key: cord-0967114-v28kilvn authors: Peyrony, Olivier; Ellouze, Sami; Fontaine, Jean-Paul; Le Cam, Micheline Thegat; Salmona, Maud; Feghoul, Linda; Mahjoub, Nadia; Mercier-Delarue, Séverine; Gabassi, Audrey; Delaugerre, Constance; Le Goff, Jérôme title: Surfaces and equipment contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in the Emergency Department at a university hospital date: 2020-08-07 journal: Int J Hyg Environ Health DOI: 10.1016/j.ijheh.2020.113600 sha: b4a13dfd70554ac1dc1f5f91e6a7a17ca0ea584c doc_id: 967114 cord_uid: v28kilvn OBJECTIVES: Environmental contamination by patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through respiratory droplets suggests that surfaces and equipment could be a medium of transmission. We aimed to assess the surface and equipment contamination by SARS-COV-2 of an emergency department (ED) during the coronavirus infectious disease-2019 (COVID-19) outbreak. METHODS: We performed multiple samples from different sites in ED patients care and non-patient care areas with sterile premoistened swabs and used real-time reverse transcriptase polymerase chain reaction (RT-PCR) to detect the presence of SARS-CoV-2 ribonucleic acid (RNA). We also sampled the personal protective equipment (PPE) from health care workers (HCWs). RESULTS: Among the 192 total samples, 10 (5.2%) were positive. In patient care areas, 5/46 (10.9%) of the surfaces directly in contact with COVID-19 patients revealed the presence of SARS-CoV-2 RNA, and 4/56 (7.1%) of the surfaces that were not directly in contact with COVID-19 patients were positive. SARS-CoV-2 RNA was present only in the patients’ examination and monitoring rooms. Before decontamination SARS-CoV-2 RNA was present on the saturation clip, the scuff for blood pressure measurement, the stretcher, the plastic screens between patients and the floor. After decontamination, SARS-CoV-2 RNA remained on the scuff, the stretcher and the trolleys. All samples from non-patient care areas or staff working rooms were negative. Only one sample from the PPE of the HCWs was positive. CONCLUSIONS: Our findings suggest that surfaces and equipment contamination by SARS-CoV-2 RNA in an ED during the COVID-19 outbreak is low and concerns exclusively patients’ examination and monitoring rooms, preserving non-patient care areas. During the novel coronavirus disease 2019 (COVID-19) outbreak, emergency departments (EDs) stood in the front line to face the significant increase of patients with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Direct transmission from an infected person to another remain the most common route of transmission of SARS-CoV-2 [1] . Direct transmission is usually mediated by saliva droplets during coughing and speaking and needs close proximity (<1 m) or hand contact between two individuals to allow these droplets to reach the mucosa [1] . Besides saliva droplet, other mediums of transmission such as fecal shedding or urinary excretion have been incriminated but with limited evidence. For instance, it is unclear if the virus is infective or has been inactivated in the intestinal lumen [2, 3] . SARS-CoV-2 may also be indirectly transmitted without close contact between two individuals, through environmental contamination, including air, surfaces and equipment contamination. Airborne transmission is mediated by micro-droplets released during aerosolization that can remain in the air for longer periods and travel at higher distances [1, 4] . Surfaces and equipment may also be contaminated through respiratory droplets or handcontact by patients infected with SARS-CoV-2 and operate as a medium of contamination [5] . Moreover, the virus has shown to remain viable and infectious in aerosols for hours and on surfaces up to days, depending on the inoculum shed and the nature of the surface [6] . Therefore, indirect transmission may be a threat for healthcare workers (HCWs) in departments attending COVID-19 patients. Some authors assessed the surface and equipment contamination rates by SARS-CoV-2 in several hospital departments showing a high contamination level in the departments dedicated to the COVID-19 patients care [7, 8] . A study reported 12.5% of positive samples in the ED without locating those samples according to the patient-care area [7] . As EDs are generally characterized by overcrowding, high patient throughput and numerous coming and goings of HCWs, the risk of surfaces and equipment J o u r n a l P r e -p r o o f contamination could be high, exposing HCWs to nosocomial infection, despite decontamination procedures and HCWs personal protective equipment (PPE) use [9, 10] . Thus, HCWs may be concerned about the risk of contamination in the ED, particularly in non-patient care areas. In this study, we aimed to assess the surface and equipment contamination by SARS-CoV-2 of an ED during the COVID-19 outbreak depending on patient care and non-patient care areas. This observational study was conducted from April 1 to April 8, 2020 in the ED of Saint-Louis university hospital, Paris, France. Prior to the outbreak, our department received on average, 115 patients per day and this number dropped to around 60 during the epidemic. Among these patients, 80% were suspected to have COVID-19 and, among those who were tested, approximately 60% were positive for SARS-CoV-2. We performed multiple samples from different sites all-around the ED and the 7-beds Short Stay Unit (SSU) in patients care and non-patient care areas. Patient care area included patients' registration desk, triage room, waiting room for suspected COVID-19 patients, examination, monitoring and short stay hospitalization rooms ( Figure 1 ). In this patient care areas, we distinguished the surfaces that were directly in contact with patients such as stretchers, cuffs for arterial blood pressure measurement, pulse oximeter clips, stethoscopes, ECG or ultrasound (US) devices, with those that were more distant, that is to say not directly in contact with the patient, but still located in the same room, into an area of approximately two meters of the patient, such as trolleys, monitor screens, benches, inside door handle, oxygen delivery manometer, plastic screen between two patients, and floor. Samples were obtained before and after decontamination. In the non-patient care area, samples were obtained from the registration area (from the J o u r n a l P r e -p r o o f HCWs side), non-suspected COVID-19 patients waiting room, corridor with personal protective equipment (PPE) storage, staff working rooms, refreshment room, toilets, changing room, research office and medical equipment stockroom ( Figure 1 ). There, we focused our samples on the surfaces that were the most in contact with or manipulated by HCWs such as telephones, keyboards, handle doors, tables, desks, benches for medication preparation, buttons, plastic jackets for medical files, food baskets, in order to assess the potential risk for indirect transmission. Basically, ED and SSU were adjacent and patient care areas were separated from non-patient care areas by a corridor (Figure 1 ). The refreshment area, toilets, medical equipment stockroom and research office were close to the patients care area whereas the changing rooms were distant. ED examination and SSU rooms had a surface of approximately 12 m 2 and the monitoring room of 16 m 2 . Thus, the distance between patient face and the swabbed surface varied between 1 meter for closer surfaces such as trolleys, chairs, plastic screen, monitor screen and oxygen manometer to 2 meters for more distant surfaces in the room such as door handle, bench, faucet or paper dispenser. It is important to underscore that these patients remained in their sketcher or bed during the whole stay in the room reducing the risk of contamination by hand contact. The air exchange rate in the different rooms where the samples were made ranged from 1 to 7 m 3 /h and room sizes from 30 to 60 m 3 , thus the entire air renewal duration of these rooms could range from 4 to more than 24 hours. Patient care and non-patient care areas ventilation systems were connected. Generally, during the epidemic, patients with COVID-19 who needed hospitalization were promptly admitted in a COVID-19 ward in order to free up examination rooms for other patients. Usually, the length of stay of such patients did not exceed four hours in examination or monitoring rooms. Then, after each patient suspect of COVID-19, examination rooms were cautiously decontaminated by HCWs before installing another patient. The decontamination procedure consisted in disinfecting the floors and all the surfaces of the rooms such as J o u r n a l P r e -p r o o f trolleys, sketchers, cuffs, door handles after each patient suspected of COVID-19 with Surfanios Premium (Anios®, France). Little objects such as stethoscopes were disinfected with Surfa'safe Premium (Anios®, France). After decontamination, the room had to remain empty for 30 minutes before installing another patient. Monitoring room and staff working rooms were regularly decontaminated every 2 or 3 hours depending on the patients or HCWs throughput. In order to consider the difference in workload, samples were collected at 3 different days during the epidemic. We sampled three times the rooms that carried the highest HCWs or patient transit such as staff work, triage, examination and monitoring rooms. In the patient care area, samples were made as a priority when patients had a high clinical probability of COVID-19. Therefore, the seven patients that were in the examination rooms or in the monitoring rooms before sampling were tested positive for SARS-CoV-2 except one. All patients admitted in the ED wore a face mask. We also sampled the PPE from HCWs after they cared for patients with COVID-19. We made samples with sterile premoistened swabs according to the protocol proposed by the World Health Organization [11] excepted for the surfaces of the swabbed area that were sometimes larger than the recommended 25 cm 2 . In our study, the surface area that was swabbed depended on the size of the device or the equipment. We tried to maximize this size without exceeding 50 cm 2 and avoiding letting the swab dry completely. We used Universal Transport Medium for Viruses (UTM® 359C, Copan, Brescia, Italy). After sampling ED surfaces, samples were immediately sent to the Virology laboratory and were processed directly on the COBAS 6800 system after virus inactivation with the COBAS 6800 lysis buffer. We used real-time reverse transcriptase polymerase chain reaction (RT-PCR) (Cobas® SARS-CoV-2 Test, Roche, Meylan, France) to detect the presence of SARS-CoV-2 ribonucleic acid (RNA). RNA was extracted within the total nucleic acids isolation and purification in the sample processing module of the COBAS 6800 system. As determined by the manufacturer, the limit of detection was 0.009 and 0.003 J o u r n a l P r e -p r o o f copies/mL (275.72 copies per reaction) [12] . The Cobas® SARS-CoV-2 test targets the nonstructural ORF1a/b region specific of SARS-CoV-2 and the structural protein envelope E gene. In our study, a sample was considered positive if either both ORF1a/b and E genes were Also, we did not detect any presence of SARS-CoV-2 RNA on the different surfaces of the patients' registration desk or COVID-19 patients' waiting room. None of the samples taken in the non-patient care areas showed SARS-CoV-2 RNA ( Table 2 ). More particularly, the samples taken from the phones and the keyboards from the ED and SSU staff working rooms that were located just in front of the examination or hospitalization rooms, were negative. Other sites located near the patient care areas such as the staff refreshment area, the HCWs toilets and the medical equipment stockroom did not show any presence of SARS-CoV-2 RNA. Other sites more distant from the patient care area but with a high throughput of HCWs such as the staff changing room or the research office were also negative. HCWs PPE (gown torso and arms, visor mask, face mask, shoes and head cover) were sampled three times (excepted for head cover that was sampled only one time) after they took care of patients with COVID-19. All samples were negative for SARS-CoV-2 except one on the front side of the gown (torso) with a Ct of 38.37. In our study, we showed that in an ED attended by patients with COVID-19 during the pandemic, only 5.2% of the surface samples were positive for SARS-CoV-2 RNA. SARS-CoV-2 RNA was present only in patients' examination and monitoring rooms but wasn't in either the non-patient care areas or in the staff working rooms. These results suggest that the risk of ED HCW infection from surfaces and equipment is low if decontamination procedures are regularly applied. If these decontamination procedures seem to be efficient in non-patient care areas, they need to be reinforced in examination and monitoring rooms which carry a high prevalence of patients with COVID-19. In particular, cuffs for arterial blood pressure measurement, finger or ear clips for oxygen saturation and plastic screens between patients need to be carefully disinfected. Other non-essential materials such as trolleys should be removed from these areas as suggested by van Doremalen et al. who showed that SARS-CoV-2 can remain viable up to 72 hours on plastic and stainless-steel surfaces [6]. Our positivity rate was somewhat lower than that published by Ye et al. who found that 12.5% of the environmental samples were positives in the ED of the Zhongnan Medical Center in Wuhan, China [7] . In this study, the positivity rates in the Intensive Care Unit (ICU), the Obstetric isolation ward and the general isolation ward for COVID-19 patients were 31.9%, 28.1% and 19.6% respectively [7] . Medical equipment was contaminated in 12.5% of the cases and public facilities, such as elevator buttons, microwave ovens, faucets, handrails, and hair drier, in 8% [7] . This high positivity rate may be explained by the highest proportion of samples that were made in patient care areas, medical equipment and PPE just after COVID-19 patient care. Whereas in our study the majority of samples were made after disinfection but also in non-patient care area. Guo et al. found that 23.7% of the surfaces tested were positive for SARS-CoV-2 in the ICU at Huoshenshan Hospital in Wuhan, China [8] . Here again, the positivity rate was high but more surfaces were tested, and J o u r n a l P r e -p r o o f particularly the floors that carried a high contamination rate. On the other hand, the positivity rate of a general COVID-19 ward was closer to ours with 4.9% positive samples [8] . patient care. In that study, surfaces were tested in three isolation rooms of a center dedicated to COVID-19 in Singapore. All positive swabs were observed before decontamination but were negative after decontamination. These results also suggest that current decontamination measures were sufficient, except that, contrary to our study, patients monitoring devices were not tested [5] . Another interesting finding of our study is that the surfaces from the patient care area that were not directly in contact with patients, such as door handles, benches or monitor screens, were mostly negative, even before decontamination. This observation is not supported by other studies that showed a high rate of contamination in the close environment of J o u r n a l P r e -p r o o f hospitalized COVID-19 patients in wards or in ICU [5, 8] . This could be explained because EDs carry a higher patient turnover than in wards or in ICU. Thus, reducing the length of stay of each patient in the examination and monitoring rooms and increasing the number of decontaminations after each visit could decrease the risk of contaminating the surrounding surfaces. Furthermore, these patients remained most of the time in their sketchers with a face mask and this also may contribute to lower the risk of contaminating more distant surfaces in the room. Also, ED HCWs became experienced and well trained to rigorous surfaces decontamination since the beginning of the epidemic. In our study we did not assess air contamination. Whereas it has shown to be a potential medium of transmission [4, 15] . The detection of SARS-CoV-2 on a surface is limited to the area browsed by the swab and it is possible that we missed some droplets. To lower that risk we performed almost 200 samples in a wide range of surfaces and sometimes, several times. It is of importance to underscore that RNA detected by RT-PCR method does not mean the viable virus is present. Because of weak amounts of viral RNA in positive samples, we did not attempt to isolate J o u r n a l P r e -p r o o f viruses in cell culture to assess SARS-CoV-2 infectivity. Indeed previous works showed the inability to isolate viruses with such weak loads [13] . Previous studies showed that even SARS-CoV-2 nasopharyngeal loads up to 5 to 6 log 10 copies/ml did not enable virus isolation in cell culture [17] . Thus, it is possible that the risk of infection from these contaminated surfaces was very low or absent. Furthermore, some authors who reported the presence of SARS-CoV-2 RNA in the environment failed to demonstrate virus viability [13, 14] . Some surfaces were sampled before decontamination but not after and vice-versa, thus, comparing the positive rate before and after decontamination in order to assess its efficacy is spurious. But, due to the high turnover of patients some days, we had to adapt our sampling to the workload. In summary, our findings suggest that surface and equipment contamination by SARS-CoV-2 in an ED during the COVID-19 outbreak is low and concerns exclusively patients' examination and monitoring rooms, preserving non-patient care areas. If these results may decrease the fear of being infected by surfaces among HCWs when decontamination procedures are rigorously applied, it shouldn't reduce their alertness and efforts to lower this risk. J o u r n a l P r e -p r o o f Outside door handle and digital code 0/1 Transmission of SARS-CoV-2: an update of current literature Evidence for gastrointestinal infection of SARS-CoV-2 TMPRSS2 and TMPRSS4 promote SARS CoV-2 infection of human small intestinal enterocytes It is Time to Address Airborne Transmission of COVID-19 Online ahead of print Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient Environmental contamination of SARS-CoV-2 in healthcare premises Aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards Perioperative COVID-19 Defense: An Evidence-Based Approach for Optimization of Infection Control and Operating Room Management Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents Evaluation of a quantitative RT-PCR assay for the detection of the emerging coronavirus SARS-CoV-2 using a high throughput system Online ahead of print Online ahead of print Relative contributions of transmission routes for COVID-19 among healthcare personnel providing patient care Virological assessment of hospitalized patients with COVID-2019 The authors wanted to thank Charles Bourget for its technical assistance in SARS-CoV-2 COBAS test implementation, Aurélien Gibaud and all the virology staff for their outstanding hard work since the beginning of the epidemic, the entire emergency department team from