German Society of Hospital Hygiene (DGKH) Congress: international experts presented their experiences of the COVID-19 pandemic

summarized by Dr. Gudrun Westermann

The German Society of Hospital Hygiene (DGKH) Congress was held as an exclusively online event from 12 to 14 April and included in the afternoon of its first day an English-language EUNETIPS Symposium during which international experts presented their experiences of the COVID-19 pandemic. Under the title “Ongoing Experience with Sars-CoV-2 and consequences for future actions”, Patrick Kreuz from Beijing first reported on the situation in China.
Prof. Walter Popp, who moderated the session together with Prof. Martin Exner, opened the topic by asking whether the reports that China was essentially COVID-free were correct or what should be made of that. Kreuz doubted that the correct figures were being reported in that regard. Besides, the definition of positive cases differed greatly. Whereas in Germany asymptomatic COVID cases were also reported, in other countries only those with symptoms were counted as positive. In China there was no standard for this: if the patient had symptoms, in particular pneumonia, and was hospitalized, this counted as a case. It was only in recent times that the figures were more reliable.
Kreuz stated that in principle it was easier to control an epidemic in Asia because there was good acceptance there of masks and social distancing, even during normal times.
The measures applied in China were essentially much stricter. While vaccination was not mandatory, it was at least a prerequisite for many things and was thus enforced in that way.
However, the Chinese vaccine had an efficacy of only around 50% – as acknowledged meanwhile also by government. There were now plans to approve the BioNTech-Pfizer vaccine in China and also manufacture it there. Vaccine prioritization was organized very differently in China compared with Germany. In China economically relevant groups were vaccinated first – government officials, those working in manufacturing and services, etc. to ensure that business activities could continue. On the other hand, few of those aged over 60 years had been vaccinated so far.
Kreuz stated that it was true that normal life had been restored in China – the schools were open, travel was possible, but there was still some uncertainty about the reliability of the infection figures reported.
Kreuz viewed the findings of the WHO experts as somewhat disappointing. There had really been no push to get to the bottom of the origin of the virus. Instead, the official Chinese reports were simply accepted.

Vaccine and SARS-CoV-2 variants

Carl Suetens from ECDC gave an update of the current figures for Europe: case numbers, hospital admissions, intensive care unit (ICU) admissions and deaths. Unfortunately, cases continued to rise and, in some regards, were higher than before Christmas.
There were of course differences between the various countries. The figures were now lower for Asia and also Africa, but in the latter case were thought to be because of the lack of testing and reporting facilities.
Next, Suetens gave an overview of the emergence of new variants of the virus. The British variant was widespread in Europe, except for e.g. in Norway. The South African variant was present in appreciable numbers in Belgium, Finland and Luxembourg, but less so in other countries.
ECDC was also monitoring the progress of the vaccination campaign. Hungary and Malta ranked first in Europe, in addition to the United Kingdom. Globally, Israel ranked first, and in the USA, too, around 35% of the population had been vaccinated in the meantime. Immunization rates among certain groups were also being monitored, e.g. immunization of healthcare workers. Just about all these groups had been fully vaccinated in e.g. Spain and Ireland as well as in Estonia.
Suetens said that it was important to track the variants and assess how effective vaccines were against these. For example, the Pfizer vaccine was less effective against the South African variant, while the same was true for the AstraZeneca vaccine and the British variant.
Suetens next elaborated on infection rates among healthcare workers. While these had higher infection rates, there was also some bias since these groups were tested more often.
According to Suetens, the most important protective measures in the healthcare setting comprised masks and gowns. Gloves were not recommended for long-term use since proper hand hygiene was more important.
With respect to vaccination, Suetens said it continued to be unclear whether the virus could still be transmitted by vaccinated persons.
Virus variants were causing increasingly more concern, with the British variant B.1.1.7 being more transmissible and possibly also leading to more severe courses of disease. Besides, natural and vaccine-induced antibodies were less effective against the variants that first emerged in South Africa and Brazil. Hence, strict compliance with the hygiene measures was needed. In particular in the healthcare setting, masks should also be worn during work break periods; additional test strategies with routine rapid tests could increase safety.

Outbreak management

Martin Exner reported on German experiences and in his talk focused on the epidemiology of SARS-CoV-2, on strategies to combat the pandemic and the future prospects. He presented statistics on the incidence and mortality rates among various age groups. Already now, the effects of vaccination were coming to light (around 13% of persons in Germany had been vaccinated so far, with priority given to the higher age groups) – in the meanwhile the incidence among those younger than 60 years was higher than among the elderly age groups.
Exner deemed the new variants to be of concern – they were apparently more transmissible and caused more severe courses of disease. Often, younger people were affected and needed ICU treatment.
The key issue was that a non-immune population was facing a new pathogen. Exner stated that this was considered a very dangerous situation by the Robert Koch Institute (RKI).
There was also widespread transmission in the community – in the workplace or in communal facilities. Outbreaks manifested very differently in various settings – for example, they tended to be of a non-explosive nature in schools.
The latest recommendations, in particular to stay at home, were not only uncritical – aerosol transmission was also possible in the home. The most important thing was to reduce contacts, while especially protecting vulnerable persons.
Exner viewed the RKI immunization recommendations as being very good and scientifically sound.
But one danger arising in the meanwhile was that vaccines were possibly not fully effective against new variants.
What lessons could we now draw from the pandemic and for outbreak management? Here Exner called for the crisis to be used to that effect. By way of example he cited the case of proven transmission in a restaurant in China as well as the outbreaks in the German meat industry. In both cases a non-filtered ventilation system was responsible for transmission over a distance of up to 12 metres. Aerosols were a special risk factor under such circumstances. Throughout the history of medicine there were examples of such transmission as demonstrated by Exner, citing the last smallpox outbreak in Meschede, Germany, in 1970.
At that time airborne transmission occurred even without direct contact with infected persons – using smoke tests it was possible to show how air currents consistent with smallpox transmission spread in the hospital.
Looking towards the future, Exner stated that the pandemic had already given rise to costs of over 11 billion US$. Only 5$ more per person was needed to significantly improve preparedness for similar scenarios in the future. More international cooperation, rather than fragmentation, was needed to that effect. Infectious diseases posed one of the greatest threats, especially in association with climate change. Therefore, it was imperative that hygiene/infection control principles should be reinforced and implemented.

Sweden: situation still critical

Birgitta Lytsy, Sweden, reported on the Swedish strategy, which she deemed highly critical. One problem was the widespread fragmentation of competencies. There were government regulations that had to be then implemented locally and regionally.
In Sweden the gastronomy industry had been opened up for a long time. Only now was there a strict recommendation in place in Sweden to work from home. Medical/protective masks were still not mandatory but were recommended when social distancing could not be observed.
As regards the outcome of that strategy, Lytsy said that in the meantime Sweden featured among the dark red countries on the map and, in comparison with the other Scandinavian countries, had the highest infection rates.
However, there was now a sharp drop in deaths due to vaccination.
Lytsy focused in particular on outbreaks in healthcare settings; in the Upsala region alone there were more than 500 different outbreaks since February 2020, mainly among healthcare workers, infected by other asymptomatic staff members who contracted the virus in the community.
Lytsy said that the knowledge that this transmission existed among healthcare workers was already an important lesson. It also demonstrated that there was a broad chasm between the recommendations and compliance levels.
It was also expected that the Swedish general public would voluntarily observe the regulations but compliance was too low.

Angel Asensio, Spain, reported on the situation in that country: the fourth wave was already underway. In the first wave there was still too little knowledge of transmission and risk groups, delaying the lockdown, overwhelming ICUs and resulting in higher mortality rates. In the second wave hospital admission rates were even higher. At the outset, in particular, it was the higher age groups that were most affected and deaths among the over 80-year-olds were very high. This also gave rise to an excess mortality of more than
88,000 cases, with 80% of the deceased aged over 74 years.
The B.1.1.7 variant was now widespread in Spain. The incidence rate was currently highly variable, also due to measures of varying strictness in the different regions.

Rose Gallagher from the United Kingdom took a close look at the impact on carers. She gave an overview of infection curves and hospital admissions in the United Kingdom and stressed that even before the pandemic the situation in parts of the care sector was precarious. Now there were also high infection rates among healthcare workers, and long COVID was common, affecting the availability of healthcare staff and compounding the situation. Healthcare workers were urgently advised to take up vaccination. But there were also many unresolved issues around vaccine efficacy and safety, as well as, for example, regarding vaccination during pregnancy and lactation.
Gallagher said that mental health problems were on the rise: anxiety, stress and fatigue. It was also difficult to implement certain recommendations in the healthcare setting, for example ventilation, with different provisions and confusion regarding airborne transmission. In general, there was no uniform policy on various aspects, as borne out by debates among epidemiologists.
That made it more difficult to formulate clear recommendations, especially in occupational settings.

France: mask wearing will be maintained

Sara Romano-Bertrand, France, raised several unresolved questions. What indicators should be used to impose a lockdown and who should decide that?
Should masks be worn in winter?
The speaker described the situation in France, which in the first wave in the spring of 2020 led to a quick rise in the number of hospitalized patients. In the second wave there was less pressure on the ICUs and fewer deaths. The second lockdown had proved very effective, during which schools and universities remained open. But in the third lockdown now underway schools were also closed.
Some 10 million French residents had now been vaccinated. The positive test rate was almost between 5 and 10% nationwide. However, the incidence everywhere reached the “red” level. Romano-Bertrand said that this raised the question of whether the incidence was a good indicator.
There was a consensus that masks would continue to be worn in winter because they helped to protect against flu and other respiratory infections; besides, wearing masks was the measure that found most acceptance in France. Romano-Bertrand said that social distancing and contact limitations were less commonly observed and there had been many infringements.
She finished off by addressing the hygiene hypothesis. According to that, the COVID-19 pandemic could lend further impetus to a development already in progress associated with a reduction in the diversity of the microbiome. Social distancing and meticulous hygiene measures had reinforced that, reducing the opportunities for reinoculation. The influence exerted by the microbiome on human health had now been recognized. However, still unresolved, but possibly of critical importance, was how the microbiome affected susceptibility to SARS-CoV-2 infection and equally how preventive measures affected the microbiome.

Netherlands: Cohorting vs. single room

Margaret Vos reported from the Netherlands. There, too, infection curves were similar to those throughout Europe, and the effects of vaccination could be seen. But many people ignored the advice of receiving only one visitor into their home – hence, most cases of infection transmission now also occurred in private homes.
Vos dealt in particular with the safe provision of care to non-COVID patients in hospitals. It was possible to make the situation safer with tests, direct separation and special masks for persons with suspected infection. Her hospital in Rotterdam was lucky to have only single rooms. That meant that visits were also possible – a luxury in these times. For the future it meant hospitals should in principle be designed with single rooms. Vos stated that this would obviate the need for cohorting. But cohorting made many things easier: room doors could be left open since all patients were infected and found themselves in the same contaminated environment. Personal protective equipment (PPE) had of course to be worn at all times.
Another pressing question was when isolation could be discontinued. Often, patients continued to have cough over several months. CT findings played an important role; nonetheless, there was uncertainty when isolation could be ended. That continued to be an important issue for the future.

Flavia Riccardo, epidemiologist at the Italian Public Health Institute, reported from Italy.
Italy was affected early on in the pandemic. In principle, Italy used the “Hammer and Dance Approach” – first, strict lockdown, followed by gradual opening up, which like a dance was constantly adapted until enough people had been vaccinated. In the transition phase it was important to invest in precautionary measures in preparation for similar scenarios in the future. Several indicators were used to monitor the situation. For the coming winter, for example, model calculations and strategies were devised. Among the measures currently applied was the testing of arrivals into Italy. In that way it had been possible for some time to keep the incidence rates lower than in other European countries, but they then rose again.
As challenges Riccardo cited the new, more transmissible variants against which the vaccines were possibly less effective, in addition to the need to continuously adapt protective measures as well as the vaccination campaign itself. She also stated that investment in preparedness for future pandemics was of crucial importance.

Off topic 1: Infection prevention and -control

Another EUNETIPS session, which did not relate to COVID-19, was held on the second conference day.
Martin Exner, Bonn, focused on how differences in the hygiene regulations in European healthcare settings could be eliminated. For example, there were marked differences in the rates of healthcare-acquired (nosocomial) infections, in the number of hospital beds and ICU beds per 100,000 inhabitants and in nurse-patient ratios in hospitals.
These examples put into sharp relief the efforts still needed to achieve uniform conditions in Europe.
Exner stated that, in particular, the major differences in antibiotic resistance levels were not acceptable. Citing the case of Italy, ECDC had considered the high rates of antibiotic resistance to pose a major public health threat. In this respect, ECDC did not mince its words because several factors, including poor management and control, had given rise to such high antibiotic resistance levels that were not being kept under control.
What should be the goals for Europe? Exner cited the “Core components of infection prevention and control” formulated by the WHO in 2016 and containing national guidelines and institution-specific guidelines. The core components also listed surveillance as an essential prerequisite for evaluation and assessment of measures and considered education and training to be an important basis for staff competence. Precisely here it was important to check: What is mandatory? And how is education and training delivered? What occupational groups are included; for example, should cleaning personnel also participate in hygiene and infection prevention training courses?

Off topic 2: Improving hand hygiene compliance

Dr Mulugeta Naizgi spoke about the implementation of cost-effective multimodal measures for improvement of hand hygiene compliance at the Ayder Hospital in Ethiopia. He started by stating that developing countries had 2- to 20-fold higher healthcare-acquired infection rates than industrialized countries. In Ethiopia the prevalence was 19.4%.
Hand hygiene was the most effective means of reducing these infections but there were many barriers. Naizigi described the baseline situation where in many cases there were no hand wash basins. Only isolated posters drew attention to hand hygiene, and there were no disinfectant dispensers.
A joint project with the German hospital Katholisches Klinikum Bochum aimed to improve hand hygiene practices and compliance. Interventions included the installation at each patient bedside of homemade hand disinfectant dispensers using the in-house produced disinfectant as well as workshops for staff and new trainees. Besides, the Hand Hygiene World Day was officially celebrated and posters displayed to remind staff about the measures.
He concluded by saying that the measures were routinely evaluated by an interdisciplinary hygiene committee as well as by means of compliance monitoring at baseline and after seven and 12 months using the WHO protocol. A prize was awarded for good compliance.
The outcome of this project was that hand hygiene measures were implemented significantly more often before and after patient contact. Compliance improved from 4.8 to 37.3 and 56.1%. Accordingly, it was possible to put the spotlight on infection control, and on hand disinfection as its key component, throughout the entire hospital, while achieving a sustainable and positive impact.

Off topic 3: Plague case due to marmot consumption

Walter Popp reported on plague in Mongolia. He described the different disease courses of plague, which was still endemic in certain countries. Bubonic plague was easy to treat with antibiotics. Left untreated, primary pneumonic plague had 100% mortality.
The reservoir was rodents such as rats, mice and also marmots, which played a special role in Mongolia, in particular. Marmots could also become diseased and die. Transmission to humans was via fleas as vectors as well as following oral ingestion or inhalation. There were recent major outbreaks in Madagascar and in the Congo, in addition to cases in the USA and in Mongolia.
Following diagnosis of cases of plague, isolation, wearing of personal protective equipment and notification to the health authorities were mandatory. Post-exposure prophylaxis was advisable.
A hygiene project was launched in Mongolia in 2010/11. Popp reported on commonly emerging diseases, including many zoonotic diseases, explained by the fact that 30% of inhabitants were still herders with close contact to animals.
The National Institute investigated the transmission of such diseases each year. In 2019 there was a report of a couple who, contrary to the ban in place since 2014, consumed raw marmot flesh – including certain organs, often recommended as traditional medicine. Presumably because of the ban, consumption of marmot flesh was kept secret, causing a major delay in diagnosis. The husband died at home, his wife died later in hospital where she had been treated with antibiotics but nonetheless developed sepsis and multi-organ failure.
Yersinia pestis was later isolated from different organs. Fearing pneumonic plague, the authorities imposed six-day quarantine throughout the entire region but there were no further cases.

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