key: cord-0889150-txtrbqxj authors: Ye, Guangming; Lin, Hualiang; Chen, Liangjun; Wang, Shichan; Zeng, Zhikun; Wang, Wei; Zhang, Shiyu; Rebmann, Terri; Li, Yirong; Pan, Zhenyu; Yang, Zhonghua; Wang, Ying; Wang, Fubing; Qian, Zhengmin; Wang, Xinghuan title: Environmental Contamination of SARS-CoV-2 in Healthcare Premises date: 2020-04-30 journal: J Infect DOI: 10.1016/j.jinf.2020.04.034 sha: 7245331cca8eb017ff75503a727234d55f4d7d7d doc_id: 889150 cord_uid: txtrbqxj Abstract Objectives A large number of healthcare workers (HCWs) were infected by SARS-CoV-2 during the ongoing outbreak of COVID-19 in Wuhan, China. Hospitals are significant epicenters for the human-to-human transmission of the SARS-CoV-2 for HCWs, patients, and visitors. No data has been reported on the details of hospital environmental contamination status in the epicenter of Wuhan. Methods We collected 626 surface swabs within the Zhongnan Medical Center in Wuhan in the mist of the COVID-19 outbreak between February 7 - February 27, 2020. Dacron swabs were aseptically collected from the surfaces of 13 hospital function zones, five major objects, and three major PPE. The SARS-CoV-2 RNAs were detected by reverse transcription-PCR. Results The most contaminated zones were the intensive care unit specialized for taking care of novel coronavirus pneumonia (NCP) (31.9%), Obstetric Isolation Ward specialized for pregnant women with NCP (28.1%), and Isolation Ward for NCP (19.6%). We classified the 13 zones into four contamination levels. The most contaminated objects were self-service printers (20.0%), desktop/keyboard (16.8%), and doorknob (16.0%). Both hand sanitizer dispensers (20.3%) and gloves (15.4%) were the most contaminated PPE. Conclusion Our findings emphasize the urgent need to ensure adequate environmental cleaning, strengthen infection prevention training, and improve infection prevention among HCWs during the outbreak of COVID-19. An outbreak of COVID-19 began in Wuhan, China in early December 2019 and is ongoing. There have been 2, 314, 621 confirmed COVID-19 cases, and 157, 847 deaths all over the world as of April 20, 2020.(1) Early on during the COVID-19 outbreak, healthcare workers (HCW) were found to beat high risk of developing COVID-19, even when infection prevention measures were in place, including usage of personal protective equipment (PPE: eye protection/face shield, respiratory protection, isolation gowns, and gloves), hand hygiene, and patient placement in negative-pressure isolation rooms. Although with adequate personal protective equipment, at least 22,073 healthcare workers were infected according to World Health Organization (WHO) and the number is still keep rising. (2) However, the World Health Organization (WHO) indicates that many of the newer cases of HCW infection have stemmed from household exposures. (3) The COVID-19 outbreak caused a sudden, significant increase in hospital visits from infected and suspected individuals over the course of two months. (4) (5) (6) The large patient surge overwhelmed hospitals, despite continuous efforts to expand hospital capacity. Hospital waiting times were extended, which increased the time before infected individuals were identified and placed into isolation. It is believed that the primary transmission mode of COVID-19 is through large respiratory droplets and close contact, although there is limited data that indicates that it may also spread through indirect contact with contaminated environments and aerosols.(3) Only one study has examined possible environmental contamination of SARS-CoV-2 in a hospital outside of the epicenter of Wuhan and it consisted of a small sample size.(7) Characterizing hospital contamination of SARS-CoV-2 is critical because hospitals have experienced massive patient surges during the outbreak and environmental contamination may contribute to disease spread.(8) Data regarding the hospital function zones with highest levels of contamination can inform hospital cleaning and disinfection protocols to reduce the risk of healthcare-associated disease. The purposes of this study were to: (1) determine the extent to which the hospital environment becomes contaminated during outbreaks of COVID-19, (2)identify the highest areas of contamination within hospitals, and (3) identify the most frequently contaminated objects, medical supplies, and used PPE in a typical hospital in Wuhan, China during the ongoing outbreak of COVID-19. The study was conducted in Zhongnan Medical Center of Wuhan University, located in Wuhan, China. Wuhan is the largest city in Central China and the capital city of Hubei Province in China. (9) It has approximately 12 million people and has a subtropical, humid monsoon climate. Historically, Wuhan has been the biggest hub in China for land, water, and air transportation, and it is also one of the most industralized cities in China. (10) The Zhongnan Medical Center possesses a Grade-III rating, the highest level according to a 3-tier system in China that recognizes a hospital's capacity and ability to provide healthcare, conduct research, and deliver education. It has over 3,300 beds and a medical team that includes over 500 senior physicians. It includes 46 clinical departments and multiple research and clinical laboratories. Samples were collected between February 7 -February 27, 2020, while the outbreak was ongoing. Three sets of surface samples were collected using dacron swabs across major hospital function zones, hospital equipment/objects and medical supplies, and HCW's used PPE. Swab samples were also collected from control areas (i.e., spaces that did not house COVID-19 patients, consisting of administrative areas and the parking lot). Dacron swabs were premoistened with cell preservation solution. Samples were shipped with ice packs and refrigerated upon arrival at the laboratory. Blank controls were also used in swab sampling. Medical equipment assessed consisted of finger clips of pulse oximetry, electrocardiogram monitors, oxygen cylinders, oxygen regulators, oxygen masks, CT scanning machine, centrifuge, biosafety cabinet, and ventilator. Objects in non-medical areas (i.e., public facilities) assessed consisted of elevator buttons, microwave ovens, faucets, handrails, and hair drier. HCW's' used PPE assessed included gloves, eye protection or face shield and hand sanitizer dispensers; samples were collected after the HCW performed their duties with a COVID-19 patient. Hospital areas were classified into contamination zones, based on the percentage of swabs that were positive in that area/object. Reverse transcription-PCR (RT-PCR) were conducted, using procedures recommended by the Chinese Center for Disease Control and Prevention. Briefly, we used the SARS-CoV-2 nucleic acid detection kits (DAAN Gene Co., Ltd, China) to extract viral RNAs.(11) Two different targets on the SARS-CoV-2 genome were used: the ORF1ab and N genes. The Ct value of the amplification curve was defined as positive if less than 40 and negative if greater than 40. Both positive controls and negative controls were routinely included in each test. The R software (version 3.5.1) was used for all analyses. First, descriptive statistics were conducted. Differences in the positive detection rates of SARS-CoV-2 RNA in the surface swabs between hospital areas, hospital objects and medical supplies, and HCW's used PPE were assessed using Chi-Square tests and/or the Fisher's exact test where appropriate based on cell size. Two-tailed tests were used, and P-values smaller than 0.05 were considered statistically significant. In total, 626 hospital environmental surface swab samples were collected; 13.6% were found to be positive for SARS-CoV-2 (Table 1) Among all examined commonly used hospital objects and medical equipment, 13.9% were found to be positive for SARS-CoV-2 (Table 2 ). This included positive samples from self-service printers (20%), it is a machine commonly used in China by patients themselves to print out their examination or test reports in a hospital), desktops (16.8%), doorknobs (16.0%), and telephones (12.5%), medical equipment (12.5%), and public facilities (8%). Only 5.6% of samples collected from walls and floors were positive. The most contaminated objects were self-service printers (20%), desktops/keyboards (16.8%), and doorknobs (16%). Of the samples collected from HCWs' used PPE (hand sanitizer dispensers, gloves, and eye protector/face shield), 12.9% were positive for SARS-CoV-2 (Table 3 ). Significant differences were found in the percentage of positive samples across the PPE types (P < 0.01). The highest positive detection rate found was from the hand sanitizer dispensers 20.3%; 15.4% and 1.7% of gloves and eye protection or face shields tested positive, respectively (Table 3) . This investigation showed that the hospital environment frequently becomes contaminated when providing care to COVID-19 patients. Contaminated areas/items included patient care areas housing COVID-19 patients, common hospital objects/items, such as self-service printers, desktops, doorknobs, and keyboards, medical equipment, and HCWs' PPE, such as gloves, eye protection, and face shields. These findings suggest that the hospital environment could potentially be a source of virus spread, including among HCWs, patients, and visitors. It is noteworthy that the hospital surface samples were collected from February 7 to February 27, 2020, which was after human-to-human spread of SARS-CoV-2 was identified. It is plausible to assume that the hospital surface contamination would have been more severe before the sampling period, when environmental cleaning protocols were not as extensive and HCWs were processes. It is, therefore, a standardize procedure to lessen the intensity and to reduce frequency of the internal infection control processes in the department, which may have led to the high positive detection rates discovered from our study. It was not surprising that the Fever Clinic had a low positive detection rate for SARS-CoV-2 (6.5%). Early on, the Fever Clinic was relocated to a semi-open area, which was well-ventilated. In addition, unlike the obstetric isolation ward, strict infection prevention measures were instituted in the Fever Clinic. These practices likely led to the low positive detection rate. It is notable that both hand sanitizer dispensers and HCWs' used gloves possessed the highest positive detection rate of SARS-CoV-2 compared to eye protection or face shields. Gloves would become contaminated by touching infected patients and/or contaminated surfaces in the hospital. There is no reported conflict of interest from each of authors. The Science and Technology Department of Hubei Province had no role in each part of the investigation, including the study design; collection, management, analysis, and interpretation of the data; development of the manuscript; and decision to submit the manuscript for publication. World Health Organization Strategic planning and recommendations for healthcare workers during the COVID-19 pandemic. The American journal of emergency medicine World Health Organization Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia Clinical Characteristics of Coronavirus Disease 2019 in China Population movement, city closure in Wuhan and geographical expansion of the 2019-nCoV pneumonia infection in China in Clinical Data on Hospital Environmental Hygiene Monitoring and Medical Staffs Protection during the Coronavirus Disease Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient Ambient air pollution and preterm birth: a prospective birth cohort study in Wuhan High temperatures enhanced acute mortality effects of ambient particle pollution in the" oven" city of Wuhan, China. Environmental health perspectives Positive RT-PCR Test Results in Patients Recovered From We wanted to express our highest appreciation to our staff who risked their lives collecting the large number of samples needed to conduct this study. We also thank the nurses and doctors in Zhongnan Medical Center for their support and assistance for collecting the samples.