Clustering and multiple-spreading events of nosocomial severe acute respiratory syndrome coronavirus 2 infection

Abstract

Background: There is growing evidence that super-spreading events (SSEs) and multiple-spreading events (MSEs) are a characteristic feature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, data regarding the possibility of SSEs or MSEs in healthcare settings are limited.

Methods: This study was performed at a tertiary-care hospital in Korea. We analysed the nosocomial COVID-19 cases that occurred in healthcare workers and inpatients and their caregivers between January and 20^th December 2020. Cases with two to four secondary cases were defined as MSEs and those with five or more secondary cases as SSEs.

Findings: We identified 21 nosocomial events (single-case events, N = 12 (57%); MSE + SSE, N = 9 (43%)) involving 65 individuals with COVID-19. Of these 65 individuals, 21 (32%) were infectors. The infectors tended to have a longer duration between symptom onset and diagnostic confirmation than did the non-infectors (median two days vs zero days, P=0.08). Importantly, 12 (18%) individuals were responsible for MSEs and one (2%) for an SSE, which collectively generated 35 (54%) secondary cases.

Conclusion: In a hospital with thorough infection-control measures, approximately 70% of the nosocomial cases of COVID-19 did not generate secondary cases, and one-fifth of the infectors were responsible for SSEs and MSEs, which accounted for approximately half of the total cases. Early case identification, isolation, and extensive contact tracing are important for the prevention of transmission and SSEs.

Keywords: COVID-19; SARS-CoV-2; Transmission.

Figure 1

Floor plan of the hospital with transmission chains. The first date when the index cases in each cluster were determined to be infectious is shown. If the index cases were asymptomatic at diagnosis, they were regarded as having been infectious two days before diagnosis. If the index cases were symptomatic at diagnosis, they were regarded as having been infectious four days before symptom onset.

Figure 2

Epidemic curve of the weekly cases of laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection at the hospital according to the date of symptom onset (bar graph) and the weekly number of domestic cases in the Republic of Korea (line graph).

Figure 3

Offspring distribution of the nosocomial cases of COVID-19 (N = 65).

Figure 4

Phylogenetic tree of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequences from Asan Medical Center. A phylogenetic tree was constructed via maximum likelihood estimation (1000 replicates) using MEGA X software. Bootstrap scores were represented at each node. Different branch colours represent different clades and subclades. The scale bar indicates nucleotide substitution per site. Red indicates 12 specimen sequences acquired from Asan Medical Center (whole-genome sequencing (WGS) group A: WA; WGS group B: WB; and WGS group C: WC).