key: cord-1008679-4iv8ezg7
authors: Maltezou, Helena C.; Dedoukou, Xanthi; Tsonou, Paraskevi; Tseroni, Maria; Raftopoulos, Vasilios; Pavli, Androula; Papadima, Kalliopi; Chrysochoou, Anastasios; Randou, Efthalia; Adamis, Georgios; Kostis, Evangelos; Pefanis, Angelos; Gogos, Charalambos; Sipsas, Nikolaos V.
title: Hospital factors associated with SARS-CoV-2 infection among healthcare personnel in Greece
date: 2020-10-22
journal: J Hosp Infect
DOI: 10.1016/j.jhin.2020.10.010
sha: eee10db0fb76293db41dc8d2ea0fbc7f43258480
doc_id: 1008679
cord_uid: 4iv8ezg7

Healthcare personnel (HCP) constitute a high-risk group for SARS-CoV-2 infection. We estimated their risk of infection per hospital characteristics. Factors significantly associated with an increased risk for SARS-CoV-2 infection were: working in a non-referral hospital compared to a COVID-19 referral hospital, working in a hospital with a high number of employees, and working in a hospital with an increased number of COVID-19 patients. Our study revealed gaps in infection control in the non-referral hospitals. There is an urgent need for continuous training in infection control practices. Compliance of HCP with the use of personal protective equipment should also be addressed.

Triage for prompt detection of patients with COVID-19 was implemented in all hospitals. A surgical mask was administered to symptomatic patients upon entering any hospital. The following personal protective equipment (PPE) was recommended for HCP caring for suspected or laboratory-confirmed COVID-19 cases: filtering face piece respirator (FFP)-2, non-sterilized single-use gloves, goggles or face shield, and gown resistant to fluid penetration. An FFP3 respirator was recommended for HCP performing aerosol-generating procedures [2] . In case of shortages, surgical masks were recommended for HCP caring for patients in order to preserve respirators for aerosol-generating procedures.

Contact tracing and risk assessment of exposed HCP were performed by the Infection Control Committee of each hospital. Exposures were categorized as highrisk, moderate-risk or low-risk and managed accordingly [2] . HCP with high-risk exposure were excluded from work for isolation purposes for seven days. Exposed HCP were tested for SARS-CoV-2 infection by reverse-transcriptase polymerase chain reaction (RT-PCR) in case of onset of symptoms. Although testing of asymptomatic HCP was officially recommended only for HCP working in high-risk settings (transplantation units, hematology-oncology units, intensive care units), this was a common practice in many hospitals, regardless of exposure-risk category or working setting [2] .

The study period extended from February 26 (first COVID-19 case detected in Healthcare-associated SARS-CoV-2 infection was defined as a case of SARS-CoV-2 infection in a HCP following occupational exposure.

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Written consent was not required, given that the data were collected within the frame of epidemiological surveillance. Data were managed in accordance with the national and European Union laws.

All the items were coded and scored, and were included in the data analysis set.

IBM SPSS 26 was used to analyze the data. The t-test was used to assess whether the means of two groups were statistically different. P-values < 0.05 were considered statistically significant.

In As expected, the designated COVID-19 referral hospitals significantly outnumbered the non-referral hospitals in terms of number of hospitalized patients with COVID-19. Nevertheless, the current study showed that the ratio of SARS-CoV-to HCP working in COVID-19 units [7.8% (37/476) versus 3.5% (11/315); p-value=0.005] [9] . In another study of ours we found that approximately half of 3,398

HCP with a history of occupational exposure to COVID-19 had been exposed to another HCP with COVID-19; we also found that administrative employees were more likely to get infected in-hospital than other profession categories, suggesting that the former either did not comply with infection control guidelines or were less trained for PPE use [2] . These findings underscore the need for continuous education of HCP in order to achieve high compliance rates with infection control guidelines, regardless of direct care of COVID-19 patients. The introduction of an integrated infection control strategy in a SARS-designated hospital in Taiwan with no negative pressure isolation rooms during the SARS epidemic, was associated with a significant reduction of the incidence rate of HCP who contracted SARS, compared to 86 hospitals that did not use the infection control strategy (0.03 cases/bed compared to 0.13 cases/bed; p-value=0.03) [5] . Beyond triage of patients and extensive installation of alcohol dispensers, the strategy included reinforcement for HCP to comply with infection control procedures, especially hand washing [5] . In addition, in the current study HCP working in hospitals with large number of employees were more likely to get infected with SARS-CoV-2, which points out to the challenges to efficiently train HCP in large hospitals. Another possible explanation is the difficulty to respect social distancing in large hospitals especially during coffee breaks and meals at the selfservice restaurant.

HCP often consider masks and other PPE uncomfortable to use [10] . Yet, studies indicate that a workplace culture supporting training of all HCP categories, communication of guidelines, and good patient care practices could improve their compliance to guidelines [10] . In response to the increasing number of HCP with A limitation of the current study is the fact that only public hospitals were studied.

However, the overwhelming majority of COVID-19 patients in Greece were cared for in public hospitals. A clear advantage is the large number of consecutively diagnosed patients and HCP with SARS-CoV-2 infection retrieved from the national surveillance database.

In conclusion, our study confirms that HCP constitute a high-risk group for SARS-CoV-2 infection. It also shows that there are gaps in infection control in non-referral hospitals. Given the ongoing epidemic in Greece and globally and the increasing potential for infected cases to seek healthcare in any healthcare facility, there is a need to raise infection control capacity and to address issues of HCP compliance with the use of PPE in all healthcare facilities.

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World Health Organization. Coronavirus disease (COVID-19) pandemic

SARS-CoV-2 infection in healthcare personnel with high-risk occupational exposure: evaluation of seven-day exclusion from work policy

Online ahead of print

Transmission of COVID-19 to health care personnel during exposures to a hospitalized patient

First experience of COVID-19 screening of health-care workers in England

Using an integrated infection control strategy during outbreak control to minimize nosocomial infection of Severe Acute Respiratory Syndrome among healthcare workers

Middle East respiratory syndrome coronavirus: implications for health care facilities

Nosocomial outbreak of COVID-19 pneumonia in Wuhan, China

Airborne transmission of severe acute respiratory syndrome coronavirus-2 to healthcare workers: a narrative review

SARS-CoV-2 infection: advocacy for training and social distancing in healthcare settings

Barriers and facilitators to healthcare workers' adherence with infection prevention and control guidelines for respiratory infectious diseases: a rapid

We thank the Infection Control Committees of all hospitals for their assistance. We also thank Sophia Poufta for technical assistance. The opinions presented in this article are those of the authors, and do not necessarily represent those of their institutions.J o u r n a l P r e -p r o o f