Stay on Guard: Lessons from a SARS-CoV-2 Nosocomial Outbreak

Reviewed by Clare Marlin, MS, BSN, CIC, Shirley Ryan AbilityLab and James “Brad” Cutrell, MD FIDSA, UT Southwestern Medical Center 

In this report from Klompas and colleagues, the evaluation of a nosocomial outbreak of 52 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections among 14 patients and 38 staff members in an academic medical center with well-established infection prevention and control program in place is described.  Through extensive transmission analysis, the authors identify this cluster originated from a patient who initially tested negative for SARS-CoV-2 upon admission, which demonstrates a potential inability to rely solely on admission testing to exclude SARS-CoV-2 infection.  In response to the cluster, the medical center actively mobilized interventions exceeding their existing infection prevention and control practices: an incident command center structure was activated for establishing increased staff and patient testing protocols; infections associated with the cluster were confirmed with whole-genome sequencing performed by the state’s department of public health; and SARS-CoV-2-positive patients were transferred to a dedicated care unit.  Additionally, a case-control study was performed to identify potential occupational and non-occupational risk factors for SARS-CoV-2 positive versus negative employees via an online survey. The survey results demonstrated that infected staff members were more likely to report having been present while infected patients received nebulizers and, also, were more likely to report having spent extended time with infected patients.  There were also documented lapses in PPE use such as lack of eye protection. Klompas and colleagues provide several observations related to SARS-CoV-2 transmissions among staff and patients in health care facilities, as well as guidance to mitigate such transmissions, including retesting all patients three to four days after admission and testing all patients before placing the patients in shared rooms.


Klompas, M., Baker, M., Rhee, C., Tucker, R., Fiumara, K., Griesbach, D., Bennett-Rizzo, C., Salmasian, H., Wang, R., Wheeler, N., Gallagher, G., Lang, A., Fink, T., Baez, S., Smole, S., Madoff, L., Goralnick, E., Resnick, A., Pearson, M., Britton, K., Sinclair, J., & Morris, C. (2021). A SARS-CoV-2 cluster in an acute care hospital. Annals of Internal Medicine, doi: 10.7326/M20-7567

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