Preventing and controlling intra-hospital spread of COVID-19 in Taiwan - Looking back and moving forward

Abstract

COVID-19 has exposed major weaknesses in the healthcare settings. The surge in COVID-19 cases increases the demands of health care, endangers vulnerable patients, and threats occupational safety. In contrast to a hospital outbreak of SARS leading to a whole hospital quarantined, at least 54 hospital outbreaks following a COVID-19 surge in the community were controlled by strengthened infection prevention and control measures for preventing transmission from community to hospitals as well as within hospitals. Access control measures include establishing triage, epidemic clinics, and outdoor quarantine stations. Visitor access restriction is applied to inpatients to limit the number of visitors. Health monitoring and surveillance is applied to healthcare personnel, including self-reporting travel declaration, temperature, predefined symptoms, and test results. Isolation of the confirmed cases during the contagious period and quarantine of the close contacts during the incubation period are critical for containment. The target populations and frequency of SARS-CoV-2 PCR and rapid antigen testing depend on the level of transmission. Case investigation and contact tracing should be comprehensive to identify the close contacts to prevent further transmission. These facility-based infection prevention and control strategies help reduce hospital transmission of SARS-CoV-2 to a minimum in Taiwan.

Keywords: Access control; Case investigation; Contact tracing; Infection prevention and control; Isolation; SARS-CoV-2 testing.

Figure 1

The concept map of national strategies and key measures to combat COVID-19 in Taiwan. (A) Three tiers of containment strategies. (B) Timely adjustment by risk and resources from containment to mitigation.

Figure 2

Number of COVID-19 cases by date of report and corresponding hospital outbreaks.

Figure 3

The framework of bi-directional contact tracing (a) a contact elicitation window of 2 days is used to ensure more infected contacts are identified, thus day 0 is considered as 2 days prior to the date of symptom onset or specimen collection for SARS-CoV-2 testing for the index case.^, (b) close contacts are defined as individuals with face-to-face contact (within 2 m) for a period of ≥15 min or direct exposure to aerosols or respiratory secretions without proper personal protection equipment from 2 days before the onset date of index case to the start of isolation. (c) The quarantine period of contacts is adjusted from 14 days to balance the public health risks and benefits against the social and economic impact.

Figure 4

Factors considered in the risk assessment for possible transmission to contacts in the absence of transmission-based isolation precaution and appropriate personal protective equipment.

Figure 5

The core elements of responding to COVID-19 confirmed cases who are hospitalized outside of dedicated COVID-19 wards or beds, and in the absence of COVID-19 specific precaution according to the Taiwan CDC recommendations (a) the guidance was first released on February 26, 2020 by the Taiwan CDC. (b) Isolation of confirmed cases and quarantine of those close contract in single rooms in designated COVID-19 units or in index units after cleaning. (c) In addition to the index case, there are additional 2 confirmed cases among those close contacts or risk contacts in inpatients units or additional 3 cases in outpatients or administrative units. In this situation, risk contacts are managed as close contacts. (d) Hospital-, campus- or building-wide responses are mandatory if there are a total of 3 or more confirmed cases (including the index case), or confirmed cases are distributed across more than one unit. These responses include active monitoring of health condition, mass screening, segregation of wards, and traffic control bundle. If deemed necessary, restrictions or delays of scheduled admissions or procedures may be implemented to reallocate capacity for isolation or quarantine purposes. For example, the facility may need to allocate manpower to support the index unit(s) to manage the outbreak.