COVID-19 Nosocomial Review Group minutes: 19 February 2021

Items and actions

1. CNRG were presented with the lessons learned during COVID-19 in Germany by University Charite, Berlin. Initial analysis of Germany’s first wave was that there was little patient to HCW transmission and that the majority of HCW infections were transmitted from HCW to HCW. It was thought that staff social behaviour outside of the hospital drove this transmission from contact tracing studies done at the time. Nosocomial outbreaks were occurring in non COVID -19 wards and the investigations revealed that staff underestimated the risk of asymptomatic transmission and had a strong belief in a negative test on admission or in a HCW, the importance of not assuming negative status from tests and IPC measures must be applied at all times.
2. As a result of this there was increased HCW training in IPC practice, increased visibility of IPC Teams, and increased HCW communications. Additionally, IPC Teams linked up with each ward/clinical department for outbreak communications. Other IPC measures considered important were mandates for the use of surgical masks for all patients and restricted visiting. It was noted that staff in Germany do not attend work when symptomatic and hospital managers would not tolerate an ill HCW being on shift. This applies for all respiratory ilnesses including COVID-19 and is part of hospital culture.
3. CNRG noted that the German IPC guidance was similar to that in the UK and recommends universal use of surgical masks for all HCW, and FFP2/ N95-masks for aerosol-inducing procedures. The FFP2 use beyond this was as a result of a politcal directive for protection of HCWs, FFP2 is also used on all COVID-wards for high risk HCW groups (nurses for 1:1 care; physiotherapists etc). There is no requirment for fit testing of FFP2 in Germany (unlike the UK) although some instructions are given for use. Furthermore, it was reported that IPC evidence to date in Germany, in line with many other countries,  indicates that proper mask wearing and adherance was key in IPC effectiveness, and of greater importance than mask type (i.e. FFP2 vs surgical mask).
4. An outline plan and driver diagram on the current work underway by the task group of CNRG on Behavioural Insights was given. CNRG were made aware that the group were focussed on enabling adherence to IPC guidance and that a multimodal approach had been adopted by the group in line with WHO.  CNRG were given a brief overview of the proposed research work using video reflexive ethnography. Interventions are being tested for proof of concept currently. The workplan will come to CNRG for endorsement. IPC webinars for front line health and social care workers have been scoped, are planned and have been scheduled to take place in March.
5. CNRG were updated on the rapid review of HCW infection risk.  The review includes studies that compared risk within HCW occupations to other key workers and that of the general population. There were 6 PCR studies, and 5 serological studies included in the literature review all based on UK studies to date. Findings were varied and inconclusive - possible that HCWs were at higher risk during early phase of pandemic, however mindful of limitations. Limitations were the following:  differences in testing, recall bias, confounders not assessed, unable to determine source of infection or direction of transmission. It was noted that this reinforced previous reviews to date published on this topic.
6. CNRG were also informed of an update on the ECDC Infection prevention and control and preparedness for COVID-19 in healthcare settings guidance (09/02). The update states that HCWs have a higher risk however it was noted that ECDC do not provide a comprehensive analysis of the evidence base regarding HCW risk in the guidance.  The ECDC guidance also states that respirator and eye protection for patient care of COVID-19 confirmed cases should be worn (taking precautionary approach). This guidance will be highlighted to the UK IPC cell for consideration in UK guidance.
7. CNRG noted that the VOC-20DEC-01 UK variant is currently the dominant strain in Scotland and the rest of the UK. CNRG were also informed of variants of the UK strain that have been detected in small clusters in England.  In Scotland, cases tested via the UK Government laboratories had a profile consistent with the new UK variant of COVID-19 (as 18 February), and had been genomically confirmed as cases.
8. CNRG noted the REACT-SCOT study concluded a hazard ratio of 1.40 (95% CI: 1.28-1.53) for death or hospital admission in SGTF (S-gene target failure) compared to non-SGTF cases.  However, CNRG were informed of the limitations of the study including representativeness, power, potential biases in case ascertainment, and unmeasured confounders. It was highlighted to CNRG members that NERVTAG concluded that the UK variant is associated with an increased risk of hospitalisation and death when compared to infection with non-VOC viruses, however is not defined as a HCID.
9. CNRG were informed that the triage question in the NIPCM COVID-19 Addendum has been strengthened in the light of emerging VOCs with travel history and IPC measures.
10. CNRG were informed that at the time of tests have be registered on the portal. It may be this is about reporting rather than uptake of testing and it was confirmed to the CNRG that work is underway to update the online reporting staff portal, and that comms will be created to communicate this update to staff.
11. Additionally, it was brought to CNRG members’ attention that there have been cohorts of staff within healthcare settings who have not been undergoing LFD testing due to their job role not being patient facing, but do interact with patient facing staff on a regular basis. CNRG were asked if they would endorse the widening of LFD testing to all staff within the healthcare setting. This was endorsed by members.
12. CNRG were given an update on the 28 day all-cause HAI COVID-19 mortality data. CNRG were informed that approximately a quarter of patients diagnosed with test taken. After adjustment for confounding factors, 28-day all-cause mortality was not significantly different in patients with probable or definite hospital onset COVID-19 and those diagnosed in the first 2 days of their admission to hospital. All-cause mortality in wave 2 was lower than wave 1. This is temporally associated with improved treatment, increased asymptomatic testing and improved adherence with IPC measures.
13. It was highlighted to CNRG that the number of new clusters and open clusters are decreasing across Scottish hospitals. It was also noted that there is improvement in the number of cases in clusters being reported with approximately half of all outbreaks having five or fewer patients reported, indicating successful control measures were implemented early to stop spread. Those outbreaks with higher number of cases are subject to further investigation for national lessons learned currently.
14. CNRG were also presented with analysis of the epidemiology of two health boards which had hospital sites that have received epidemiological support from ARHAI Scotland as a result of previous funnel plot analysis shared. It was noted that the learning from this had been shared with the ICM network.
15. The incidence of nosocomial (probable and definite) hospital onset COVID-19 was presented to members alongside the incidence of COVID-19 in the wider population. It was noted that the increasing trend in COVID-19 in the wider population is in mirrored in nosocomial COVID-19. The increasing trend is most pronounced in the local authority area which in the catchment of the hospital with the highest incidence of nosocomial COVID-19. The relationship between increasing community incidence and situation in hospitals has been described previously and it was noted that this is complex and multifactorial in nature.
16. CNRG were also updated on the ongoing built environment indicator work. CNRG were updated that NHS ARHAI and HFS are developing some built environment quality indicators, and these are being tested with some boards/ hospitals.