Transmission dynamics of SARS-CoV-2 in the hospital setting
Authors: Mo Yin , Eyre David W. , Lumley Sheila F. , Walker Timothy M. , Shaw Robert H. , O’Donnell Denise , Butcher Lisa , Jeffery Katie , Donnelly Christl A. ,   Oxford COVID infection review team, Cooper Ben S. 
Published: May 2021

AbstractBackgroundSARS-CoV-2 can spread efficiently in hospitals, but the transmission pathways amongst patients and healthcare workers are unclear.MethodsWe analysed data from four teaching hospitals in Oxfordshire, UK, from January to October 2020. Associations between infectious SARS-CoV-2 individuals and infection risk were quantified using logistic, generalised additive and linear mixed models. Cases were classified as community- or hospital-acquired using likely incubation periods.ResultsNine-hundred and twenty of 66184 patients who were hospitalised during the study period had a positive SARS-CoV-2 PCR test within the same period (1%). Out of these, 571 patients had their first positive PCR tests while hospitalised (62%), and 97 of these occurred at least seven days after admission (11%). Amongst the 5596 healthcare workers, 615 (11%) tested positive during the study period using PCR or serological tests. For susceptible patients, one day in the same ward with another patient with hospital-acquired SARS-CoV-2 was associated with an additional eight infections per 1000 susceptible patients (95%CrI 6-10). Exposure to an infectious patient with community-acquired COVID-19 or to an infectious healthcare worker was associated with substantially lower infection risks (2/1000 susceptible patients/day, 95%CrI 1-2). As for healthcare worker infections, exposure to an infectious patient with hospital-acquired SARS-CoV-2 or to an infectious healthcare worker were both associated with an additional one infection per 1000 susceptible healthcare workers per day (95%CrI 1-2). Exposure to an infectious patient with community-acquired SARS-CoV-2 was associated with half this risk (0.5/1000 susceptible healthcare workers/day, 95%CrI 0.3-0.7).InterpretationExposure to patients with hospital-acquired SARS-CoV-2 poses a substantial infection risk. Infection control measures to limit nosocomial transmission must be optimised to protect both staff and patients from SARS-CoV-2 infection.FundingNational Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Oxford University in partnership with Public Health England (PHE) (NIHR200915). Medical Research Council, Nosocomial transmission of SARS-CoV-2 (MR/V028456/1).Research in contextEvidence before this studyWe searched the PubMed database using the search terms (”COVID-19” OR ”SARS-CoV-2”) AND (”nosocomial” OR ”hospital”) AND (”transmission”) in either the abstracts or titles, for English-language articles published up to March 31, 2021. This returned 748 results, out of which ten reported transmission events in the hospital setting quantitatively. These publications can be broadly categorised to epidemiological descriptions of isolated outbreaks (5) or contact tracing of patients exposed to infected healthcare workers (1), retrospective cohort studies involving a particular group of patients, e.g., patients who underwent surgical procedures (2), and using genomic sequencing to identify transmission clusters (2). None of the studies reported the comparative transmission rates of SARS-CoV-2 amongst patients and staff.Added value of this studyThis study reports the analysis of a large observational dataset collected from a group of hospitals in the UK over eight months, consisting of both hospitalised patients and healthcare workers. Based on these detailed individual-level data, we quantified the associations between patient and healthcare worker characteristics and risks for acquiring nosocomial SARS-CoV-2 infection after adjusting for their exposures to SARS-CoV-2. Over the study period, we describe how risk of acquisition changes both with calendar time and over a patient’s hospital stay. By linking the presence of infected and susceptible patients and healthcare workers by time and ward locations, we quantify the relative importance of the transmission pathways for both the susceptible patients and healthcare workers.Implications of all the available evidenceNosocomial transmission of SARS-CoV-2 is common. Identifying the drivers of SARS-CoV-2 transmissions in the hospital setting is essential for designing infection prevention and control policies to minimise the added pressure from such events on our health systems. We found that newly infected patients who acquired SARS-CoV-2 in the hospital pose the highest risk of onward transmission to other patients and healthcare workers. Infection control and prevention efforts need to be enhanced around these patients to prevent further transmissions and studies assessing the effectiveness of these policies are needed.