Actually defining what an ‘outbreak’ is in a hospital will bring clarity. But it also signals why identifying and communicating outbreaks in hospitals is tricky,
Hospital officials must balance transparency against scaring public
About a quarter of Ontario’s hospital sites have reported outbreaks of COVID-19. Now, the province has just decided what that actually means — releasing its definition of when to declare a hospital outbreak of the novel coronavirus more than three months into the epidemic.
The long-awaited definition — two cases in patients or staff, identified within 14 days and likely acquired in hospital — will help bring clarity but also signals why identifying and communicating outbreaks in hospitals is so much thornier than in other settings. Compared to facilities like nursing homes, hospitals are bigger and more complex, with both staff and patients streaming in and out on a daily basis.
And when it comes to public reporting, the balance of concerns is far trickier. Disclosing a hospital outbreak informs the public, which improves trust and transparency. But doctors also worry about misconceptions that could scare people away from seeking care — a problem that will only worsen the scope of illness and death caused by this pandemic.
“Not all outbreaks are equal and it’s not the Hollywood picture of an outbreak,” said Dr. Janine McCready, an infectious disease physician at Michael Garron Hospital, who works in infection prevention and control. “Hospitals are still safe places and just because they’ve called an outbreak (it) doesn’t mean that the hospital is overrun with COVID.”
“I know it seems weird, but we should be really thankful when hospitals identify outbreaks,” said Dr. Andrew Morris, an infectious disease specialist at Sinai Health and University Health Network. “The problems are when hospitals don’t identify outbreaks.”
As long as there have been hospitals and infectious diseases, there have been “nosocomial outbreaks,” which refer to outbreaks that originate inside a health-care facility. More than 70 communicable diseases are reportable to public health units across the province and in late January, COVID was added to this list.
To date, 73 COVID outbreaks have been reported by hospitals, according to provincial statistics, with some reporting more than one. But in the absence of a standard definition, many have been working with their local health units to apply their own criteria for declaring COVID outbreaks, resulting in a patchwork of definitions.
Toronto Public Health, for example, has been defining an outbreak as two health-care associated cases identified within a 14-day window, though some hospitals have declared outbreaks after finding just one case. At Trillium Health Partners, a COVID outbreak is declared when there are two confirmed cases of staff or patients within a five-day period and a reasonable epidemiological link between the two, said Dr. Lorne Small, medical director of infection prevention and control.
“With many hospitals across Ontario and Canada erring on the side of caution during COVID-19, we are seeing more health-care organizations, including hospitals declare outbreaks more frequently,” Small said in an email.
On Monday night, however, the province finally released a definition for a hospital outbreak of COVID, which it provided in advance to the Star: two or more laboratory-confirmed cases in either patients or staff, identified within a specific area in a 14-day period, where both could have “reasonably acquired their infection in the hospital.”
But arriving at this single-sentence definition was a lengthy process that required collaboration and consensus from several expert bodies, including Public Health Ontario and the Ontario Hospital Association, according to the ministry of health.
Part of the difficulty is that while it is crucial to identify a COVID outbreak as quickly as possible, there are also downsides to declaring one prematurely or unnecessarily, said Dr. Dominik Mertz, medical director of infection control at Hamilton Health Sciences.
“Once you pull the trigger and say there is an outbreak, you have to sometimes put pretty significant measures in place,” he said. “You want to be specific enough not to overcall outbreaks and harm people by closing units ... (or) shutting down part of the hospital for no good reason because in fact it’s not an outbreak, it’s just a single case. Finding that balance is challenging.”
At Toronto Western Hospital, where four outbreaks have been declared in five units since April 18, the first was identified when a non-COVID patient started developing symptoms of the novel coronavirus, despite having already been hospitalized for more than14 days — the outer limit of COVID’s incubation period, said Dr. Susy Hota, medical director of infection prevention and control at the University Health Network, which includes Toronto Western.
After consulting with Toronto Public Health, the hospital decided to declare an outbreak, even though it was just a single case at that point, Hota said. Subsequent investigations and expanded testing did eventually reveal a second case — the first patient’s roommate — and other infections in patients and staff, some of whom were asymptomatic, she said.
But news of the outbreak had unintended ripple effects. One day after Toronto Western’s outbreaks were publicized, visits to the hospital’s emergency department plunged by nearly 40 per cent, said Dr. Erin O’Connor, deputy medical director of the UHN Emergency Department.
ER visits have remained low ever since, she said. Meanwhile, at Toronto General — which is also operated by UHN and staffed by the same doctors — ER traffic has remained relatively consistent.
“The outbreaks didn’t happen because people came through the emergency department,” O’Connor said. “I’m not a believer in hiding the truth, I think that it’s important for us to be clear and transparent with the public ... (But) I think it’s very, very important for us to educate about what the (outbreak) numbers actually mean.”
While the word “outbreak” is scary for the public, the term is used in the infection prevention and control (IPAC) field “to describe a pattern and allows health-care organizations to take additional actions and steps,” said Small, from Trillium Health.
When outbreaks are declared,
“it’s not as though everyone’s running around in a haz-mat suit,” McCready said. “It’s very measured and focused, just more testing and really trying to investigate where that case could have come from.”
She said outbreaks are often contained in specific wards and, once declared, a hospital’s already-rigorous infection-control measures will be ramped up and significant resources are poured into identifying and containing further spread.
“In some scenarios, being in an outbreak hospital is safer, in a sense, than being at a grocery store,” said Dr. Zain Chagla, an infectious disease physician who does infection control at St. Joseph’s Healthcare Hamilton. “But that may not be the impression of the public, because the word outbreak instills a lot of fear.”
When hospital outbreaks do occur, it’s often because of a breakdown in routine practices, McCready said — a missed handwashing moment or a surface that was overlooked for cleaning. Investigations will often try to hone in on where lapses in protocol might have occurred.
Investigators will also probe whether health-care workers might have infected each other, Metz said. He has heard from people that gaps tend to occur when they are winding down with colleagues, perhaps over lunch breaks or while smoking together.
But while hospitals are wellpractised in responding to nosocomial outbreaks, there are certain features that make COVID a particularly “worthy adversary,” Hota said. We now know COVID cases can be asymptomatic or contagious prior to showing symptoms, making it particularly difficult to discern whether a patient was infected at the hospital or already incubating when they were admitted, she said.
During a hospital outbreak, investigators might find a positive case on one side of the unit and another on the far side, with no obvious common link in between.
At UHN, officials have also cast a “wide net” for testing both patients and staff, Hota added. This makes it difficult to tease out whether health-care worker infections occurred at work versus in the community, she said. “When you look, you find,” she said. “With health-care workers, we do test a lot more than the general public and we find a lot more for that reason.”
“Not all outbreaks are equal and it’s not the Hollywood picture of an outbreak.”
DR. JANINE MCCREADY MICHAEL GARRON HOSPITAL