Coronavirus Disease 2019 (COVID-19): Protecting Hospitals From the Invisible
Authors: Michael Klompas
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions11 March 2020Coronavirus Disease 2019 (COVID-19): Protecting Hospitals From the InvisibleFREEMichael Klompas, MD, MPHMichael Klompas, MD, MPHHarvard Medical School, Harvard Pilgrim Health Care Institute, and Brigham and Women's Hospital, Boston, Massachusetts (M.K.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-0751 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail It is increasingly apparent that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is optimized to spread widely. It causes mild but prolonged disease, infected persons are contagious even when minimally symptomatic or asymptomatic, the incubation period can extend beyond 14 days, and some patients seem susceptible to reinfection (1–3). These factors make it inevitable that patients with respiratory viral syndromes that are mild or nonspecific will introduce the virus into hospitals, leading to clusters of nosocomial infections. The signs and symptoms of coronavirus disease 2019 (COVID-19) are largely indistinguishable from those of other respiratory virus infections. Less than one half of patients with confirmed disease have fever on initial presentation (4). The sensitivity of a single nasopharyngeal swab early in the course of disease is only 70% (5). Multiple reports already exist of delayed diagnoses leading to nosocomial transmissions.How bad will it be? Characterizing the morbidity rate of COVID-19 is challenging because case detection in the early stages of an outbreak is biased toward severe disease. An initial series reported a mortality rate of 15% (6). A subsequent analysis that included patients who were less sick reported a mortality rate of 2.3% (7), but this is still likely an overestimate. Mortality rates are substantially lower outside than inside Hubei province, where the outbreak began (114 deaths among 13 152 patients [0.9%] vs. 2986 deaths among 67 707 patients [4.4%] as of 8 March 2020). This is presumably because of Hubei's initial focus on patients with severe disease, constraints on the province's testing and care capacity, and the passage of more time since the outbreak began in Hubei versus other provinces allowing more time for patients to declare themselves (8). More to the point, current mortality estimates minimally account for patients with mild or asymptomatic infections, an important aspect of this epidemic (9). Case detection is still primarily focused on identifying patients with fever, cough, or shortness of breath; this focus leads to underestimation of the number of infected persons, overestimation of the mortality rate, and ongoing spread of disease.What can we do to prevent further spread of infection? We have to be more aggressive about case detection. Current screening is still focused on identifying patients with foreign travel or contacts with known cases. Both of these foci no longer reflect the current status of this epidemic given increasing evidence of community spread. We need to be able to test patients with milder syndromes regardless of travel or contact history. The U.S. Centers for Disease Control and Prevention has updated its “person under investigation” criteria to permit this, but there is still a severe shortage of readily available tests.More broadly, however, the best way to protect hospitals against COVID-19 is to bolster our approach to routine respiratory viruses (that is, influenza, respiratory syncytial virus, parainfluenza, adenovirus, human metapneumovirus, and “conventional” coronaviruses). This will simultaneously improve care for current patients, make work safer for clinicians, and help prevent the incursion of occult COVID-19 into hospitals. We underestimate the contagiousness and seriousness of routine respiratory viruses. We underappreciate that 30% to 50% of cases of community-acquired pneumonia are caused by viruses, that nosocomial transmission of respiratory viruses is common, and that “routine” respiratory viruses cause substantial morbidity and mortality that may not differ much from those caused by SARS-CoV-2 once minimally symptomatic COVID-19 is accounted for. Respiratory viruses infect millions of persons each year (about 10% of the population) and cause tens of thousands of deaths in the United States alone (10). They can cause severe pneumonia, predispose patients to bacterial superinfection, and exacerbate cardiac and pulmonary conditions up to and including death.Most hospitals, however, manage respiratory viruses passively. We rely on signs alone to deter visitors with upper respiratory tract infections from visiting, we isolate patients in private rooms only if they test positive for influenza virus (even though many other viruses can cause influenza-like syndromes that are equally morbid), we discontinue precautions in patients with acute respiratory tract syndromes if they test negative for viruses (even though viral tests have variable and imperfect sensitivity), we consider masks alone to be adequate protection (even though viruses can be transmitted via fomites and eye contact as well as mouth and nose contact), and we tolerate health care workers coming to work with upper respiratory tract infections so long as they are not febrile.Our halfhearted approach to endemic respiratory viruses is a source of harm to our patients and puts us at increased risk for COVID-19 infiltration. To cause a nosocomial outbreak, it will take just 1 patient with occult COVID-19 who is hospitalized, tests negative for influenza virus, and is taken off precautions despite persistent respiratory symptoms. Or just 1 visitor with COVID-19 and mild respiratory symptoms who is permitted free access to the hospital because it does not have an active screening and exclusion policy for visitors with respiratory tract symptoms. Or just 1 infected health care worker who decides to soldier through a shift despite a sore throat and runny nose.We need to be more aggressive about respiratory hygiene and placing restrictions on patients, visitors, and health care workers with even mild symptoms of upper respiratory tract infection. Potential policies to consider include the following: 1) screening all visitors for any respiratory symptoms that may be related to a virus, including fever, myalgias, pharyngitis, rhinorrhea, and cough, and excluding them from visiting until they are better; 2) restricting health care workers from working if they have any upper respiratory tract symptoms, even in the absence of fever; and 3) screening all patients, testing for all respiratory viruses (including SARS-CoV-2) in those with positive screening results regardless of illness severity, and using precautions (single rooms, contact precautions, droplet precautions, and eye protection) for patients with respiratory syndromes for the duration of their symptoms regardless of viral test results. A collateral benefit is that if a patient is subsequently diagnosed with COVID-19, staff who used these precautions will be considered minimally exposed and will be able to continue working.None of these measures will be easy. Restricting visitors will be psychologically difficult for patients and loved ones, maintaining respiratory precautions for the duration of patients' symptoms will strain supplies in all hospitals and bed capacity in hospitals that depend on shared rooms, and preventing health care providers with mild illness from working will compromise staffing. But if we are frank about the morbidity and mortality of all respiratory viruses, including SARS-CoV-2, this is the best thing we can do for our patients and colleagues regardless of COVID-19.References1. Holshue ML, DeBolt C, Lindquist S, et al; Washington State 2019-nCoV Case Investigation Team. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020;382:929-936. [PMID: 32004427] doi:10.1056/NEJMoa2001191 CrossrefMedlineGoogle Scholar2. Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany [Letter]. N Engl J Med. 2020;382:970-971. [PMID: 32003551] doi:10.1056/NEJMc2001468 CrossrefMedlineGoogle Scholar3. Lan L, Xu D, Ye G, et al. Positive RT-PCR test results in patients recovered from COVID-19. JAMA. 2020. [PMID: 32105304] doi:10.1001/jama.2020.2783 CrossrefMedlineGoogle Scholar4. Guan WJ, Ni ZY, Hu Y, et al; China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020. [PMID: 32109013] doi:10.1056/NEJMoa2002032 CrossrefMedlineGoogle Scholar5. Fang Y, Zhang H, Xie J, et al. Sensitivity of chest CT for COVID-19: comparison to RT-PCR. Radiology. 2020:200432. [PMID: 32073353] doi:10.1148/radiol.2020200432 CrossrefMedlineGoogle Scholar6. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506. [PMID: 31986264] doi:10.1016/S0140-6736(20)30183-5 CrossrefMedlineGoogle Scholar7. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. Vital surveillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) — China, 2020. China CDC Weekly. 2020;2:113-22. CrossrefGoogle Scholar8. World Health Organization. Coronavirus disease 2019 (COVID-19): situation report – 48. 8 March 2020. Accessed at https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200308-sitrep-48-covid-19.pdf on 9 March 2020. Google Scholar9. Hoehl S, Berger A, Kortenbusch M, et al. Evidence of SARS-CoV-2 infection in returning travelers from Wuhan, China [Letter]. N Engl J Med. 2020. [PMID: 32069388] doi:10.1056/NEJMc2001899 CrossrefMedlineGoogle Scholar10. Rolfes MA, Foppa IM, Garg S, et al. Annual estimates of the burden of seasonal influenza in the United States: a tool for strengthening influenza surveillance and preparedness. Influenza Other Respir Viruses. 2018;12:132-137. [PMID: 29446233] doi:10.1111/irv.12486 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Carmen McDermott MD, FACPProvidence Sacred Heart Medical Center and University of Washington School of Medicine25 March 2020 Emerging Knowledge of Gastrointestinal Manifestations in COVID-19 Elevates Concern For Bio-aerosol Transmission. Thank you Dr. Klompas for your thoughtful article. Additionally, given the novelty of SARS-CoV2, we lack evidence to determine whether or not bio-aerosol transmission occurs as discussed in an analysis by bio-aerosol expert Dr. Lisa Brosseau (1). New evidence describes gastrointestinal manifestations in up to 33% of patients with SARS-CoV-2, fecal shedding in potentially 50% of patients, and reports of probable in-hospital transmission from patients with gastrointestinal symptoms to health care providers and other patients (2-5). Given these findings, experts have raised concern for transmission not only through fecal surface contamination, but also the potential for infectious aerosols which are known to be produced by toilet flushing (7-9). Clearly more research is urgently needed to clarify this issue, yet until then, a precautionary approach to infection control in the hospital and community is prudent. Interim considerations for mitigating this mode of transmission in the hospital setting could include: using lids on toilets, use of non-flushing bedside toilets, modifying ventilation, and using air filtration systems. Increased public messaging about the potential for bio-aerosol transmission and gastrointestinal manifestations is important as well. In this time of urgent need to reducing transmission, we can engage experts and expedited research into the potential for bio-aerosol transmission.REFERENCES:1. Brosseau, Lisa. http://www.cidrap.umn.edu/news-perspective/2020/03/commentary-covid-19-transmission-messages-should-hinge-science2. Johnson, David commentary: https://www.medscape.com/viewarticle/926856?src=/do/10.5555/comment1213/listitem/mkm_ret_200322_mscpmrk_gastroenterology_covid&uac=315924MJ&impID=2318549&faf=13. Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. pii: S0016-5085(20)30281-X. [Epub ahead of print] https://doi.org/10.1053/j.gastro.2020.02.0544. Xiao F, Tang M, et al. Evidence for gastrointestinal infection of SARS-CoV-Gastroenterology. 2020 Mar 3. pii: S0016-5085(20)30282-1. [Epub ahead of print] https://doi.org/10.1053/j.gastro.2020.02.0555. Luo S, Zhang X, Xu H, Don't overlook digestive symptoms in patients with 2019 novel coronavirus disease (COVID-19), Clinical Gastroenterology and Hepatology (2020), doi: https://doi.org/10.1016/j.cgh.2020.03.043.6. Liang W, Feng Z, Rao S, et al Diarrhoea may be underestimated: a missing link in 2019 novel coronavirus. Gut Published Online First: 26 February 2020. http://dx.doi.org/10.1136/gutjnl-2020-3208327. Knowlton, Samantha D et al. “Bioaerosol concentrations generated from toilet flushing in a hospital-based patient care setting.” Antimicrobial resistance and infection control vol. 7 16. 26 Jan. 2018, https://doi.org/10.1186/s13756-018-0301-98. Johnson, David et al. “Aerosol Generation by Modern Flush Toilets.” Aerosol science and technology: the journal of the American Association for Aerosol Research vol. 47,9 (2013): 1047-1057. https://doi.org/10.1080/02786826.2013.8149119. Johnson, David L et al. “Lifting the lid on toilet plume aerosol: a literature review with suggestions for future research.” American journal of infection control vol. 41,3 (2013): 254-8. https://doi.org/10.1016/j.ajic.2012.04.330 Neelesh GuptaUniversity of South Alabama Medical Center, Mobile, AL, USA19 March 2020 In symptomatic patients viral respiratory panel check is mandatory to contain the pandemic I peruse with interest and agree with the idea of Michael Klompas about mandatory check of symptomatic patients with viral respiratory panel. Now as the picture is unfolding and experience is accumulating fast. The negative result of respiratory panel in a symptomatic patient could be an indication of COVID-19. In infection with COVID-19, usually no virus and bacteria grow. However, as the silent careers are not very uncommon in the society usual precautions must be applied at everyplace and all the times. Disclosures: Nil Sugihiro Hamaguchi, Kie Yaguchi, Yohei Nakamoto, Tetsuro Aita, Yoko ShimotaniDepartment of General Internal Medicine, Fukushima Medical University18 March 2020 The more PCR, the more burden Dear EditorAs long as the virus spread relatively all over the country, aggressive detection of covid-19 infection by PCR in the early stage of illness can cast a heavy burden of patients with no or mild symptoms on health care providers especially medical personnel at hospitals. We suggest that the aggressive case detection by PCR not be a mainstay strategy anymore to conquer the battle against this rampant viral pandemic in the country.Japan has been criticized both nationally and internationally about the limited number of PCR implementation and there is a public concern about potentially more undetected cases with no or mild symptoms who are spending their daily lives.(1)However, the number of deaths is still 28 in Japan as of March 17th, 2020 after excluding the number of cases infected in the Diamond Princess cruise ship.(2) This figure is extremely smaller and its increase rate is much slower than that of other countries, considering the fact that the first case in Japan was reported on January 14th when other countries did not have many patients yet.One of the most notorious characteristics compared to other viral infections is its large potential of developing pneumonia, leading to the high mortality rate in elderly patients or those with chronic underlying illnesses.(3) Mortality of this infection has nothing to do with the number of PCR implemented since there is no specific treatment for this virus at the moment and early detection of cases does not alter the therapeutic strategy. On the other hand, all cases who died of unexplained pneumonia in this period would receive PCR test for covid-19 and there is almost no possibility of underreporting in the number of patients who died of covid-19 pneumonia in Japan. Therefore, the small number of deaths indicates that the overall infection control has been successful.What we need to do is, regardless of more PCR implementation, reducing the mortality while being more aggressive about respiratory/hand hygiene, and public health measures such as restrictions on people’s movement to prevent potential cluster spreads. Case detection by PCR and positive case tracing are effective for the prevention of disease spread when the number of cases is still small. As the number of cases increases, however, we need to change the strategy from relying on PCR to basic public health methods and care for patients according to the disease severity.1. Takahashi R. Coronavirus testing now covered by Japan's national insurance. The Japan times News; 2020.2. Ministry of Health LaW 2020;Pageshttps://www.mhlw.go.jp/stf/seisakunitsuite/bunya/newpage_00032.html on 16 March 2020.3. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020. Faisal SiddiquiVA Sierra Nevada Healthcare System16 March 2020 Transfers of COVID-19 patients within the hospital Dear Editor:I am writing this letter in response to a recently published article by Dr Klompas. Recently in our intensive care unit we received a patient -a “PUI” (person under investigation for corona virus disease - COVID 19), on non invasive ventilation (NIV) from the emergency department. A question was raised of how to transfer the patient safely while on mechanical ventilation (MV) or NIV. I have taken this opportunity to address the issues related to patient admission and airborne precautions during their stay [1].Patient should not be transported out of the negative pressure isolation room unless it is absolutely necessary.If patient is on room air and needs to be transported he needs to wear a surgical mask. Healthcare professionals (HCP) need to maintain at least 3 feet distance from the patient during transfer unless medically necessary. HCPs should also wear standard personal protective equipment (PPE) and a surgical mask with a face shield during transfers [2]. If patient is on oxygen delivered via nasal cannula the transfer/transport guidance is the same as #2. During transfer it should be ensured that hallways and elevators are cleared and in the enclosed spaces there is only necessary staff along with the patient [3].If the patient is intubated we need to ensure that there are high efficiency particulate air (HEPA) filters for both the inspiratory and expiratory circuits on the transport ventilator. HCPs should also wear standard PPE and a surgical mask with a face shield during transfers [4]. If the patient is on NIV then the recommendation would be to consider discontinuing NIV if possible, or intubating the patient if clinically justified. This has to be judged against risks and benefits related to the transfer. If patient is transported with NIV then he would be considered “very-high” risk for airborne transmission of the virus. In that case the recommendation would be to consider N-95 masks for all the healthcare workers who are involved in the transportation in addition to standard PPEs. Consider additional precautions as mentioned in #4. References:1. https://www.cdc.gov/coronavirus/2019-ncov/index.html2. Lindsley WG, Noti JD, Blachere FM, Szalajda JV, Beezhold DH. Efficacy of face shields against cough aerosol droplets from a cough simulator. J Occup Environ Hyg. 2014;11(8):509-183. Gammon J, Hunt J. A review of isolation practices and procedures in healthcare settings. Br J Nurs. 2018 Feb 08;27(3):137-1404. Seto WH. Airborne transmission and precautions: facts and myths. J. Hosp. Infect. 2015 Apr;89(4):225-8 Author, Article, and Disclosure InformationAuthors: Michael Klompas, MD, MPHAffiliations: Harvard Medical School, Harvard Pilgrim Health Care Institute, and Brigham and Women's Hospital, Boston, Massachusetts (M.K.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-0751.Corresponding Author: Michael Klompas, MD, MPH, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215; e-mail, mklompas@bwh.harvard.edu.Author Contributions: Conception and design: M. Klompas.Drafting of the article: M. Klompas.Critical revision of the article for important intellectual content: M. Klompas.Final approval of the article: M. Klompas.This article was published at Annals.org on 11 March 2020. 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