Understanding and reducing the spread of COVID-19 in English hospitals and healthcare settings

Transmission of COVID-19 in hospitals and social care settings in patients, residents and staff has been recognised as an important feature of the Covid-19 epidemic throughout the world, while efforts to prevent infections have had varying success, according to Data Evaluation and Learning for Viral Epidemics (DELVE), a multi-disciplinary group convened by the Royal Society.

A report, Covid-19 acquisition and its control in healthcare settings, says that although surveillance systems and large-scale hospital-based research studies have recently been set up in England, there remain gaps in our knowledge and in availability of surveillance data on hospital-acquired infections, particularly of healthcare workers (including agency staff) and in nursing homes; important questions remain unanswered, including about the impact on Black, Asian and minority ethnic (BAME) healthcare workers.

Anne Johnson, Professor of Infectious Disease Epidemiology at University College London, Vice President of the Academy of Medical Sciences and a member of the DELVE committee said: “We now better understand the risks of COVID-19 transmission within hospital and care settings although improved data are needed.  As in many countries, outbreaks have occurred and continue to occur, though renewed prevention efforts are now in place. Now we need to learn from our experience and use our greater understanding of how the pandemic has played out, to ensure we are better prepared to prevent and manage new outbreaks and a potential second wave, protecting everyone.”

Population surveys show that patient-facing health and social care workers are at significantly increased risk of COVID-19 compared with the general population. The report estimates that between 26 April and 7 June around 10% of all COVID-19 infections in England were among patient-facing healthcare workers and resident-facing social care workers. An estimated further 1% of infections in this period were acquired by inpatients in hospital, with additional infections among care home residents (estimated at least6% of all infections). Many countries in Europe appear to have experienced problems of a similar magnitude although countries such as South Korea and Singapore report successful prevention and control of hospital acquired infections.

Nigel Field, Chair of the DELVE working group which wrote the report and Director of the Centre of Molecular Epidemiology and Translational Research at the Institute for Global Health, University College London said: “The NHS is an amazing resource and many improvements have been made during a particularly challenging period. Standardised infection prevention and control guidelines have been published, emphasising the need for mask wearing and PPE, test and trace, and safe patient discharge practices to prevent transmission into the community. However, we also need better systems in place to understand how COVID-19 is spreading and greater coordination of our efforts to control hospital acquired infections and protect patients, staff and their families. We have a window of opportunity now to reinforce effective and efficient systems and infection control efforts.”

According to DELVE, over the course of the epidemic there has been insufficient systematic data collection to identify sources and risks for hospital-acquired transmission, and to allow effective targeted outbreak response and infection control. For example, there has been limited exploration of the extent to which infections acquired within hospitals amplify wider community spread, including to and from institutional settings such as care homes.

The report considers what further actions are needed to build comprehensive surveillance and infection control systems, with awareness that such an approach would require further resources and expert support to the hospital, public health, and care sectors. It sets out a suggested framework for strengthening effective centralised surveillance and monitoring of hospital-acquired infections linked to rapid infection control responses with sharing of best practice, coordinated through local teams. Overall, an ambitious and comprehensive approach is needed to prevent infection transmitted through respiratory droplets and aerosol routes in hospitals.

The report highlights six key areas where further action could be considered:

Many of the ideas below are being developed within the Covid-19 response by the JBC and PHE among others; our aim is to highlight the urgent need for their systematic and joint implementation, and transparent rapid access to data.

1.  Rapid identification of Covid-19 cases within hospitals. Establish a standardised risk-based protocol for testing individuals within hospitals, both for Covid-19 and other key respiratory pathogens such as influenza, including consistent intensity, breadth of coverage and speed of results turnaround. This protocol would need to reach beyond existing systems for testing patients to cover hospital employees (including staff without patient-facing roles), students and volunteers.
2. Centralised surveillance and monitoring of Covid-19 infections acquired within hospitals. Building on existing reporting systems, standardised Covid-19 case reporting would allow the rapid identification of hospitals with certain or probable outbreaks and cases linked to them, with the potential for external oversight (e.g. the Care Quality Commission). Direct surveillance might be supported by using routinely available data, such as on staff absences which can also inform workforce planning decisions, and processed results such as phylogenetic data. Reports should be publicly available, and include case numbers and reductions over time, as part of hospital performance metrics.
3. Connected Covid-19 data systems across community, care institutions and hospitals. Information on local community incidence and links to institutional settings, including long-term care facilities, may empower hospitals to assess the risk of importing and exporting cases, and take appropriate preventative measures.
4. Standardised, tiered infection prevention and control guidelines. These guidelines should vary by risk level, based on closely monitored infection levels; much of this already exists, but requires integration with the other considerations in this section.
5. Regional or local outbreak investigations for Covid-19. A minimum standard for outbreak investigations should be set centrally, with external oversight (e.g., the Joint Biosecurity Committee, Public Health England) and a standardised reporting structure. The preferred approach to outbreak management should be through empowerment of Trust or hospital-level structures (e.g., Directors of Infection Prevention and Control), which may require central resources. Outbreak investigations should include support from successful local/regional peer institutions, including Public Health England and Directors of Public Health. Report findings should lead to enforceable, externally monitored recommendations of interventions to reduce hospital transmission, with mandated executive-level responsibility for implementation. All hospital-acquired infections should be linked to existing Test and Trace systems.
6. Research platform. Data obtained from surveillance, monitoring and outbreak investigations should feed into epidemiological and modelling research and evaluation. This research is needed to evaluate which interventions are cost-effective and feasible in preventing hospital and social care transmission in the long-term.

The Society gratefully acknowledges the financial support of the Leverhulme Trust.

The DELVE report, Covid-19 acquisition and its control in healthcare settings, can be found here: https://rs-delve.github.io/reports/2020/07/06/nosocomial-scoping-report.html