Understanding COVID-19 transmission in HCWs without direct patient care

Editor's Note

Using a systems engineering approach to analyze a cluster of COVID-19 in healthcare workers (HCWs) without direct patient care, researchers at the University of Wisconsin, Madison, found both modifiable and nonmodifiable elements of the work system contributed to the cluster.

Between October 2 and November 24, 2020, eight of 16 HCWs from Department A and one HCW with an epidemiological link to Department A tested positive for COVID-19. Two HCWs from Department A tested negative, and six HCWs did not report COVID-19 symptoms, exposure, or testing. One HCW reported no symptoms, six worked while symptomatic, and nine worked while potentially infectious.

Cases 1 and 2 were household contacts, Case 6 was neighbors with Cases 1 and 2, and Cases 4 and 5 were household contacts.

Cases 1 to 4 had identical or nearly identical sequencing results. Cases 5 and 6 had distinct strains unrelated to others in the cluster. Cases 8 and 9 had identical sequencing results to one another, but were distinct from cases 1 to 4. Case 7 tested positive at an outside clinic, and their specimen was unable to be sequenced.

Using the Systems Engineering Initiative for Patient Safety (SEIPS) model to analyze the working system elements that may have contributed to the cluster, the researchers found the following factors contributed to transmission in this cluster:

• HCW working while symptomatic
• Personal relationships between HCWs outside work
• Lapses in PPE and physical distancing because of small shared spaces.

Factors such as personal relationships between HCWs are not modifiable, and institutions should be cognizant of nonworkplace spread of the virus; however, other factors are modifiable but require cultural changes (eg, working while sick), which makes layers of infection prevention steps necessary, the researchers say.