Are the Current Guidelines Sufficient to Establish Infection Control Strategies for COVID-19 Related Issues in Hospitals?

As hospitals are where elderly patients and those with underlying comorbidities are mainly cared for, a high mortality rate is expected if a coronavirus disease 2019 (COVID-19) outbreak occurs in hospitals. Therefore, strict measures to prevent the spread of COVID-19 in hospital settings are crucial.

There are some guidelines to prevent the spread of COVID-19 in hospitals at the national and international levels.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 This study aimed to review whether national and international guidelines provide detailed recommendations to tackle issues with infection control and prevent the spread of COVID-19 in hospitals.

We performed a systematic search for controversial issues regarding infection control during the management of patients with COVID-19 in the hospital. Controversial issues and key questions were selected based on discussions with four infectious diseases specialists (B.K., E.S.K., K.H.S., and H.B.K.). The selected issues and subordinate questions are listed in Supplementary Table 1. For the review of domestic and international guidelines, official websites of the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), European Centre for Disease Prevention and Control (ECDC), and Korea Disease Control and Prevention Agency (KDCA) were screened. Guidelines issued between January 1, 2020, and September 30, 2020, were investigated independently by two researchers (W.J. and B.K.), and contents relevant to the selected issues and subordinate questions were extracted (Supplementary Fig. 1). The reviewed guidelines and their official websites are presented in Supplementary Table 2. The contents were rephrased based on consensus among investigators (W.J. B.K., E.S.K., K.H.S., and H.B.K.).

As for the screening and selective treatment policy, there were no guidelines on the criteria for permission to enter a general outpatient clinic. Since the COVID-19 pandemic began, many hospitals have been operating outdoor screening clinics for managing patients with suspected COVID-19 symptoms, such as fever and respiratory symptoms.18 However, screening clinics are equipped with minimal facilities and a workforce that can only provide a minimal examination. Therefore, many hospitals often care for patients with fever and respiratory symptoms who are unlikely to have COVID-19 in the general outpatient clinic because screening clinics have difficulty providing careful evaluation and management. There might be differences among hospitals regarding criteria for permission to enter general outpatient clinics due to the lack of clear guidance on this issue.

A single-center study conducted in South Korea found that 350 suspected COVID-19 cases, defined by symptom and epidemiological associations, were preemptively isolated, and none of them were confirmed with COVID-19.19 Based on the result of this study, both WHO and CDC guidelines, which suggested that isolation can be discontinued if there are no symptoms or if the PCR test is negative, seem appropriate. After all, both WHO and CDC guidelines might be used only in the low possibility of confirmation, such as no close contact with COVID-19 patients.

CDC recommended PCR tests for screening of COVID-19 even for hospitalized patients without COVID-19-related symptoms. The proportion of asymptomatic patients among COVID-19 cases was about 20–30%, and viral shedding also occurred in such patients; there have been concerns about spreading COVID-19 by asymptomatic patients.20, 21, 22 According to the Infectious Diseases Society of America, the prevalence of COVID-19 among asymptomatic individuals is < 1 to 10%, and considering results of missing a diagnosis of COVID-19 and the sensitivity of the PCR tests, screening for asymptomatic patients is expected to be effective in regions with more than 2% prevalence.23 A study conducted in long-term care facilities in the United States showed that the prevalence of COVID-19 in facilities that performed broad preemptive PCR tests on inpatients was 0.5%, which was significantly lower than 28.0% in facilities that did not perform them.24 This result supports the effectiveness of PCR screening on asymptomatic inpatients.

There were no guidelines for patients who were released from isolation despite a positive PCR test. Although the probability of the existence of infectious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is very low after 10 days from the onset of COVID-19 symptoms in most cases, patients who are severely ill or immunocompromised could transmit infectious virus particles even after 10 days.25, 26, 27, 28, 29 Therefore, there have been concerns about the possibility of spreading COVID-19 from hospitalized patients who were released from isolation despite a positive PCR test, especially those who need aerosol-generating procedures.28, 30, 31, 32 Given that the cut-off values for quantitative RT-PCR and quantitative immunoassays tend to be correlated with infectivity of COVID-19, some researchers have suggested that certain cut-off values could be used as a surrogate marker for the decision to release hospitalized patients from isolation.28, 33, 34 Further research is needed to determine clear test-based criteria that can guarantee the lack of infectivity of the virus.

Regarding strategies for healthcare workers, there were many recommendations on PPE, but few guidelines for the management of healthcare workers. More specific recommendations are required for patients and healthcare workers because outbreaks in medical institutions could also be spread by medical personnel.35 In addition, there are various reports that healthcare workers in charge of managing patients with COVID-19 are complaining of psychological distress and being exposed to the risk of infection; thus, recommendations to prevent burnout are also needed.36, 37

There were some potential limitations to this study. Recommendations on key topics might have been updated since then. First, guidelines from only four organizations were reviewed due to linguistic limitations. Second, we reviewed WHO, CDC, ECDC, and KDCA guidelines in September 2020. Even though there have been no critical changes of recommendations on key topics, some significant newly introduced recommendations have been found in revised guidelines until November 2021 (Supplementary Table 3). Given that the average incubation period of COVID-19 is 4 to 5 days after exposure to SARS-CoV-2, CDC currently recommends performing a second PCR test to remove preemptive isolation and return to work for the persons with a higher level of suspicion for COVID-19.38 Moreover, since mRNA vaccines against COVID-19 showed significant efficacy, CDC currently suggests preemptive isolation and PCR tests only for unvaccinated patients if they have no symptoms.39 However, as it has been confirmed that the effectiveness of the vaccine decreases over time, further consideration of the validity period of the vaccine is needed.40

In conclusion, the current guidelines are not yet concrete and uniform enough to be applied to hospital settings, and there is a lack of clear guidelines on controversial vital topics that need to be considered in real medical situations. Therefore, it is necessary to develop recommendations that can be applied to hospital settings after an analysis based on clinical experiences and discussion with experts.

Supplementary Table 1

Controversial issues for infection control during the management of COVID-19 patients within hospitals

Supplementary Table 2

Reviewed infection prevention and control guidelines for hospital settings and their official websites

Supplementary Table 3

Updated infection control measures aginst COVID-19 in the hospital

Supplementary Fig. 1

Flowchart of the study procedure.