icu at a teaching hospital, monmouth medical center in long branch, new jersey. it was approved by our institutional review board. all hcp caring for covid-19 patients in the icu setting from march 1, 2020, to april 30, 2020, were eligible for inclusion in the study. a cross-sectional survey questionnaire was utilized to collect demographic characteristics and to exclude hcp who (1) tested positive for sars-cov-2 by reverse transcriptasepolymerase chain reaction assay (rt-pcr), (2) had symptoms consistent with covid-19, or (3) had covid-19 exposure in a household setting. in total, 134 icu hcp responded to the survey, and 121 hcp were eligible for sars-cov-2-specific igg antibody testing. means and interquartile ranges (iqrs) were used for continuous variables. all participants provided written consent. antibody testing was performed on the sera using a rapid immunochromatography test (standard q covid-19 igm/igg duo, sd biosensor, suwon-si, korea) by lateral flow in a clinical laboratory improvement amendments certified (clia), high-complexity laboratory. the manufacturer's stated sensitivity and specificity for igg, 15-21 days after symptoms onset are 96.2% and 96.6%, respectively. blood specimens were drawn from 2 weeks after the specified period commencing may 14, 2020, and ending may 19, 2020. overall, 134 icu hcp responded to the survey: 75% were women, 47.73% were registered nurses, 9.85% were attending physicians, 26.52% were resident physicians, 6.82% were patient care assistants, 6.82% were respiratory therapists, 1.52% were technicians, and 0.76% were anesthetists. the mean age of the respondents was 39.2 years (iqr, 28-48.5). the mean duration of work was 29.3 days (iqr, 16.0-40.0). of 134 icu hcp eligible staff, 13 were excluded and 121 underwent sars-cov-2-specific igg antibody testing. one individual tested positive and 1 test result was inconclusive due to a faulty test kit and was removed from the analysis. in this study, the prevalence of asymptomatic seroconversion was 0.83%. information about the prevalence of asymptomatic seroconversion of sars-cov-2 in hcp is limited. in a preliminary report released by the centers for disease control and prevention (cdc), nearly 9,282 hcp have contracted covid-19, and 27 have died. 3 okba et al 4 demonstrated that most pcr-confirmed sars-cov-2 patients seroconverted after 2 weeks of disease onset. 4 our study revealed a prevalence of 0.83%, which indicates that seroconversion in icu hcp was a rare event. these data indicate that proper education and utilization of personal protective equipment (ppe) is effective. 5 additionally, ventilated patients have less aerosolization and were housed in a negative-pressure environment in the icu isolation rooms, which also may have been factors in avoiding transmission to hcp. our study has several limitations. it was conducted in a single-center icu and did not include long-term clinical or laboratory follow-up. studies with larger sample sizes in different healthcare settings would be useful to validate the clinical impact of our findings. aerosol-generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review seroprevalence of sars-cov-2-specific antibodies among adults in characteristics of healthcare personnel with covid-19-united states severe acute respiratory syndrome coronavirus 2−specific antibody responses in coronavirus disease 2019 patients effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) acknowledgments. we acknowledge dr violet e kramer md and dr margaret h eng md for their assistance. we acknowledge joann wolfson dnp, msn, ccrn, with critical care services and joseph jaeger, drph, chief academic officer, as well as ali jaffery, for contributing to data collection. we acknowledge barbara mihelic for institutional review board support at monmouth medical center, long branch, new jersey.financial support. no financial support was provided relevant to this article.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-289901-xb1wg3xv authors: krantz, steven g.; rao, arni s.r. srinivasa title: level of underreporting including underdiagnosis before the first peak of covid-19 in various countries: preliminary retrospective results based on wavelets and deterministic modeling date: 2020-04-09 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.116 sha: doc_id: 289901 cord_uid: xb1wg3xv nan new methods using harmonic analysis and wavelets that we are developing-some of them recently accepted-will be of timely use. 5 we propose a model-based evaluation of underreporting of coronavirus in various countries using the methods we recently developed using harmonic analysis, 5 that is, to develop full epidemic data from partial data (using a wavelet approach). however, the current article is a preliminary analysis and modeling was done using the data available as of march 9, 2020. these data do not represent the pandemic in its entire scale; such data will need to be reevaluated when the pandemic is completely controlled. however, our predictions for underreporting as of march 9 in a couple of european countries were close to the reported number of covid-19 cases as more cases surfaced from march 9 to march 16, 2020. wavelets of reported cases and adjusted estimates with the underreported cases are shown in figure 1 . we also anticipate using other techniques [5] [6] [7] [8] [9] to further understand the reporting once more data become available. we collected covid-19 and population data for each country from the world health organization (who), 1 worldometer, 2 and world bank 10 sources. we used population densities, proportion of the population living in urban areas, and populations delineated by 3 age groups: 0-14 years, 15-64 years, and ≥65 years. furthermore, we considered daily new cases (>10) up to the first reported peak of covid-19 cases and the corresponding date ranges for all the countries for which such data were available. this range of days varied between 8 and 16 days (table 1) . we use 2 coupled differential equations and the united states: 0.75 and 1.5. the difference between model-predicted numbers and the actual numbers reported within the range were treated as underreported, which includes underdiagnosed cases. we constructed the meyer wavelets for the reported and adjusted data after adjusting the infected number in the population for underreporting. the meyer wavelet is a differentiable function, ! ð þ, which is infinitely differentiable in the domain with a function u as follows: table 1 . here, u x ð þ ¼ 0 for x<0, u x ð þ ¼ x for x 2 0; 1 ð þ, and u x ð þ ¼ 1 for x1 for further details, please refer to krantz et al 5 and krantz. 9 as of march 16, 2020, we did not have enough data on covid-19 transmissibility rates from infected to uninfected persons based on migration of populations to construct countrywide networks. we also had no clear idea of the duration that sars-cov-2 virus remains active on nonliving surfaces such as plastics, metals, paper, etc; thus, we did not consider the interaction between humans and nonliving surfaces. mathematical modeling can be made more complex by adding more parameters, but caution is necessary to ensure that these studies are well designed and that these parameters use readily available, scientifically collected data. once we obtain more data on the duration of covid-19 living on nonliving surfaces, we can build more complex models with more parameters. who situational report-49 identification of covid-19 can be quicker through artificial intelligence framework using a mobile phone-based survey in the populations when cities and towns are under quarantine nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study true epidemic growth construction through harmonic analysis understanding theoretically the impact of reporting of disease cases in epidemiology underreporting and case fatality estimates for emerging epidemics modelling underreporting in epidemics a panorama of harmonic analysis. the carus mathematical monographs the world bank open data website acknowledgments. we thank the journal's editor-in-chief, associate editor (handling), and the statistical consultant for their constructive comments.financial support. no financial support was provided relevant to this article. authors contributions. both the authors contributed in writing. asrs rao designed the study, developed the methods, collected data, performed analysis, computing, wrote the first draft. sg krantz designed the study, contributed in writing, performed analysis, editing the draft. key: cord-335932-0phqok4g authors: vanhems, philippe; saadatian-elahi, mitra; chuzeville, michel; marion, elodie; favrelle, louise; hilliquin, delphine; martin-gaujard, geraldine; gourmelon, robin; noaillon, mathilde; khanafer, nagham title: rapid nosocomial spread of sars-cov-2 in a french geriatric unit date: 2020-03-30 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.99 sha: doc_id: 335932 cord_uid: 0phqok4g lyon study group on covid19 infection (geriatric sectionalphabetic order): adrait, a, benoist f, castel-kremer e, chuzeville m, dupin ac, doh s, kim b, favrelle l, hilliquin d, kanafer n, marion e, martin-gaujard g, moyenin y, paulet-lafuma h, ricanet a, saadatian-elahi m, vanhems p. to the editor-sars-cov2 nosocomial transmission has been reported among healthcare professionals and patients. 1 however, few studies have focused on nosocomial clusters in elderly patients at high risk of morbidity and mortality. 1 with >6,600 cases, france is the fourth most affected european country. edouard herriot university hospital (1,100 beds) is the largest emergency hospital in the lyon area. we report the extremely rapid spread of covid-19 in a 24-bed geriatric unit. epidemiological investigation revealed the existence of 2 potential index cases. the first was a 97-year-old male admitted to the emergency room (er) with fever and dyspnea on february 29. the nasal swab for influenza and respiratory syncytial virus collected the same day was negative by polymerase chain reaction assay (pcr). the patient was transferred to the geriatric ward without complementary precautions. a second nasal swab was collected on march 7 and was positive for sars-cov2 by reverse-transcriptase pcr (rt-pcr). the second potential index case was a 76-year-old man admitted to the er with cough and fever on february 1. infection control measures were set up and nasal swab for influenza and respiratory syncytial virus (rsv) was negative by pcr. on march 3, the patient was transferred to the geriatric ward, where preventive air and contact measures were in place. the nasal swab previously collected was retested on march 6 and confirmed positive for sars-cov2 by rt-pcr. the first secondary case of covid-19 was diagnosed on march 10, and 5 other cases (including a medical doctor) occurred in the same unit until march 13 (fig. 1) . strict infection control measures and close monitoring of suspected cases of patients and healthcare professionals were subsequently performed to contain the intraunit transmission of the sars-cov-2 virus. the infection rate among patients was 20%. two patients (28.6%) died on march 14. no additional cases occurred. the likelihood of other sources of infection remains low, and no cases occurred in other areas of the ward. the area where the cases occurred was not primarily selected for covid-19 hospitalizations, and only 123 cases had been reported to the lyon regional health agency as of march 14, for a metropolitan area of 2,300,000 inhabitants. the rapid spread of nosocomial covid-19 in this ward confirms the contagiousness of sars-cov-2 in healthcare settings and the high mortality rates in this population. the existence of super-shedders has been suggested, 2,3 which could facilitate cluster emergence. we wish to stress the urgency of strict application of covid-19 infection control guidelines in healthcare facilities, particularly in geriatric units. exploring the reasons for healthcare workers infected with novel coronavirus disease 2019 (covid-19) in china secondary attack rate and superspreading events for sars-cov-2 pattern of early human-to-human transmission of wuhan rapid nosocomial spread of sars-cov-2 in a french geriatric unit key: cord-340132-t77pab71 authors: mohammadzadeh, nima; shahriary, mahla; nasri, erfan title: iran’s success in controlling the covid-19 pandemic date: 2020-04-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.169 sha: doc_id: 340132 cord_uid: t77pab71 nan to the editor-coronavirus disease 2019 (covid-19) is a respiratory tract infection ranging from mild respiratory illness (eg, respiratory symptoms, cough, fever, shortness of breath and breathing difficulties) to severe illness (eg, pneumonia, severe acute respiratory syndrome, kidney failure, and death) 1 that has caused an unprecedented global crises in <90 days in all 206 countries of the world. 2 today, most of the world's major cities are in full quarantine and all social and economic behaviors have been limited due to the sars-cov-2 outbreak. controlling the spread of the virus has become one of the most important challenges for governments across the globe. the increase in covid-19 cases in the advanced industrial countries, including italy, germany, france, spain, and united states, reflects the rapid spread of the virus. as of april 4, 2020, the following countries have been most affected: italy, with a populations of almost 60 million, has~119,827 covid-19 patients ( is rapidly increasing. iran, with a population of almost 81 million, has~44,605 covid-19 patients, with 2,898 deaths (fig. 1) . although iran has been heavily sanctioned in all fields of industry and pharmacy, it has taken important steps from the earliest days of the outbreak to combat the virus. 3 for example, italy, with an outbreak date similar to that of iran, has more than twice the disease incidence rate of iran. according to reports released by the ministries of health in iran and italy, 4, 5 iran formed a headquarters for the covid-19 crisis on february 23, when the virus count was~15 people per day. in contrast, in italy, the covid-19 crisis headquarters was formed on march 13, when the outbreak count was~2,500 per day. also, these countries' respective health ministries published safety and prevention guidelines for many locations, especially crowded centers including hospitals, clubs, transportation systems, schools, etc, in the early days of the outbreak. they also sought widespread collaboration with ngos and volunteers as well as extensive intragovernmental collaboration to ensure the observation of safety protocols to control the spread of disease. although traffic and concentration laws as well as heavy fines were not considered in the early days, these collaborations ultimately resulted in an 80% reduction in traffic between cities and as well as in social gatherings and even family gatherings. ultimately, all of these measures have led iran to better control the spread of the virus than other aforementioned industrialized countries. nevertheless, iran has a long way to go to achieve complete control of the pandemic. because iran is located among neighboring countries in a very high-risk area for many diseases, including tuberculosis, rabies, crimean congo fever, cholera, brucella, malaria, polio, and some others, it has been even more successful in controlling such diseases than the united states. 6 this experience and history are expected to be very useful and effective in controlling covid-19. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia covid-19 coronavirus pandemic. worldometer website covid-19) situation report-74. world health organization website iranian ministry of health and medical education website italian ministry of health and medical education brief outcome of five decades of battle with infectious diseases in iran acknowledgments.financial support. no financial support was provided relevant to this article.conflicts of interest. all authors report no conflicts of interest relevant to this article. key: cord-352671-k2lslpha authors: apaijitt, patthamaporn; wiwanitkit, viroj title: knowledge of coronavirus disease 2019 (covid-19) by medical personnel in a rural area of thailand date: 2020-04-22 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.159 sha: doc_id: 352671 cord_uid: k2lslpha nan to the editor-coronavirus disease (covid-19) is a new respiratory infection that is a global public health problem; as of february 28, 2020, it had already caused disease in >60 countries. after it first appeared in china, 1 thailand became the second country where covid-19 occurred. 2 presently, covid-19 is under surveillance in thailand. even after several attempts to control the disease, both imported cases and local transmissions still occur. 3 based on the knowledge, attitude, practice (kap) theory, good knowledge is necessary for successful disease control. here, we report the results of a questionnaire on knowledge of covid-19 administered to medical personnel in a rural area of thailand. the setting is the nang rong district, a rural region of thailand in buriram province,~410 km from bangkok and adjacent to cambodia. briefly, a 10-question questionnaire (table 1 ) was used to test the overall knowledge of 124 medical personnel (42 males and 82 females; average age, 36.7 ± 7.9 years) working in the study area (5 physicians, 81 nurses, 20 nurse assistants, 12 public health workers, and 6 other medical workers). the average total knowledge score was 6.26 ± 1.42. we observed no association between the total knowledge score and sex or age, but there was a significant association between total knowledge score and type of medical personnel. many medical personnel still have a low level of overall knowledge about covid-19, despite the emergence of the disease in thailand and after several public health policies counteracting the outbreak have been implemented. surprisingly, some physicians have a lower knowledge score than nonphysicians. these data indicate the necessity to improve education about the new disease among medical personnel. medical personnel also educate the local population regarding disease and precautions, and if medical personnel are not knowledgeable, disease control may not succeed. emerging new coronavirus infection in wuhan, china: situation in early 2020 editorial: wuhan coronavirus outbreak and imported case imported cases of 2019-novel coronavirus (2019-ncov) infections in thailand: mathematical modelling of the outbreak acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-298693-x25r0gtt authors: advani, sonali d.; yarrington, michael e.; smith, becky a.; anderson, deverick j.; sexton, daniel j. title: are we forgetting the “universal” in universal masking? current challenges and future solutions date: 2020-07-16 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.333 sha: doc_id: 298693 cord_uid: x25r0gtt nan overall, hcp compliance with protective measures such as universal masking often correlates with the level of risk they perceive. individuals are more likely to comply with recommended prevention measures if they perceive themselves to be at higher risk of harm in a particular situation or setting. 5 hcps commonly perceive their risk of contracting covid-19 from an infected patient to be higher than the risk of exposure to an asymptomatic coworker. ironically, hcps spend more time in close proximity to their coworkers than infected patients. a recent study demonstrated that <5% of exposed hcps tested positive for sars-cov-2 despite exposure to an infected patient without adequate personal protective equipment (ppe), although most hcp attribute greater risk to this type of exposure. 6 the propensity among hcps to perform inaccurate risk assessments has been seen with other basic infection prevention measures such as hand hygiene. 7 earlier this year, public health authorities pointed out a lack of evidence related to the use of universal masking by the general public to prevent acquisition of sars-cov-2. later, a member of the world health organization (who) stated in june 2020 that asymptomatic spread of sars-cov-2 is 'very rare.' the who quickly modified and clarified this statement by stating that asymptomatic spread is incompletely understood even though it actually occurs, contributing to ongoing confusion. furthermore, a few high-ranking political leaders and millions of citizens routinely ignore the current recommendation to use face coverings in indoor settings and when in close proximity with others. inconsistent, contradictory and unclear advice from public health authorities has contributed to widespread confusion about the utility of universal masking in preventing the spread of sars-cov-2 (response efficacy). 5 the cdc recently updated their exposure guidelines and issued a new "frequently asked question" on may 29, 2019, recommending the use of eye protection when caring for patients in areas of "moderate to substantial community transmission [of sars-cov-2]," even if covid-19 is not suspected. 8, 9 in our opinion, this guidance is confusing and adds an unnecessary emphasis on the use of additional ppe by hcps when in direct contact with patients and does not place emphasis on the need for universal masking of patients when staff are in close proximity to patients. covid-19 fatigue, a term that describes drift in following preventative measures as this pandemic goes on, is an important cause of poor compliance with policies related to universal masking. 10 this "fatigue" among hcps may be potentially related to their long work hours, required interactions with other team members throughout the day, the burden of wearing additional eye protection and uncomfortable or poor-quality masks. for effective behavioral change, wearing a mask must become a habit for hcps in all shared spaces inside and outside the workplace, outside of their immediate household and when appropriate physical distancing is not possible. 11 we need to work closely with hcps to better understand the root causes for poor masking compliance and to identify and remove barriers to doing the right thing. simple solutions such as educational campaigns on the rationale for masking, creation of a mask committee comprised of key stakeholders from various worker types to serve as champions, making physical changes to the environment to facilitate distancing, offering better quality masks, as well as suitable and accessable alternate locations that allow for physical separation to occur while hcps are unmasked during breaks, will likely lead to improved compliance. finally, we need clear, simple, and consistent messaging from public health authorities for successful implementation of universal masking policies. our goal should be to focus on the simple message of universal masking to prevent the transmission of sars-cov-2. healthcare epidemiologists and public health professionals need to learn the art of salesmanship during these times because the message itself, though important, is only as good as the leader that presents it to the public. 12 universal masking in hospitals in the covid-19 era: is it time to consider shielding? pandemic planning resources universal masking in hospitals in the covid-19 era universal masking is an effective strategy to flatten the sars-2-cov healthcare worker epidemiologic curve overcoming covid-19: addressing the perception of risk and transitioning protective behaviors to habits covid-19 infections among hcws exposed to a patient with a delayed diagnosis of covid-19 observing and improving hand hygiene compliance: implementation and refinement of an electronicassisted direct-observer hand hygiene audit program practice and technique of using face mask amongst adults in the community: a cross-sectional descriptive study an intervention designed to investigate habit formation in a novel health behaviour hospital epidemiologists and the art of salesmanship acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-331369-q7opbz7v authors: alharthy, abdulrahman; faqihi, fahad; mhawish, huda; balhamar, abdullah; memish, ziad a.; karakitsos, dimitrios title: configuring a hospital in the covid-19 era by integrating crisis management logistics date: 2020-07-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.365 sha: doc_id: 331369 cord_uid: q7opbz7v nan to the editor-the novel coronavirus sars-cov-2 disease (covid-19) emerged in china and has spread throughout the world. 1 the first case of covid-19 in saudi arabia was confirmed on march 2, 2020, and presently almost 200,000 people have been infected here. 2 the ministry of health (moh) has responded to the covid-19 outbreak by designing clusters of governmental hospitals to accommodate the increased flow of patients. although our bed-occupancy rates never exceeded 80% until 2019, the situation has changed dramatically since march 2020, when the intensive care unit (icu) occupancy rates reached 100% due to the pandemic. hence, our hospital has been under pressure to upgrade our icu services. we have used crisis management tactics in configuring our medical city (table 1) . first, we created a multidisciplinary crisis management team (cmt) to supervise the operations, and we promptly applied a surge plan based on the available scientific evidence. our cmt policies, icu configuration strategy, staff and resource utilization, admission protocols, and therapeutic guidelines have been reviewed continually based on new international updates, emerging therapies, and the recommendations of our national health authorities. [2] [3] [4] [5] by adjusting, and retrofitting existing icus, and acute wards. we have expanded the icu bed capacity in a stepwise manner: phase 1, 180 beds; phase 2, 240 beds; phase 3, 300 beds). our main challenge has been to install new structures (ie, gas access, power circuits, monitors, and hepa purifiers) in the pop-up units. we could not maintain single-patient occupancy; thus, we isolated cohorts of covid-19 patients in multiple-occupancy glass rooms. nursing stations have been set up outside these rooms; new circuits have been installed for the transmission of data and alarms; and new procedure carts have been arranged for each new unit. the icu-bed triage and staff governance have been controlled by the cmt. our cmt members have provided coverage 24 hours per day, 7 days per week to arrange the icu admission flow and the transfer of patients to other hospitals based on the daily moh plan. we have followed a tiered strategy in which we allocate experienced inten-sivists and nurses to supervise redeployed noncritical care physicians and nurses, and we also established back-up teams. the refinement of the respiratory and icu care included changing the ventilator circuits and filters based on patient needs, avoiding nebulizers, creating specialized intubation and prone-positioning ventilation teams, and upgrading the oxygen supply system. the latter has been a major problem for our oxygen supply management team. hence, we have promoted awake prone positioning and more oxygen-support therapies (ie, high-flow nasal cannula, and helmet continuous positive pressure ventilation) to avoid mechanical ventilation if possible. interventional therapies (ie, extracorporeal membrane oxygenation and therapeutic plasma exchange) have been carefully screened by expert teams to optimize resource utilization. the icu pharmacy operations have been linked to the moh central stock and supervised by pharmacists of the cmt to facilitate the prompt delivery of medications. infection control measures have been strictly implemented in all hospital areas by creating specific zones and protocols for donning and doffing personal protective equipment, providing sanitizer dispensers, applying strict room-disinfection protocols, and providing safe waste handling. 6 moreover, we have utilized novel transportation capsule isolation technology to minimize the risk of sars-cov-2 acquisition during inter-and intrahospital transportation. 7 new hospital communication systems have been installed in the pop-up icus. the communication between frontline staff and the cmt is continuous. because visitors were not allowed, family meetings were organized via web-based applications to reduce patient and family stress. training and emotional staff support have been provided on a daily basis. we have utilized daily covid-19 training sessions to provide additional emotional reassurance (ie, dual training and emotional support strategy). moreover,~600 covid-19 patients have been hospitalized in our icu over the past 4 months. our staff's nosocomial infection rate was~3% during the early stages of the pandemic, and it has decreased to 0.5% since may 2020. as the current wave of covid-19 subsides, we are focusing on maintaining our costly infrastructure upgrades. these could ensure that a proper set-up would be available to meet future needs. [3] [4] [5] stores of equipment, medications, and technical gadgets remains under cmt supervision. continuous medical education of our staff about covid-19 by our moh could facilitate the management of future outbreaks. regardless of the limitations in any healthcare system, hospitals should be prepared for future pandemics. clinical characteristics of coronavirus disease 2019 in china covid-19) guidelines (revised version 1.7). saudi ministry of health website hospital preparedness for covid-19: a practical guide from a critical care perspective critical care crisis and some recommendations during the covid-19 epidemic in china covid-19 in china: ten critical issues for intensive care medicine escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (covid-19) due to sars-cov-2 in hong kong novel transportation capsule technology could reduce the exposure risk to sars-cov-2 infection among health care workers: a feasibility study acknowledgments. we acknowledge all healthcare workers for their hard work and sacrifice in the fight against covid-19 in saudi arabia.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-305560-ade9wqwk authors: nestler, matthew j.; godbout, emily; lee, kimberly; kim, jihye; noda, andrew j.; taylor, perry; pryor, rachel; markley, j. daniel; doll, michelle; bearman, gonzalo; stevens, michael p. title: impact of covid-19 on pneumonia-focused antibiotic use at an academic medical center date: 2020-07-23 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.362 sha: doc_id: 305560 cord_uid: ade9wqwk nan to the editor-optimizing antimicrobial use and stewardship during the global spread of severe acute respiratory coronavirus virus 2 (sars-cov-2) is an important goal for health systems. a review published in may 2020 found that only 8% of patients with coronavirus disease 2019 (covid-19) had a bacterial or fungal coinfection, while 72% of patients received antimicrobial therapy. 1 many patients requiring hospitalization for covid-19 present with symptoms mimicking community-acquired bacterial pneumonia prompting empiric antibiotic use. 2 high antibiotic use might also stem from provider experience with hospitalized influenza patients of which 11%-35% may have a bacterial superinfection. 2, 3 antibiotic usage trends are starting to be published; a study by velasco arnaiz et al 4 showed increased pediatric inpatient azithromycin and ceftriaxone use in march and april of 2020 compared to the same months in 2019. we examined inpatient pneumonia-focused antibiotic use trends at virginia commonwealth university (vcu) health system, an 865-bed urban academic medical center. we hypothesized that antibiotic days of therapy per 1,000 patient days (dot per 1,000 pd) for key antimicrobials targeting pneumonia would be affected for april and may of 2020 when compared to the average dot per 1,000 pd over the preceding year due to the impact of covid-19 on our health system. the antibiotics ceftriaxone, azithromycin, levofloxacin, doxycycline, cefepime, piperacillin-tazobactam, meropenem, and vancomycin were chosen due to their common use for either communityacquired pneumonia (cap) or hospital-acquired/ventilatorassociated pneumonia (hap/vap) coverage. antibiotic dot per 1,000 pds were examined for 3 units: a medical intensive care unit (micu), a coronary intensive care unit (cicu), and a progressive medicine unit. the percentages of covid-19-positive patient days were calculated for each unit by month. for each unit, the normality of the april 2019-march 2020 monthly data were confirmed using a histogram and kurtosis or skewness scores. seasonality was also checked via graph and determined to not be a substantial influence on the data. a 2-sample t test assuming equal variances was performed with the first group being the april 2019-march 2020 monthly data and the second being april or may 2020. thus, we tested the null hypothesis that antibiotic use in april or may 2020 was the same as the mean use from april 2019 to march 2020. the 2-tailed p values are reported in table 1 and p ≤ .05 was considered significant. the analyses were conducted using excel version 2002 software (microsoft, redmond, wa). we detected a significant increase in april 2020 ceftriaxone use in the micu (p < .001), the cicu (p ≤ .001), and the progressive medicine unit (p = .0024) as well as april 2020 azithromycin use in the micu (p = .031) and pm (p < .001). there was a significant decrease for may 2020 levofloxacin use in the micu (p = .0066) and the progressive medicine unit (p = .029) ( table 1) . all 3 units demonstrated a significant increase in ceftriaxone use in april 2020. the micu and the progressive medicine unit also demonstrated increased azithromycin use in april 2020. notably, azithromycin use did not significantly increase in the cicu (perhaps related to a greater concern for risk for cardiac toxicity from this drug). ceftriaxone and azithromycin are commonly used for community-acquired pneumonia, and we suspect that their use increased to empirically cover bacterial superinfection in patients who were suspected of having covid-19. interestingly, the april and may use patterns appeared to be independent of unit covid-19 patient days (table 1 ). our hospital began testing all patients for sars-cov-2 on admission to the hospital on april 27, which may explain the reversion to baseline usage from april to may, especially in the cicu, where the total percentage of covid-19-positive patients remained low. our micu is a closed unit with a limited number of attending providers, and patients with covid-19 in the progressive medicine unit were mostly cared for by our hospital medicine group. possibly, these 2 respective groups developed experience with managing these patients over the course of april and this impacted the reversion author for correspondence: michael p. stevens, e-mail: michael.stevens@vcuhealth. org cite this article: nestler mj, et al. (2020) . impact of covid-19 on pneumonia-focused antibiotic use at an academic medical center. infection control & hospital epidemiology, https://doi.org/10.1017/ice. 2020.362 in antibiotic use trends. more research is needed to more fully understand these use trends. there was no significant increase in the use of antipseudomonal β-lactams (ie, cefepime, piperacillin-tazobactam, and meropenem) or vancomycin across the units studied. this finding suggests that clinicians were empirically using cap-focused antibiotics in april 2020 (with the exception of the cicu with azithromycin) as opposed to empirically giving hap-or vap-focused antibiotics. our hospital has a longstanding and aggressive antimicrobial stewardship program that has published cap and hap/vap guidelines. we suspect that these guidelines helped limit the use of hap/vap-focused antibiotic coverage in april; hap is defined in our guidelines as occurring ≥48 hours after admission with pneumonia not present at the time of admission. additionally, meropenem is restricted at vcu health. the decrease in levofloxacin use in the micu and pm units during may 2020 is not well understood and warrants further study. this analysis has several limitations. because it was conducted at a single medical center, our results may not be generalizable. additionally, our vancomycin use data include both iv and oral formulations, although we think the impact of this factor on our data is very low because iv administration is predominant at our hospital. the covid-19 pandemic has dramatically impacted health systems, and concern that antibiotic use may drive antibiotic resistance is widespread. our results indicate an initial uptick in capfocused empiric antibiotic use with a subsequent reversion to baseline use. notably, we did not see a significant increase in the use of antipseudomonal β-lactam antibiotics or vancomycin. the roles of active antimicrobial stewardship, local treatment protocols, and universal covid-19 testing on antibiotic use all warrant further study. bacterial and fungal co-infection in individuals with coronavirus: a rapid review to support covid-19 antimicrobial prescribing covid-19: don't neglect antimicrobial stewardship principles! the frequency of influenza and bacterial coinfection: a systematic review and metaanalysis pediatric antimicrobial stewardship in the covid-19 outbreak infect control hosp epidemiol acknowledgments.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-315585-bjij8ds7 authors: wee, liang en; hsieh, jenny yi chen; phua, ghee chee; tan, yuyang; conceicao, edwin philip; wijaya, limin; tan, thuan tong; tan, ban hock title: respiratory surveillance wards as a strategy to reduce nosocomial transmission of covid-19 through early detection: the experience of a tertiary-care hospital in singapore date: 2020-05-08 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.207 sha: doc_id: 315585 cord_uid: bjij8ds7 objectives: patients with covid-19 may present with respiratory syndromes indistinguishable from those caused by common viruses. early isolation and containment is challenging. although screening all patients with respiratory symptoms for covid-19 has been recommended, the practicality of such an effort has yet to be assessed. methods: over a 6-week period during a sars-cov-2 outbreak, our institution introduced a “respiratory surveillance ward” (rsw) to segregate all patients with respiratory symptoms in designated areas, where appropriate personal protective equipment (ppe) could be utilized until sars-cov-2 testing was done. patients could be transferred when sars-cov-2 tests were negative on 2 consecutive occasions, 24 hours apart. results: over the study period, 1,178 patients were admitted to the rsws. the mean length-of-stay (los) was 1.89 days (sd, 1.23). among confirmed cases of pneumonia admitted to the rsw, 5 of 310 patients (1.61%) tested positive for sars-cov-2. this finding was comparable to the pickup rate from our isolation ward. in total, 126 hcws were potentially exposed to these cases; however, only 3 (2.38%) required quarantine because most used appropriate ppe. in addition, 13 inpatients overlapped with the index cases during their stay in the rsw; of these 13 exposed inpatients, 1 patient subsequently developed covid-19 after exposure. no patient–hcw transmission was detected despite intensive surveillance. conclusions: our institution successfully utilized the strategy of an rsw over a 6-week period to contain a cluster of covid-19 cases and to prevent patient–hcw transmission. however, this method was resource-intensive in terms of testing and bed capacity. results: over the study period, 1,178 patients were admitted to the rsws. the mean length-of-stay (los) was 1.89 days (sd, 1.23). among confirmed cases of pneumonia admitted to the rsw, 5 of 310 patients (1.61%) tested positive for sars-cov-2. this finding was comparable to the pickup rate from our isolation ward. in total, 126 hcws were potentially exposed to these cases; however, only 3 (2.38%) required quarantine because most used appropriate ppe. in addition, 13 inpatients overlapped with the index cases during their stay in the rsw; of these 13 exposed inpatients, 1 patient subsequently developed covid-19 after exposure. no patient-hcw transmission was detected despite intensive surveillance. conclusions: our institution successfully utilized the strategy of an rsw over a 6-week period to contain a cluster of covid-19 cases and to prevent patient-hcw transmission. however, this method was resource-intensive in terms of testing and bed capacity. (received 3 april 2020; accepted 30 april 2020) in the covid-19 pandemic caused by the novel coronavirus, sars cov-2, attempts at containment have the best chance of reducing mortality. 1 as part of containment efforts, heightened surveillance is necessary to prevent sustained transmission in new locations. 2 early isolation of patients with probable or suspected covid-19 is important to reduce the likelihood of nosocomial spread of the disease. early reports highlighted significant nosocomial transmission, with almost one-third of patients comprising healthcare workers (hcws) and hospitalized inpatients. 3 however, patients with covid-19 may present with respiratory syndromes indistinguishable from those caused by common respiratory viruses, 4 which poses a challenge for early isolation and containment. during previous outbreaks of respiratory disease caused by novel pathogens, such as severe acute respiratory syndrome (sars) and middle eastern respiratory syndrome (mers), various admission strategies were utilized for containment, such as isolating all patients with febrile pneumonia 5,6 or a history of travel to at-risk areas. 7, 8 however, fever may not occur in all patients with covid-19 on initial presentation. 9 with significant community transmission, the value of a travel history invariably declines. given the devastating consequences of onward nosocomial transmission, 10 screening all patients presenting with respiratory syndromes for covid-19 has been advocated as a strategy. 11 however, the practicality of such a resource-intensive effort has yet to be studied. in singapore, the first imported case of covid-19 was reported at the end of january 2020; followed by the first documented case of local transmission in early february 2020. 12 by the end of february 2020, most cases were locally transmitted. 13, 14 a substantial proportion of cases were detected by enhanced surveillance, in which patients who did not fulfill case criteria for covid-19 were selected for testing. 15 here, we report our experience with a novel concept, a respiratory surveillance ward (rsw), which was introduced as a strategy for admission, triage and disposition of patients presenting with respiratory syndromes during a sars-cov-2 outbreak. singapore general hospital (sgh) is a 1,785-bed, public, tertiarycare hospital in singapore. on average, almost 2,000 cases of pneumonia are admitted through the emergency department (ed) each year, or~36 patients per week. 16 at our hospital, most patients are nursed in multibed cohort rooms rather than in single-occupancy rooms. we describe the experience with our institution's rsws over a 6-week period from february 5 through march 18, 2020, during the sars-cov-2 outbreak with community transmission. respiratory surveillance wards (rsws): admissions criteria, layout, infection control, and transfer criteria at our institution, high-risk patients that fulfilled suspect case criteria for covid-19 were admitted to an isolation ward with 37 negative-pressure rooms. for protection, staff in the isolation ward used n95 masks, eye protection (face shields), and disposable caps, gowns, and gloves. in general, the official suspect case criteria from our local ministry of health comprised a compatible clinical syndrome (pneumonia or acute respiratory disease of varying severity), together with a history of travel to high-risk countries affected by covid-19, and/or epidemiologic risk factors (eg, contact with a confirmed case of covid-19). 17 our institution employed a broader set of internal screening criteria in our triage process in the emergency department (ed) to identify and isolate suspected covid-19 cases early, with a cumulative sensitivity of 84.3% over the first 3 months of the outbreak. 17 however, given the presence of ongoing local transmission, we recognized that patients presenting with respiratory syndromes, but without any suspicious travel history or epidemiology links, might still have unsuspected covid-19. hence, all admissions with concomitant respiratory syndromes, without a travel history in the past 14 days or epidemiologic risk factors, were first admitted to the rsws where covid-19 was ruled out. at the point of admission to the rsw, a distinction was made between pneumonia (defined as the presence of infiltrates on the chest radiograph) and upper respiratory tract infection (urti, defined as the presence of respiratory symptoms such as breathlessness, cough, coryzal symptoms, but with a normal chest radiograph). for inpatients who did not have respiratory syndromes on admission but subsequently developed symptoms within 14 days of admission, primary physicians could discuss the possibility of transfer to the rsw with an infectious diseases (id) physician. over the study period, 115 beds were set aside for the rsws, comprising 38 single rooms (with dedicated bathroom) and 77 beds in cohort rooms (with 2-3 patients to a room and shared bathrooms). this ward comprised almost 10% of our hospital's bed capacity. single rooms or cohort rooms without any other patients were prioritized for admissions prior to the utilization of shared cohort rooms. patients suspected of having viral pneumonia (eg, normal procalcitonin, lymphopenia) were also prioritized for nursing in single rooms, depending on the clinical judgement of the attending physician and bed availability. rsws were run by respiratory medicine or internal medicine specialists. smaller subspecialty cohorts were created for oncology, cardiology, renal and surgical inpatients; these cohorts were run by designated clinical leads from these subspecialties. in the rsw, we recognized the small potential risk of an unsuspected covid-19 case; thus, a riskstratified approach was employed for the use of personal protective equipment (ppe). at the onset, n95 masks were used when handling patients with pneumonia, and surgical masks were used for handling patients with urti alone. from february 28 onward, given a rising number of unlinked cases detected in the community, n95 masks were used throughout the rsws. from march 18 onward, given the increased case detection in our rsw, healthcare workers (hcws) used full ppe including n95 masks, disposable gowns, gloves, and face shields. within the rsw, social distancing measures were employed; patients were advised to avoid mingling and provided surgical masks to wear at all times, and no visitors were allowed. beds were spaced at least ∼2 m apart by reducing the number of beds in a cohort room from 6 to 3, and partitions were placed between patient beds. 18 patients admitted to the rsw could be transferred for clinically urgent procedures/imaging investigations prior to the results of sars-cov-2 tests. in this case, patients wore surgical masks when being transferred and hcws transporting patients wore n95 masks with ppe at the receiving end, adapted to the kind of procedure being performed (eg, full ppe for all potential aerosol-generating procedures). patients in the rsw had access to full inpatient services, including allied health services, because our objective was to maintain infection control measures but not compromise patient care. patients admitted to the rsw for pneumonia had respiratory samples taken for sars-cov-2 testing on arrival; patients would only be transferred if sars-cov-2 tests were negative on 2 consecutive occasions at least 24 hours apart. 19 the requirement for 2 tests 24 hours apart was supported by local studies demonstrating increased testing yield due to the possibility of intermittent viral shedding or variations in sampling technique. 20 for patients admitted into the rsw with a primary nonrespiratory condition who concomitantly had urti, sars-cov-2 testing was performed if the patient was to be transferred from the designated wards, with the caveat that testing should only be done at day 5 of symptoms. this procedure was supported by local studies that obtained good testing yield when sampling patients presenting with a median of 5 days of symptoms. 20 additionally, because patients with urti symptoms were generally more well, this approach conserved testing resources in the initial phase of the outbreak. from march 1 onward, all patients with urti alone had 1 swab done on admission, followed by the second swab on day 5 of symptom onset. respiratory samples (oropharyngeal, nasopharyngeal, or sputum) were processed in our hospital's laboratory. investigation for sars-cov-2 rna was conducted using in-house qualitative realtime reverse transcription pcr (rrt-pcr) testing. the routine panel for respiratory virus testing included testing for influenza a, influenza b, respiratory syncytial virus (rsv), rhinoviruses, parainfluenza virus types 1-4, human metapneumovirus, coronaviruses, and adenoviruses. all patients with pneumonia also had sputum and blood specimens collected for culture; if they were deemed to have community-acquired pneumonia, urine was also tested for streptococcus and legionella antigens. this descriptive study was on surveillance data and only aggregate data were collected without patient identifiers; thus, ethics approval was not required under our hospital's institutional review board guidelines. over the study period, 1,739 inpatients underwent testing for sars-cov-2 in our institution. of these, 446 (25.6%) were classified as "suspected covid-19 cases" on admission, given suspicious epidemiological features, and they were directly admitted to the isolation ward. over the same period, 1,178 patients were admitted to the rsw because they were determined to have symptoms and signs of pneumonia or urti at the point of ed triage, but they did not have suspicious epidemiological features. the remaining 115 patients were not initially admitted to an isolation ward or the rsw, but they had a sars-cov-2 test, either because they were asymptomatic on admission but developed respiratory symptoms within 14 days of admission and approval for testing was given after discussion with an id physician, or because they were admitted directly to the intensive care unit (icu). thus, 1,178 of 1,739 inpatients (67.7%) tested for sars-cov-2 came from the rsw (fig. 1a) . in the rsws, 888 of these 1,178 (75.3%,) were managed within the general medicine rsws (fig. 1b) ; a minority were managed in the subspecialty cohorts. among the 888 patients managed in the general medicine rsws, the mean length-of-stay (los) was 1.89 days (sd, 1.23); 319 patients (35.9%) were discharged from the ward and the rest were transferred after their sars-cov-2 testing was negative. over the study period, 5 patients died on the general medicine rsw, but none died from covid-19. the average age of admitted patients was 68 years (sd, 17.49). also, 310 patients (34.9%) in the general medicine rsw had a diagnosis of pneumonia confirmed by the managing physician, and 200 (22.5%) had a diagnosis of urti. the remaining 378 patients had an alternative nonrespiratory or noninfective diagnosis (eg, fluid overload). differences in demographics, clinical characteristics, and outcomes of the 510 patients with pneumonia or urti admitted to general medicine rsws are presented in table 1 . patients diagnosed with pneumonia, compared with those admitted with urtis, tended to be older (mean age, 72.4 vs 58.3 years; p < .001) and had higher odds of presenting with raised inflammatory markers such as a raised white cell count or procalcitonin. they also had lower odds of being directly discharged from the rsws (29.0% vs 61.0%; odds ratio [or], 0.23; 95% confidence interval [ci], 0.17-0.42). the consolidated results of patients stratified by pneumonia and urti are presented in fig. 2 . among the 310 patients diagnosed with pneumonia, a microbiological diagnosis other than sars-cov-2 was obtained for 41 (13.2%) of these patients. in 27 patients, a viral etiology was identified; 18 had a bacterial etiology, 1 patient had pulmonary tuberculosis and 1 patient had pneumocystis pneumonia. the most common viral pathogen identified was rhinovirus (n = 7), followed by parainfluenza (n = 5) and metapneumovirus (n = 3). among the 200 patients with a urti, a microbiological diagnosis was obtained for 50 of them (25.0%). in 51 patients, a viral etiology was identified, and 4 had a bacterial etiology. the most common viral pathogen identified was rhinovirus (n = 16), followed by other coronaviruses (n = 8) and parainfluenza (n = 7). of the 510 patients with a final diagnosis of pneumonia or urti admitted to the rsw, 5 (0.98%) tested positive for sars-cov-2. over the same time period, among patients that fulfilled suspect case criteria for covid-19 admitted to our institution's isolation ward, 15 of 446 patients (3.36%) tested positive for sars-cov-2. over the same period, no covid-19 cases were admitted initially to nondesignated areas outside of the rsws or isolation wards. when cases of covid-19 were detected, the cases were transferred to the isolation ward, the cohort room was locked down, and any potentially exposed patients (defined as a patient sharing the same cubicle as a confirmed case) were also transferred to the isolation ward as a precautionary measure. in total, 126 hcws were potentially exposed; however, only 3 of these hcws (2.38%) required quarantine due to noncompliance with ppe guidelines. no exposed hcws developed covid-19 after exposure, despite intensive surveillance over a 14-day period. 21 hcws deemed to have significant unprotected exposure based on our local ministry of health guidelines were placed under a 14-day quarantine or home isolation, during which they were monitored for respiratory symptoms and submitted temperature measurements twice daily via our institution's electronic surveillance system. hcws with contact not amounting to significant unprotected exposure were allowed to continue work but were placed on daily active phone surveillance by our hospital. if symptoms developed within 14 days from the date of exposure, the hcw was instructed to return to the staff clinic for further evaluation and sars-cov-2 testing. among 126 exposed staff, 73 (57.9%) were subsequently tested for sars-cov-2 due to the development of symptoms after exposure; all were negative. in total, 13 inpatients were potentially exposed. of these 13 exposed inpatients, 1 patient subsequently went on to develop covid-19 after the exposure within the estimated incubation period. 22 this constituted a cluster of covid-19 cases with potential nosocomial transmission. in this case, staff had previously observed mingling between the mobile patients in the room, without compliance to surgical masks; subsequently, social distancing was reinforced, and advisories were posted in prominent areas to prevent mingling. 18 during an outbreak of sars-cov-2 with local transmission, an rsw to cohort all inpatients admitted from the community with respiratory symptoms may enhance case detection and reduce the potential of nosocomial transmission. 23 despite the apparent low yield of testing in the rsw, our efforts were part of the national strategy of containment of this novel pathogen at that juncture of the outbreak. our institution drew on experience with sars, in which exposed patients were triaged, quarantined, and cohorted in open-plan wards, 24 to conceptualize the rsw. this approach allowed high-risk covid-19 suspects to be prioritized for management in limited isolation facilities while maintaining vigilance by managing potentially at-risk patients in designated zones to contain the risk of nosocomial transmission. aggressive case detection through screening of all patients presenting with acute respiratory infection has been advocated as a potential containment strategy. 11, 25 our institution employed this strategy over a 6-week period, successfully containing a cluster of covid-19 infection with potential nosocomial transmission and avoiding patient-hcw transmission amongst exposed staff. although 5 previously unsuspected cases surfaced in the rsw over the 6-week period, only 13 patients were potentially exposed due to enhanced cohorting, whereas a single patient that surfaced in our institution's cohorted general ward resulted in the potential exposure of 18 patients. 18 given the importance of adequate ppe, 26 even a single case of covid-19 can result in the quarantine of large numbers of hcws if detected late, further straining hospital resources. 27 however, our study also reflects the practicality and costs of such a resource-intensive effort. beds set aside for the rsw comprised almost 10% of our institution's bed capacity. beds were freed up by reducing elective surgery; however, this method would not be sustainable in the long run. almost two-fifths of patients entering the rsw were subsequently deemed not to have pneumonia or urti, despite being originally triaged to these wards from the ed. this was unavoidable as during the outbreak our ed needed to quickly admit patients with suspected respiratory symptoms rather than risk potential exposure in the crowded ed. the requirement for 2 negative tests 24 hours apart reduced bed turnover, reflecting the cost of an aggressive containment strategy. several strategies might have reduced resource utilization; however, they would have compromised case detection. for instance, reducing the number of negative covid-19 tests from 2 to 1 would have reduced testing yield 20 ; the first covid-19 case detected in our rsw would have been missed using such an approach. focusing on febrile patients, as in sars, was also a consideration. 6 only 40% of patients admitted to our rsw had fever (>37.9°c) at presentation to the ed. however, our first case did not present with fever and would have been missed using this strategy. our study has several limitations. in our hospital, pcr testing for sars-cov-2 was utilized as a diagnostic modality. however, given that the diagnostic yield would likely be dependent on the quality and type of respiratory tract sample, as with other coronaviruses, 28 covid-19 cases may have been missed due to sampling issues. additionally, emerging data suggest the possibility of transmission in presymptomatic patients. 29 patients with atypical symptoms and presymptomatic patients could have been missed, similar to our institution's experience with sars, in which the index patient in our institution presented in a surgical ward. 30 although we did not screen all admissions for covid-19 due to the logistical challenges involved, 115 patients tested for sars-cov-2 did not have symptoms on admission and 378 patients were deemed not to have a diagnosis of pneumonia or urti on evaluation in the rsw; none of these patients tested positive. a risk-stratified approach of limiting testing to patients with respiratory symptoms on admission, as well as patients who developed respiratory symptoms within a pre-defined incubation period, 22 might offer a balanced approach to containing covid-19 during an outbreak with community transmission. in our institution, recognizing the possibility that not all covid-19 patients may be contained within the isolation ward or rsw, the usage of surgical masks in all clinical areas was made a mandatory minimum for all hcws. our results also reflect the experience of a healthcare institution in a covid-19 outbreak during which the prevailing national strategy was one of containment 13 ; exhaustive testing and surveillance may not be feasible in a healthcare system that is overwhelmed. 10 in conclusion, the strategy of using an rsw was successful in containing patients with covid-19 in designated areas where enhanced ppe and infrastructural enhancements could potentially reduce nosocomial transmission. a strategy of testing all admitted patients with pneumonia/urti picked up unsuspected cases of covid-19, allowing for rapid institution of measures to reduce potential onward transmission. on a knife's edge of a covid-19 pandemic: is containment still possible? novel coronavirus outbreak in wuhan, china, 2020: intense surveillance is vital for preventing sustained transmission in new locations clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china clinical features of patients infected with 2019 novel coronavirus in wuhan severe acute respiratory syndrome: historical, epidemiologic, and clinical features sars: hospital infection control and admission strategies active screening and surveillance in the united kingdom for middle east respiratory syndrome coronavirus in returning travellers and pilgrims from the middle east: a prospective descriptive study for the period 2013-2015 infection control measures for the prevention of mers coronavirus transmission in healthcare settings clinical characteristics of coronavirus disease 2019 in china covid-19 in a long-term care facility-king county coronavirus disease 2019 (covid-19): protecting hospitals from the invisible outbreak of covid-19-an urgent need for good science to silence our fears covid-19 in singapore-current experience: critical global issues that require attention and action using predicted imports of 2019-ncov cases to determine locations that may not be identifying all imported cases. biorxiv investigation of three clusters of covid-19 in singapore: implications for surveillance and response measures prognostic factors for mortality due to pneumonia among adults from different age groups in singapore and mortality predictions based on psi and curb-65 containing covid-19 in the emergency room: the role of improved case detection and segregation of suspect cases minimising intrahospital transmission of covid-19: the role of social distancing de-isolating covid-19 suspect cases: a continuing challenge testing for sars-cov-2: can we stop at two? clin infect dis containment of covid-19 cases amongst healthcare workers: the role of surveillance, early detection and outbreak management the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application curtailing transmission of severe acute respiratory syndrome within a community and its hospital management of inpatients exposed to an outbreak of severe acute respiratory syndrome (sars) the global community needs to swiftly ramp up the response to contain covid-19 exploring the reasons for healthcare workers infected with novel coronavirus disease 2019 (covid-19) in china covid-19 and the risk to healthcare workers: a case report mers coronavirus: diagnostics, epidemiology and transmission presymptomatic transmission of sars-cov-2-singapore sars transmission and hospital containment acknowledgments. the authors acknowledge the unstinting efforts of our colleagues against covid-19.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-341529-dmiy0l9c authors: siniscalchi, antonio; gallelli, luca title: could covid-19 represent a negative prognostic factor in patients with stroke? date: 2020-04-20 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.146 sha: doc_id: 341529 cord_uid: dmiy0l9c nan to the editor-coronavirus infectious disease 2019 (covid-19) is a highly contagious disease that has become a worldwide pandemic. coronaviruses (covs), positive-stranded rna viruses, are known to cause respiratory or intestinal infections in humans and animals. 1 coronaviruses are known to affect the cardiovascular system. 2 the sars-cov-2 virus uses the enzyme 2 receptor (ace2) to gain entry into cells, 3 and these receptors have been revealed in the neuronal and glial cells of the human brain. thus, they may be a potential target of sars-cov-2, which might explain the death of olfactory cells in patients with covid-19. 1 covs can enter the central nervous system through 2 distinct pathways: retrograde neuronal diffusion or hematogenous diffusion. the spread of sars-cov-2 through the cribriform plaque of the ethmoid bone during an initial or subsequent infection phase can lead to brain involvement. in the systemic circulation, the presence of ace2 receptors on both capillary and neuronal endothelial cells could be responsible for the subsequent spread and damage to the cerebral nervous system without substantial inflammation. the presence of covs in the cerebral nervous system has been confirmed in the cerebrospinal fluid and brain tissues of patients during autopsies. 4, 5 several symptoms indicative of cns involvement are present in approximately one-third of covid-19 patients: dizziness, headache, impaired consciousness, ataxia, epilepsy, and acute cerebrovascular disease. 1 changes in the coagulation system (ie, d-dimer and platelet abnormalities) 2,6 and in inflammatory biomarkers (eg, interleukin-6, c-reactive protein, and ferritin) 7 have been reported in covid-19 patients. in patients with stroke, the presence of covid-19 could be a potential extrinsic factor in the genesis or worsening of stroke. infection or high levels of proinflammatory biomarkers indicate significantly increased risk of ischemic stroke, especially in the elderly. [8] [9] [10] the onset or worsening of a stroke in these patients could be caused either by direct damage of the covs on the nervous system and/or by an activation of the mechanisms of covid-19 inflammation induced as well coagulation disorders. as the disease spreads and new evidence emerges, we need to identify the existence of additional pathophysiological mechanisms of stroke in covid-19 patients. we should establish a prospective registry of these patients to better identify the factors most responsible for a possible greater onset or worse prognosis of stroke in these patients and to identify and/or predict a better or lesser response of these patients to thrombolytic treatments. consensus for prevention and management of coronavirus disease 2019 (covid-19) for neurologists. stroke vasc neurol potential effects of coronaviruses on the cardiovascular system: a review evidence of the covid-19 virus targeting the cns: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms possible central nervous system infection by sars coronavirus detection of severe acute respiratory syndrome coronavirus in the brain: potential role of the chemokine mig in pathogenesis anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy clinical predictors of mortality due to covid-19 based on analysis of data o f 150 patients from wuhan, china. intensive care med previous infection and the risk of ischaemic stroke in italy: the in2 study anti-inflammatory strategies in stroke: a potential therapeutic target cerebral stroke injury: the role of cytokines and brain inflammation acknowledgments. antonio siniscalchi serves as national member for the italian national society of neurovascular disease (sinv).financial support. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.conflicts of interest. all authors state that they have no conflict of interest regarding this study. key: cord-313292-w0ud098l authors: moradi, hazhir; vaezi, atefeh title: lessons learned from korea: covid-19 pandemic date: 2020-04-03 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.104 sha: doc_id: 313292 cord_uid: w0ud098l nan appeared, and all of the places where the case patients had gone (eg, hotels, markets, and health facilities) were disinfected. 3 on february 21, when epidemiologic studies revealed 2 main sources of transmission, those places were defined as "special care zones" where a specialized team focused on controlling transmission, 9 and the alert level was elevated to the highest (severe). 10 rapid diagnosis and widespread testing were other areas of focus in korea. the proportion of confirmed to suspected cases varied from 0.5 in the initial days to 3.9 in the peak days. early detection helped korea eliminate the infection from the community and restrict it to health facilities, which is an essential aspect of outbreak response. also, research teams started their work in the very early days to develop rapid tests, treatments, and vaccines. from january 31 onward, the 6-hour test was distributed in some health facilities, and from february 7 onward, all health facilities all around the country had this test. 10 moreover, the kcdc started reporting the situation from january 20 onward to provide accurate and real-time data. these reports included the number of confirmed cases and patients under investigation, history of confirmed cases, and prevention advice for the public. the number of the kcdc call center has been mentioned in almost every report, and koreans were asked not to travel to china and wuhan, to avoid public outdoor activities, to cough or sneeze safely, and to wear masks when visiting a health center. besides, the guideline for management and screening get updated whenever needed; travel to wuhan which was in the definition of suspected cases where changed to travel to china, and finally omitted. 10 altogether, the main goal of outbreak response in korea was prevention of entrance of covid-19 and at the same time, inhibition of the spread of the virus throughout the country. these goals were achieved through 3 main strategies: (1) containment and mitigation based on outbreak situation; (2) risk communication to attract community participation; and (3) science-based and factdriven actions. who director-general's opening remarks at the media briefing on covid-19. world health organization website a novel coronavirus from patients with pneumonia in china covid-19) situation reports. world health organization website world health organization. a framework for global outbreak alert and response. geneva: world health organization public health crisis preparedness and response in korea the first case of 2019 novel coronavirus pneumonia imported into korea from wuhan, china: implication for infection prevention and control measures how to manage a public health crisis and bioterrorism in korea an update on the 2019-ncov outbreak transmission potential of covid-19 in south korea press release: news room, 2020. korean centers for disease control and prevention website acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-354538-vqi67h6a authors: sydney, elana r.; kishore, preeti; laniado, isaac; rucker, lisa m.; bajaj, komal; zinaman, michael j. title: antibody evidence of sars-cov-2 infection in healthcare workers in the bronx date: 2020-08-26 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.437 sha: doc_id: 354538 cord_uid: vqi67h6a nan 1. were there demographic differences among antibody-positive healthcare workers? 2. what departments had the highest number of positive antibody tests? 3. what is the prevalence of antibody positivity in symptomatic healthcare workers? 4. how many of the asymptomatic healthcare workers developed antibodies? 5. what is the prevalence of antibodies in those healthcare workers with self-reported positive and negative sars-cov-2 pcr tests? data were extracted from the electronic medical record and were deidentified for analysis. in total, 1,700 healthcare workers were tested for sars-cov-2 igg antibody between april 28 and may 4, 2020. we analyzed the data by looking at those healthcare workers that had positive antibodies and stratified it based on department, presence or absence of symptoms, and previously reported positive pcr. of the 1,700 individuals tested, sars-cov-2 igg antibodies were detected in 327 individuals (19%). among them, 221 healthcare workers with positive antibodies (67.6%) were women. the mean age of those that tested positive was 44 years (range, 22-73). the percentage of african-american healthcare workers that tested positive for antibodies was 27.2%. this was statistically significant compared to other racial groups that tested positive (p < .05). the highest prevalence (26% presence of igg) was detected in the emergency department and the behavioral health department ( table 1 ). the behavioral health department included the psychiatric emergency room and inpatient and outpatient psychiatry. suprisingly, the lowest prevalence was found in critical care staff, with 11% testing positive. more than half (53%) of the individuals tested reported having symptoms suggestive of covid-19. of these healthcare workers, 28% showed the presence of igg antibody, and 9% of asymptomatic healthcare workers had igg antibodies. notably, 12% of those who tested positive for the presence of igg reported a negative sars-cov-2 pcr result. as expected, 92% of individuals that reported a positive pcr test developed igg antibodies. a small number of individuals, representing 1% of those reporting a positive sars-cov-2 pcr test prior to being tested, had a negative antibody test. this finding is consistent with a previous report from china in which a small number of patients with covid-19 did not develop antibodies. 6 our results reflect a higher overall rate of sars-cov-2 antibody development among healthcare workers in the bronx compared to reported rates in nyc healthcare workers. 3 however, the rates were lower than the reported bronx community prevalence. 4 this finding is not unexpected because hospital staff had better access to protective equipment than did the general population as well as a heightened awareness of the seriousness of the infection. based on our findings, hospitals with psychiatric services, especially with psychiatric emergency departments, should consider increasing the use of sars-cov-2 transmission prevention resources. our african-american healthcare workers had a significant difference in antibody positivity. this finding needs to be confirmed in a larger study, and additional investigation is necessary to understand the reasons for this finding. the low rate of antibody development in critical care areas could be explained by the controlled environment and lower volume compared to other areas. finally, 12% of hospital staff who developed antibodies in spite of a negative pcr test could be explained by false-negative pcr testing, infection after the pcr test, or inaccurate self-report. it is unclear whether the presence of igg antibodies confers long-term immunity. emphasis is being placed on antibody testing for reopening the economy and return-to-work policies. 7, 8 however, only 1 in 5 healthcare workers developed antibodies during the peak of the pandemic at our hospital; thus, the utility of antibody testing to guide staffing considerations is limited. ultimately, development of prophylactic treatments and therapies for covid-19 is needed to ensure the safety of our healthcare workers pending the arrival of a vaccine. covid-19 data. nyc health website variation in covid-19 hospitalizations and death across new york city boroughs governor cuomo announces moratorium on covid-related evictions will be extended until eua authorized serology test performance. us food and drug administration website performance characteristics of the abbott architect sars-cov-2 igg assay and seroprevalence testing in idaho antibody responses to sars-cov-2 in patients with covid-19 covid-19: testing times bmj the promise and peril of antibody testing for covid-19 acknowledgments. we acknowledge the contribution of mr. ryan fraleigh in the data analysis of this manuscript.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-306913-7i7f3ntr authors: lin, hui-ling; fink, james b.; tsai, ying-huang; wan, gwo-hwa title: managing humidity support in intubated ventilated patients with coronavirus disease 2019 (covid-19) date: 2020-08-12 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.418 sha: doc_id: 306913 cord_uid: 7i7f3ntr nan to the editor-humidification is vital in supporting the airways of intubated and mechanically ventilated patients. we address the technical and practical issues of humidification methods selection, with recommendations to minimize bioaerosol dispersion during mechanical ventilation of infected patients with severe coronavirus disease 2019 (covid-19)-related acute respiratory distress. severe pneumonia or sepsis has an estimated 20% occurrence with covid-19, 1 and these conditions often require intubation and mechanical ventilatory support. clinical reviews have recommended the use of a heat and moisture exchanger (hme) for humidification during mechanical ventilation for intubated patients with infectious disease to minimize the risk of exposure the pathogens to healthcare workers (hcws). 2, 3 hmes are designed to capture heat and humidity from exhaled gas and to condition inhaled gas to a temperature of 29-32°c with 29-32 mg/l absolute humidity. a systematic review comparing the use of an hme with a heated humidification system during mechanical ventilation showed no difference in artificial airway occlusion, mortality, or pneumonia rate. however, the work of breathing was greater in the hme group, possibly due to increased resistance to gas flow. 4 additionally, hme is not recommended for use in patients with copious, thick secretions or low tidal volumes, which have been associated with mechanical ventilation of covid-19 patients. patients managed under lung-protective strategies likely have low tidal volume, and the additional dead space of an hme may further increase the ventilation requirement as well as increase the partial pressure of carbon dioxide. 1, 2 humans produce exhaled breath particles (ebp) ranging from 0.3 to 2.0 μm. 4 ebp concentrations are positively associated with tidal volume, ventilation ratio (tidal volume to vital capacity), deep exhalation, and breath volume. 4-6 a taiwanese study found that the ebp concentration from mechanically ventilated patients were in the range of 0.47-2,554 particles per breath. most ebps are <5 μm, and 80% of them range between 0.3 and 1 μm. 7 therefore, a bacterial/viral filter should be routinely placed at the end of expiratory limb of the ventilator circuit to prevent the pathogencontaining ebps from spreading to the hospital environment. simple hmes may allow up to 60% of medical aerosol to pass through, 8 so only the use of hme with an electrostatic bacterial filter (hmef) should be considered to reduce exhaled pathogens from intubated patients during mechanical ventilation. there are 2 types of bacterial filters: pleated hydrophobic filters and electrostatic filters. 9 the efficiency of electrostatic bacterial filters is greatly affected by humidity, in addition to internal volume, resistance, and fully saturated time. when gas pressure is applied to a wet filter in the ventilator circuit, the bacteria and viruses on the filter might be carried through the filter. furthermore, the condensate in an hmef might increase gas flow resistance and the risk blockage due to ingress and absorption of the water. a pleated hydrophobic filter is more suitable than an electrostatic filter in a humidified ventilator system. 9 we strongly recommend using a high-efficiency particulate air (hepa) filter at the expiratory port of the ventilator as a superior alternative to an hmef for pathogen filtration in a humidified ventilator system. one advantage for choosing an hme over heated humidification is the prevention of contaminated condensate spray generated when the ventilator circuit is disconnected from the patient. however, this benefit has not been characterized. during circuit disconnection, sudden depressurization generates shear-force from high ventilator gas flow, resulting in the expulsion of potentially contaminated condensates as bioaerosols. the dual-limb heated ventilator circuits have thermal insulation and breathable properties (ie, evaqu ventilator circuit) to reduce the condensate production in the circuits. one study showed that both a conventional reusable ventilator circuit system and a disposable ventilator circuit system combined with an autofilled heated humidifier and a closed suction catheter grew a large number of bacteria in the ventilator circuits. 10 thus, it is necessary to minimize the need for disconnecting the circuit from the ventilator, which greatly reduces the pathogen exposure via droplets and contact transmission to hcws. intubated, mechanically ventilated covid-19 patients who develop thick secretions may need to receive heated humidification rather than hme. in clinical practice, single-limb heated-wire ventilator circuit is more commonly used, and the system is sensitive to the surrounding temperature, generating a large volume of condensates in the circuit, especially in the expiratory limb of the ventilator circuit system. we recommend the use of aerosol precautions by hcws while opening the circuit when changing the hme or ventilator circuit to decrease the risk of exposure to bioaerosols. when changing the hme or dual-limb heated ventilator circuit, the ventilator should be placed on "stand-by" or "off" mode before disconnecting the circuit from the patient. the end of circuit should be capped immediately to prevent the expulsion of bacteriaor virus-containing ebps from the patient. in conclusion, to protect hcws caring for covid-19 patients during mechanical ventilation, the of using an hme or a dual-limb heated ventilator circuit with minimal condensate production should be considered. the selection should made according to the patient's minute ventilation and the amount and properties of secretions to provide adequate inhaled gas temperature and humidity. to protect hcws, a pleated hydrophobic filter with at least 99.97% filtration efficiency should be placed in the expiratory limb of the ventilator, and it should not be replaced by an hmef in a mechanical ventilation system. clinical management of severe acute respiratory infection (sari) when covid-19 disease is suspected interim guidance. world health orgnization website preparing your intensive care unit for the covid-19 pandemic: practical considerations and strategies critically-ill covid-19 patient effect of airway opening on production of exhaled particles characterization of exhaled particles from the healthy human lung-a systematic analysis in relation to pulmonary function variables effects of breath holding at low and high lung volumes on amount of exhaled particles particle size concentration distribution and influences on exhaled breath particles in mechanically ventilated patients secondhand aerosol exposure during mechanical ventilation with and without expiratory filters: an in-vitro study heat and moisture exchangers and breathing system filters: their use in anaesthesia and intensive care. part 2-practical use, including problems, and their use with paediatric patients potential risk for bacterial contamination in conventional reused ventilator systems and disposable closed ventilatorsuction systems acknowledgments. none.financial support. no financial support was provided relevant to this article. all authors report no conflicts of interest relevant to this article. key: cord-315689-a3tvoana authors: tan, caixia; xiao, yuanyuan; meng, xiujuan; huang, xun; li, chunhui; wu, anhua title: asymptomatic sars-cov-2 infections: what do we need to know? date: 2020-05-06 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.201 sha: doc_id: 315689 cord_uid: a3tvoana nan to the editor-the global outbreak of coronavirus disease 2019 (covid19) was officially declared as a pandemic by world health organization (who) on march 11, 2020, 1 and it has imposed unprecedented, far-reaching impacts upon public health and the global ecomony. as of april 30, 2020, >3 million cases of covid-19 have been confirmed, including >210,000 deaths. 2 meanwhile, a growing body of are reporting that many covid-19 infections might present no or only mild symptoms, with a much higher proportion of asymptomatic infections than previously expected. [3] [4] [5] asymptomatic covid-19 includes asymptomatic infected persons and presymptomatic infected persons. those with positive reverse transcription-polymerase chain reaction (rt-pcr) results who never develop any signs or clinically symptoms of covid-19 are considered asymptomatic infected persons. those with positive reverse transcription-polymerase chain reaction (rt-pcr) results who fail to show any signs or clinically symptoms of covid-19 at testing but eventually developed symptoms are considered presymptomatic infected persons. approximately 60% of covid-19 cases may have no symptoms or mild symptoms, according to an article published online in nature on march 20. 6 in fact, as of april 14, 2020, some 6,764 asymptomatic infections have been recognized in mainland china, including 588 imported infections and 1,297 cases that had been recategorized as confirmed cases. 7 also, sars-cov-2 can not only damage human lungs but can also attack many other organs, including the gut and blood vessels, kidneys, etc, thus presenting different symptoms and signs. 8 so, why do some infected persons still show no symptoms or only mild symptoms? the virus is transmitted by exhaled virus-laden droplets that are inhaled by susceptible individuals; these droplets enter the nose and throat, and the virus attacks the cell-surface receptor called angiotensin-converting enzyme 2 (ace2). 9 because sars-cov-2 is a new pathogen to this individual, the immune cells do not recognize it and it escapes the defense system of the body and replicates itself to invade new host cells. these host cells are destroyed in this process, and these pathological changes alert the immune system to begin fighting the diseased cells as well as the virus. a recent study indicated that the genes involved in innate immunity are coexpressed in nasal epithelial cells with viral-entry-associated genes. 9 thus, if the early immune response can suppress enough viral replication to prevent it from continuing into the lungs, the infected individual could have no or only mild symptoms. another ex vivo study has shown that sars-cov-2 induced significantly less host interferon and proinflammatory response than sars-cov, and the low degree of innate immune activation could account for the mild or even lack of symptoms in many covid-19 patients. 10 to date, the exact reasons for no or only mild symptoms in many covid-19 patients remain unclear, and further research is urgently needed to explore the causes and transmission of asymptomatic infections. the sars-cov-2 viral load in upper respiratory specimens is almost as high in asymptomatic infections as symptomatic infections. 11 several studies have indicated that asymptomatic and presymptomatic patients can transmit virus to others. [12] [13] [14] a study published in nature medicine reported that patients with laboratory-confirmed covid-19 began to shed virus 2-3 days before the onset of symptoms and that their infectivity peaked before symptom onset. 15 another study conducted by the department of statistics and actuarial science of the university of hong kong concluded that there was no difference in the transmission rates of coronavirus between symptomatic patients and asymptomatic cases. 16 overall, these studies provided evidence that the risk of transmission by asymptomatic patients might be not lower than that by symptomatic patients. moreover, some individuals infected with the virus experience no or only mild symptoms, and they might be unaware of their disease and thus not isolate themselves or seek treatment. they might be overlooked by healthcare works (hcws) and possibly trigger a "butterfly effect." finally, although many detection methods are available, individuals in the "window period" of covid-19 infection can be missed, and up to 29% of patients could have an initial rt-pcr false-negative result, 17 a paper prepublished on the medrxiv website suggests, so it is possible that a large portion of asymptomatic infections are going undetected. all of this evidence indicates that the spread of pandemic of covid-19 will be difficult to curb by focusing on symptomatic infections alone. therefore, how can we detect as many asymptomatic infections as possible and hopefully prevent a new wave? first, to achieve universal participation during the pandemic, authorities should fully use mainstream media and the internet to provide timely release of relevant information about the pandemic in an open and responsible manner. then citizens can correctly understand the severity of the outbreak and act accordingly. mass media need to disseminate health promotion messages such as indications for wearing a mask and handwashing routine and the importance of maintaining 2-m (6 feet) social distancing. also, considering that medical supplies are in short supply worldwide, cloth face coverings can be used as an additional, voluntary public health measure. 18 third, once asymptomatic infections have been confirmed, self-quarantine is necessary, and these cases should be required to monitor their health status daily, to contact and follow the advice of their medical provider, and to stay home or wear a mask and remain 2 m away from other people if they go out. 19 because the rate of asymptomatic sars-cov-2 infection may be high among the close contacts of a symptomatic patients, these contacts should be closely monitored to rule out infection, even if they remain asymptomatic. finally, scientists and public health experts should conduct research on sars-cov-2 to quickly improve the detection capacity and to achieve mass testing of citizens, especially those living in large enclosed facilities and those living and working in high-risk facilities (eg, healthcare workers). who characterizes covid-19 as a pandemic. world health organization website covid-19) situation report -101. world health organization website evolving epidemiology and impact of non-pharmaceutical interventions on the outbreak of coronavirus disease 2019 in wuhan, china early spread of sars-cov-2 in the icelandic population estimating the asymptomatic proportion of coronavirus disease 2019 (covid-19) cases on board the diamond princess cruise ship covert coronavirus infections could be seeding new outbreaks asymptomatic covid-19 cases reach 6,764 on chinese mainland. the state council the people's republic of china website how does coronavirus kill? clinicians trace a ferocious rampage through the body, from brain to toes sars-cov-2 entry factors are highly expressed in nasal epithelial cells together with innate immune genes comparative replication and immune activation profiles of sars-cov-2 and sars-cov in human lungs: an ex vivo study with implications for the pathogenesis of covid-19 sars-cov-2 viral load in upper respiratory specimens of infected patients presumed asymptomatic carrier transmission of covid-19 asymptomatic and presymptomatic sars-cov-2 infections in residents of a long-term care skilled nursing facility substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2) temporal dynamics in viral shedding and transmissibility of covid-19 comparison of transmissibility of coronavirus between symptomatic and asymptomatic patients: reanalysis of the ningbo covid-19 data false-negative results of initial rt-pcr assays for covid-19: a systematic review recommendation regarding the use of cloth face coverings, especially in areas of significant community-based transmission. centers for disease prevention and control website centers for disease prevention and control website acknowledgments. none. conflicts of interest. all authors report no conflicts of interest related to this work. key: cord-351694-nb7230s1 authors: jatt, lauren p.; winnett, alexander; graber, christopher j.; vallone, john; beenhouwer, david o.; goetz, matthew bidwell title: widespread severe acute respiratory coronavirus virus 2 (sars-cov-2) laboratory surveillance program to minimize asymptomatic transmission in high-risk inpatient and congregate living settings date: 2020-06-16 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.301 sha: doc_id: 351694 cord_uid: nb7230s1 we describe a widespread laboratory surveillance program for severe acute respiratory coronavirus virus 2 (sars-cov-2) at an integrated medical campus that includes a tertiary-care center, a skilled nursing facility, a rehabilitation treatment center, and temporary shelter units. we identified 22 asymptomatic cases of sars-cov-2 and implemented infection control measures to prevent sars-cov-2 transmission in congregate settings. (received 6 may 2020; accepted 10 june 2020) approximately 1.7 million cases of sars-cov-2 infection have been reported in the united states. 1 in los angeles county, >57,000 cases and 2,443 deaths have been reported, and more than half (n = 1,233) of these deaths have occurred in residential congregate settings. 2 preliminary evidence shows that infection-control strategies focused solely on symptomatic individuals are insufficient to prevent transmission in congregate living facilities. [3] [4] [5] [6] the veterans' affairs greater los angeles healthcare system (vaglahs) is a large healthcare facility that includes an inpatient tertiary-care center and multiple congregate living facilities on a single campus. as part of its coronavirus disease 2019 (covid-19) response, vaglahs implemented a widespread laboratory surveillance program for sars-cov-2 in both hospital and residential facilities. herein, we describe the laboratory surveillance program; we discuss how data gathered influenced infection control measures; and we highlight key lessons learned during implementation. vaglahs consists of a tertiary-care hospital with 160 acute-care beds (plus an inpatient psychiatry unit and geriatric dementia unit), a skilled nursing facility (snf) with 3 units totaling 150 beds, and a 151-bed residential rehabilitation treatment center. additionally, during the pandemic, vaglahs created temporary shelter units with capacity to shelter 218 homeless individuals. either a nasopharyngeal swab in universal/viral transport media or a cobas polymerase chain reaction (pcr) media dual swab kit was used with the cobas 6800/8800 diagnostic system (roche, basel, switzerland) to collect nasopharyngeal or combined nasopharyngeal and oropharyngeal specimens, respectively. reverse-transcription (rt)-pcr was performed by a reference laboratory, the vaglahs pathology and laboratory medicine service (palms) or the veterans' affairs long beach healthcare system (valbhs). a daily meeting organized by facility leadership coordinated covid-19 planning and implementation of testing. participants included leadership from palms, infectious disease, nursing, inpatient medicine, outpatient medicine, snf, the residential rehabilitation treatment center, and the temporary shelter units. from march 11 through 26, 2020 vaglahs sent all specimens for sars-cov-2 testing to a reference laboratory. during this time, results returned in a median of 5 days (interquartile range [iqr], 4-8). on march 27, palms completed their emergency use authorization for the us food and drug administration and validation of in-house sars-cov-2 rt-pcr testing (30-60 tests per day capacity). from march 27 through 30, most rt-pcr testing was performed in house, decreasing turnaround time to a median of 2 days (iqr, 2-3). finally, on march 31, the laboratory at valbhs initiated sars-cov-2 testing using the cobas system and began accepting specimens from other va facilities, substantially increasing testing capacity and further decreasing turnaround time to a median of 1 day (iqr, 1-1). from march 11 to april 29, 2,230 tests for sars-cov-2 were performed on 1,781 individuals (table 1) . of these individuals, 78 tested positive: 58 patients and 20 employees. surveillance testing for patients was implemented over time as testing capacity increased, starting with the highest risk settings (fig. 1 ). employees were tested if they developed symptoms or had close contact with a known positive case without appropriate personal protective equipment. upon entrance to all facilities, all individuals were asked about fever, respiratory symptoms, and/or close contact with persons known to have covid-19; if any of these symptoms were present, the individual was appropriately triaged and was not allowed to enter the building. on march 26 and 27, 2 symptomatic snf residents were tested for sars-cov-2; on march 28, both tests returned positive. given the high-risk implications of an outbreak and increased availability of in-house testing, all snf residents (n = 100) were tested regardless of symptoms. this surveillance identified 14 asymptomatic sars-cov-2-positive residents from 2 snf units who were moved to the tertiary-care facility and isolated under appropriate precautions. on april 3 and april 6, 57 residents who originally tested negative but lived in the same snf unit as the sars-cov-2 positive individuals were retested, and 2 additional asymptomatic cases were identified. on april 13, a third round of testing was conducted among 39 residents who lived on the same unit as the sars-cov-2-positive residents were retested between april 3 and 6; none were positive. a fourth surveillance round (n = 87) on april 23 also yielded negative results. on april 8 and 9, 45 patients from the inpatient psychiatry unit and 21 patients in the geriatric dementia unit all tested negative. following this unit-wide testing, all new admissions were required to have a negative sars-cov-2 test. on april 10, universal hospital-wide sars-cov-2 testing was implemented on all inpatients (medical or surgical) who had not previously been tested or tested negative on admission. overall, 32 inpatients were tested and 2 new positive cases were identified. also, 22 patients with a previously negative test were retested; all remained negative. from april 10 onward, all new admissions were tested and all inpatients were retested every 7 days. between april 10 and 29, 12 new inpatient admissions tested positive, 2 of whom lacked classic covid-19 symptoms and would otherwise not have met symptom-based testing criteria. from april 14 to 17, 106 individuals participating in temporary shelter programs were tested for sars-cov-2; all tests were negative. also, 2 individuals who had tested positive before arriving at the campus were housed in an area designated for sars-cov-2-positive patients for 14 days prior to shelter entry. on april 16, 76 residents from the on-campus residential rehabilitation treatment center for substance use were tested; all were negative. from april 22 to 28, 55 patients receiving dialysis at vaglahs were tested; 2 tested positive. although neither had symptoms or signs characteristic of covid-19, both were admitted to acute care for isolation and monitoring. to our knowledge, this is the first description of a widespread laboratory surveillance program for sars-cov-2 on an integrated medical campus. in the early days of the pandemic, testing capacity was limited, so efforts focused predominantly on symptomatic individuals. as testing capacity increased in early april and the importance of asymptomatic transmission was recognized, we transitioned to a more comprehensive program in which we identified 22 asymptomatic individuals who would not otherwise have been diagnosed. two key components enabled the success of this widespread laboratory surveillance program: (1) close collaboration with palms to secure access to high-volume molecular testing and (2) strong coordination of staff from multiple disciplines to implement testing. the early initiative taken by palms to develop an in-house test for sars-cov-2 was instrumental in increasing testing capacity and decreasing turnaround time. without this in-house test, surveillance testing of the >100 residents in the snf within a single week would not have been possible. similarly, the roll-out of a high-volume, high-throughput testing system at valbhs further increased capacity to >1,900 tests over 4 weeks. finally, to avoid shortages in specimen swabs, vaglahs repurposed swab kits for chlamydia trachomatis and neisseria gonorrhoeae testing to test for sars-cov-2. close coordination and frequent communication between nurses, physicians, and other staff, facilitated by daily leadership meetings, in both the hospital and congregate living facilities were critical in implementing the surveillance program. overall, the implementation of a widespread surveillance testing strategy likely prevented asymptomatic transmission of sars-cov-2, thereby preventing potential outbreaks of covid-19 within an integrated medical campus. cases in the us la county department of public health website assessment of sars-cov-2 infection prevalence in homeless shelters-four us cities detection of sars-cov-2 among residents and staff members of an independent and assisted living community for older adults presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility asymptomatic and presymptomatic sars-cov-2 infections in residents of a long-term care skilled nursing facility acknowledgments. we would like to thank salem toney and dr carmen kletecka with pathology and laboratory medicine services for their tireless work to increase testing capacity and throughput during the pandemic. we would also like to thank michael simmons, rn, dr linda sohn, and dr anjani reddy for facilitating and coordinating the testing of hospitalized patients, snf residents, and individuals in the temporary shelters and residential rehabilitation treatment center respectively.financial support. this work was supported in part by funds and facilities provided by the veterans affairs greater los angeles healthcare system (vaglahs). all authors report no conflicts of interest relevant to this article. key: cord-283623-umqu07te authors: ponce-alonso, manuel; sáez de la fuente, javier; rincón-carlavilla, angela; moreno-nunez, paloma; martínez-garcía, laura; escudero-sánchez, rosa; pintor, rosario; garcía-fernández, sergio; cobo, javier title: impact of the coronavirus disease 2019 (covid-19) pandemic on nosocomial clostridioides difficile infection date: 2020-09-08 journal: infection control and hospital epidemiology doi: 10.1017/ice.2020.454 sha: doc_id: 283623 cord_uid: umqu07te objectives: the coronavirus disease 2019 (covid-19) pandemic has induced a reinforcement of infection control measures in the hospital setting. here, we assess the impact of the covid-19 pandemic on the incidence of nosocomial clostridioides difficile infection (cdi). methods: we retrospectively compared the incidence density (cases per 10,000 patient days) of healthcare-facility–associated (hcfa) cdi in a tertiary-care hospital in madrid, spain, during the maximum incidence of covid-19 (march 11 to may 11, 2020) with the same period of the previous year (control period). we also assessed the aggregate in-hospital antibiotic use (ie, defined daily doses [ddd] per 100 occupied bed days [bd]) and incidence density (ie, movements per 1,000 patient days) of patient mobility during both periods. results: in total, 2,337 patients with reverse transcription-polymerase chain reaction–confirmed covid-19 were admitted to the hospital during the covid-19 period. also, 12 hcfa cdi cases were reported at this time (incidence density, 2.68 per 10,000 patient days), whereas 34 hcfa cdi cases were identified during the control period (incidence density, 8.54 per 10,000 patient days) (p = .000257). antibiotic consumption was slightly higher during the covid-19 period (89.73 ddd per 100 bd) than during the control period (79.16 ddd per 100 bd). the incidence density of patient movements was 587.61 per 1,000 patient days during the control period and was significantly lower during the covid-19 period (300.86 per 1,000 patient days) (p < .0001). conclusions: the observed reduction of ~70% in the incidence density of hcfa cdi in a context of no reduction in antibiotic use supports the importance of reducing nosocomial transmission by healthcare workers and asymptomatic colonized patients, reinforcing cleaning procedures and reducing patient mobility in the epidemiological control of cdi. (received 30 june 2020; accepted 24 august 2020) clostridioides difficile is the leading cause of nosocomial infectious diarrhea and one of the most prevalent nosocomial pathogens. 1, 2 the key elements that determine its incidence are exposure to c. difficile spores and the administration of antibiotics. 3 controversy exists over the utility of various infection control measures, given that most interventions have shown very low levels of evidence, 4 whereas bundle-based programs that include antibiotic restriction are almost always effective. 4, 5 the covid-19 pandemic in spain has been particularly intense, with >6,000 cases per million inhabitants and exceeding 28,000 deaths 6 ; it was even more serious in the capital madrid. our hospital suddenly became a monographic covid-19 hospital, with a peak in the pandemic on march 30, 2020, when 86.91% of admitted patients (983 of 1,131) were diagnosed with covid-19. this situation in which almost all patients remained isolated and all healthcare workers wore personal protective equipment (ppe) constituted a type of "natural experiment" for the study of c. difficile epidemiology in hospitals. the objective of this study was to assess the impact of the covid-19 pandemic on the incidence of cdi and to analyze the factors that could have influenced the incidence. we compared the incidence density (cases per 10,000 patient days) of nosocomial cdi in a tertiary-care teaching hospital in madrid over 2 periods: (1) the peak incidence of covid-19 at our hospital (covid-19 period: march 11, 2020, to may 11, 2020) and (2) the same period of the previous year (control period: march 11, 2019, to may 11, 2019) . we used the standard epidemiological classification of cdi, 7 only considering hospital-onset healthcare facility-associated (ho-hcfa) and community-onset healthcare facility-associated (co-hcfa) infections as nosocomial, and ruling out community, indeterminate, and recurrence cases for the incidence density calculation. we also calculated the incidence density for all types of cdi during the interval between the 2 periods to better describe the time trend of cases. for the covid-19 period, we reviewed whether the hospitalized patients who were screened for cdi also presented a diagnosis of covid-19, with microbiological confirmation by reverse transcription-polymerase chain reaction (rt-pcr). we used the computerized registry of the microbiology department to obtain all data regarding cdi and covid-19 tests, and we gathered hospital admission data regarding hospital stays. the algorithm employed for the microbiological diagnosis of cdi was the same throughout the study period, which included sequential qualitative detection of glutamate dehydrogenase (c. diff quik chek, techlab, blacksburg, va) and a and b toxins (tox a/b quik chek, techlab) from c. difficile. we assessed discrepancies by detecting the c. difficile toxin b gene by rt-pcr (bd max cdiff, becton dickinson, franklin lakes, nj). we assessed patient mobility by determining all of the patients' administrative location changes during both periods using the hospital information systems service. these changes included transfers to the operating room, change in room or change to intensive care units, as well as transfers to perform additional tests (eg, radiological examinations, endoscopies, or other procedures). we then calculated the "incidence density" of the patients' movements by dividing the sum of the location changes by the hospital stays in both periods. for the same study period, we extracted aggregate in-hospital antibiotic use data from the computerized hospital administration records and an automated medication-dispensing system. data on antibiotic use are expressed as defined daily doses per 100 occupied bed days (ddd per 100 bd) and the percentage of change between study periods, according to the criteria of the world health organization collaborating centre for drug statistics methodology. we also extracted data regarding time of exposure to antibiotics, expressed as days of therapy (dot) per 100 patient days. for this study, we considered only the consumption of antibiotics from anatomical therapeutic chemical group j01. finally, as a subrogate measurement of antibiotic exposure, the proportion of admitted patients who suffered from at least 1 episode of microbiologically confirmed nonviral infection was calculated for both periods. we compared the categorical data using the χ 2 test and the student t test to compare the continuous variables when a normal distribution could be assumed or the mann-whitney u test otherwise. we assessed the normality of the continuous variables using the shapiro-wilk test. in total, 2,337 patients with rt-pcr-confirmed covid-19 and 283 with suspected covid-19 were admitted to the hospital during the covid-19 period. there were 44,831 hospital stays during this time, whereas during the same period of 2019 there were 39,795 stays. the mean age of the admitted patients was 66.74±17.65 years for the covid-19 period and 64.41±21.23 years for the control period (p < .0001). the total requests for c. difficile detection in the hospitalized patients were similar between the covid-19 period (n = 209) and the control period (n = 203), with a 9.8% reduction in the rate of requests during the covid-19 period (4.6 per 1,000 hospital stays vs 5.1 per 1,000 hospital stays). also, 12 hcfa cdi cases were identified during the covid-19 period (10 corresponding to ho-hcfa and 2 to co-hcfa), which resulted in an hcfa cdi incidence density of 2.68 per 10,000 patient days. in the control period, we identified 34 hcfa cdi cases (21 corresponding to ho-hcfa and 13 to co-hcfa), which resulted in an hcfa cdi incidence density of 8.54 per 10,000 patient days. thus, the hcfa cdi incidence density was~3 times lower for the covid-19 period than for the non-covid-19 period (incidence rate ratio, 0.31; 95% ci, 0.16-0.61; p = .000257). figure 1 shows the evolution of cdi cases and the incidence density of hcfa cdi during the 2 study periods and the 10-month interval between them. among the 209 hospitalized patients screened for cdi during the covid-19 period, a lower proportion of cdi was observed in those with rt-pcr-confirmed covid-19 (5 of 106; 4.7%) compared with that observed in patients without a microbiological diagnosis of covid-19 (8 of 103; 7.8%). however, these differences were not statistically significant (p = .36). patient mobility was drastically reduced during the covid-19 period, with 4,858 bed movements (2,274 involving a nursing unit change), whereas 7,338 bed movements (1,877 involving a nursing unit change) were observed during the control period. the number of surgical interventions was reduced to 668 during the covid-19 period, contrasting with the 2,227 surgeries observed during the control period. the total numbers of diagnostic or care procedures that involved patient movement were 7,963 for the covid-19 period and 13,819 for the control period. the incidence density of movements was 300.86 per 1,000 patient days for the covid-19 period and 587.61 per 1,000 patient days for the control period (p < .0001). the consumption of antibiotics measured by ddd per 100 bd was higher during the covid-19 period (89.73 ddd per 100 bd) than during the control period (79.16 ddd per 100 bd), remaining stable during the months between the 2 periods (77.50±1.64 ddd per 100 bd). the qualitative analysis showed a dramatic increase during the covid-19 period in the use of third-generation cephalosporins (6.34 ddd per 100 bd for the control period vs 19.39 ddd per 100 bd for the covid-19 period) and macrolides (5.76 ddd per 100 bd vs 25.49 ddd per 100 bd, respectively). we observed the same trend in terms of time of exposure to both third-generation cephalosporins (6.64 dot per 100 patient days for the control period vs 20.98 dot per 100 patient days for the covid-19 period) and macrolides (3.97 dot per 100 patient days vs 15.97 dot per 100 patient days, respectively). conversely, we observed a remarkable reduction in the consumption of quinolones (8.68 ddd per 100 bd for the control period vs 4.61 ddd per 100 bd for the covid-19 period) and inhibitor-penicillin combinations (25.7 ddd per 100 bd vs 16.60 ddd per 100 bd, respectively). treatment duration was also reduced for quinolones (8.14 dot per 100 patient days for the control period vs 3.98 dot per 100 patient days for the covid-19 period) and inhibitor-penicillin combinations (27.94 dot per 100 patient days vs 17.95 dot per 100 patient days, respectively). there were no relevant differences in the use or in treatment duration of carbapenems between the 2 periods (7.42 ddd per 100 bd for the control period vs 6.34 ddd per 100 bd for the covid-19 period; 8.06 dot per 100 patient days vs 6.93 dot per 100 patient days, respectively). finally, as an indirect measurement of antibiotic exposure, the proportion of admitted patients who suffered from at least 1 episode of microbiologically confirmed nonviral infection was higher during the control period (15.5%; 984 of 6,365 patients) than during the covid-19 period (14%; 783 of 5,600 patients). an infection prevention bundle was implemented during the covid-19 period (table 1 ). all healthcare workers wore personal protective equipment (ppe) when caring for patients with covid-19 and wore nonwaterproof masks, gloves, and gowns when treating patients without covid-19. environmental cleaning by trained cleaning staff was reinforced, and visits were prohibited (except in exceptional situations). patients with covid-19 were grouped in wards, with rooms intended for a maximum of 2 patients; however, a third bed had to be included in some cases. patients with cdi were isolated in a single room with contact precautions during both the covid-19 and control periods. moreover, the same cleaning products were employed for both periods. our results show a remarkable reduction in the incidence density of nosocomial cdi during the period with the maximum incidence of covid-19 compared with the same period the previous year. the number of cdi cases remained stable in the previous months; thus, such a decrease during the covid-19 period cannot be explained by the previous trend. moreover, the number of cdi test requests for the hospitalized patients from both periods was similar; therefore, there is no reason to envision a reduction in the clinical suspicion of cdi in patients with diarrhea (despite the frequent use of lopinavir-ritonavir as covid-19 therapy). based on our findings, the consumption of antibiotics does not appear to explain the decrease in cdi. although the use of quinolones was reduced, the overall consumption of antibiotics increased during the covid-19 period. this observation contrasts with the lower proportion of admitted patients who suffered from at least 1 episode of microbiologically confirmed nonviral infection during the covid-19 period (14%), compared to the control period (15.5%). the increment in antibiotic consumption could be explained by the fact that, for a time, the institutional protocol for the treatment of patients with covid-19 contemplated the optional use of empiric ceftriaxone, and many doctors added it as standard regimen from the emergency room. in fact, a recent systematic review 8 pointed out that 71.9% of patients with covid-19 received antibiotics despite the low rate of bacterial infection observed in those patients (6.9%). this finding could explain the noticeable increase in both the use and time of exposure to third-generation cephalosporins observed in our study, a subgroup of antimicrobial agents associated with a higher risk for developing cdi 9 . due to the exceptional epidemiological situation during the covid-19 period, our institution introduced an extraordinary reinforcement of all infection control measures, including patient isolation, universal ppe, limited patient visits and movement, and reinforcement of cleaning regimens, all of which have indirectly limited the nosocomial spread of c. difficile. during this period, we observed an almost 70% reduction in the incidence density of nosocomial cdi. we postulate that this observation confirms fig. 1 . evolution of c. difficile infection (cdi) over time, from control period (left) to covid-19 period (right). the bar chart shows the total cdi case count, grouped by epidemiological definition. the solid line represents total hospital stays during each period (in days), which were used to calculate the incidence density of nosocomial cdi cases (dashed line). note. ho-hcfa cdi, hospital-onset healthcare facility-associated c. difficile infection; co-hcfa cdi, community-onset healthcare facility-associated c. difficile infection; id cdi, indeterminate-onset c. difficile infection; ca cdi, community-acquired c. difficile infection; rcdi, recurrent c. difficile infection; hcfa cdi (id), incidence density of healthcare facility-associated c. difficile infection. the importance of strategies aimed at reducing nosocomial transmission of c. difficile. notably, not only the reinforcement of infection control measures but also the exceptionally dramatic situation during the covid-19 period could have contributed to an increase in adherence to those measures by healthcare workers, as has already been pointed out. 10, 11 the extension of containment measures to all of our hospitalized patients during the covid-19 pandemic could have also limited transmission from asymptomatic patients, who represent an important source of transmission, 12, 13 despite this group transmitting less effectively. 14 in addition, the suppression of consultations and surgical procedures in the hospital has meant fewer opportunities for introducing c. difficile into the hospital from the community. our results contrast with those of a recent study that found no benefits on the incidence of cdi from improving hospital cleaning procedures. 15 closing hospitals and transferring patients to individual rooms located in new facilities has not conclusively been associated with a reduction in cdi rates 16, 17 ; however, our results support previous studies that linked the mobility of patients to common areas with increased risk of developing cdi 9 and the potential risk of transmission by the hands of healthcare workers. 18, 19 notably, in both cases, transmission was not associated only with direct contact with symptomatic patients 20 and multidisciplinary measures were necessary to limit the spread of c. difficile. the retrospective nature of our study precludes us from controlling for numerous factors and from measuring certain variables in detail, such as the degree of compliance with cleaning and the previous state of c. difficile colonization of patients, which might have been lower than usual upon admission. we also cannot rule out the possibility that our covid-19 population was mostly composed of previously healthy patients, although our data showed that patients admitted during the covid-19 period were significantly older than those admitted during the control period. another limitation of our study lies in the effect of the covid-19 pandemic on outpatient care, as recently highlighted in other more serious diseases. 21 this factor could explain part of the reduction observed in nosocomial cdi cases by reducing opportunities for co-hcfa diagnosis and requests for care due to the covid-19 epidemic. nevertheless, even considering only ho-hcfa cases, the observed reduction was~50%. despite the aforementioned limitations, our observation of a dramatic decrease in cdi in a context of no reduction in the use of antibiotics supports the importance of reducing the nosocomial transmission by healthcare workers or asymptomatically colonized patients, reinforcing cleaning procedure and reducing hospital mobility of patients in the epidemiological control of cdi. burden of clostridium difficile infection in the united states underdiagnosis of clostridium difficile across europe: the european, multicentre, prospective, biannual, point-prevalence study of clostridium difficile infection in hospitalised patients with diarrhoea (euclid) clostridium difficile infection guidance document for prevention of clostridium difficile infection in acute healthcare settings reducing clostridium difficile in the inpatient setting: a systematic review of the adherence to and effectiveness of c. difficile prevention bundles spain coronavirus: cases and deaths. worldometer website guidelines for diagnosis, treatment, and prevention of clostridium difficile infections bacterial co-infection and secondary infection in patients with covid-19: a living rapid review and metaanalysis using spatial and temporal mapping to identify nosocomial disease transmission of clostridium difficile dramatically improved hand hygiene performance rates at time of coronavirus pandemic barriers and facilitators to healthcare workers' adherence with infection prevention and control (ipc) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis effect of detecting and isolating clostridium difficile carriers at hospital admission on the incidence of c. difficile infections understanding clostridium difficile colonization quantifying transmission of clostridium difficile within and outside healthcare settings an environmental cleaning bundle and health-care-associated infections in hospitals (reach): a multicentre, randomised trial decline in incidence of clostridium difficile infection after relocation to a new hospital building with single rooms time-series analysis of health care-associated infections in a new hospital with all private rooms clostridium difficile contamination of health care workers' hands and its potential contribution to the spread of infection: review of the literature contamination of healthcare workers' hands with clostridium difficile spores after caring for patients with c. difficile infection whole-genome sequencing reveals nosocomial clostridioides difficile transmission and a previously unsuspected epidemic scenario impact of coronavirus disease 2019 (covid-19) outbreak on outcome of myocardial infarction in hong kong, china acknowledgments. the authors thank gerardo gómez montero, department of information systems of hospital ramón y cajal, for his contributions in the collection of patient movement records.financial support. this work was supported by the instituto de salud carlos iii and reipi (grant no. 0d16/0016/0011), cofinanced by the european development regional fund "a way to achieve europe" (erdf). m. ponce-alonso was supported by a research contract from instituto de salud carlos iii, spain (rio hortega program, grant no. cm19/00069). l. martínez-garcía was supported by a research contract from instituto de salud carlos iii, spain (rio hortega program, grant no. cm19/00136). all authors report no conflicts of interest relevant to this article. 