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EVENTS |
Foto: iStock
Foto: iStock
Live and in colour: DGKH Congress online
International experts present their experiences of the COVID-19 pandemic –
EUNETIPS Symposium at the DGKH Congress, 12 to 14 April 2021
Gudrun Westermann
The German Society of Hospital Hygiene there of masks and social distancing, Carl Suetens from ECDC gave an update
(DGKH) Congress was held as an exclu- even during normal times. of the current figures for Europe: case
sively online event from 12 to 14 April The measures applied in China were numbers, hospital admissions, intensive
and included in the afternoon of its first essentially much stricter. While vac- care unit (ICU) admissions and deaths.
day an English-language EUNETIPS cination was not mandatory, it was at Unfortunately, cases continued to rise
Symposium during which international least a prerequisite for many things and and, in some regards, were higher than
experts presented their experiences of was thus enforced in that way. before Christmas.
the COVID-19 pandemic. Under the title However, the Chinese vaccine had There were of course differenc-
“Ongoing Experience with Sars-CoV-2 an efficacy of only around 50% – as es between the various countries. The
and consequences for future actions”, acknowledged meanwhile also by gov- figures were now lower for Asia and
Patrick Kreuz from Beijing first report- ernment. There were now plans to also Africa, but in the latter case were
ed on the situation in China. approve the BioNTech-Pfizer vaccine in thought to be because of the lack of
China and also manufacture it there. testing and reporting facilities.
Prof. Walter Popp, who moderated the Vaccine prioritization was organized Next, Suetens gave an overview of
session together with Prof. Martin Exner, very differently in China compared with the emergence of new variants of the
opened the topic by asking whether Germany. In China economically rele- virus. The British variant was wide-
the reports that China was essentially vant groups were vaccinated first – gov- spread in Europe, except for e.g. in Nor-
COVID-free were correct or what should ernment officials, those working in man- way. The South African variant was
be made of that. Kreuz doubted that the ufacturing and services, etc. to ensure present in appreciable numbers in Bel-
correct figures were being reported in that business activities could continue. gium, Finland and Luxembourg, but
that regard. Besides, the definition of On the other hand, few of those aged less so in other countries.
positive cases differed greatly. Whereas over 60 years had been vaccinated so far. ECDC was also monitoring the pro-
in Germany asymptomatic COVID cases Kreuz stated that it was true that gress of the vaccination campaign.
were also reported, in other countries normal life had been restored in Chi- Hungary and Malta ranked first in
only those with symptoms were counted na – the schools were open, travel was Europe, in addition to the United King-
as positive. In China there was no stand- possible, but there was still some uncer- dom. Globally, Israel ranked first, and
ard for this: if the patient had symptoms, tainty about the reliability of the infec- in the USA, too, around 35% of the
in particular pneumonia, and was hos- tion figures reported. population had been vaccinated in the
pitalized, this counted as a case. It was Kreuz viewed the findings of the meantime. Immunization rates among
only in recent times that the figures were WHO experts as somewhat disappoint- certain groups were also being moni-
more reliable. ing. There had really been no push to tored, e.g. immunization of healthcare
Kreuz stated that in principle it was get to the bottom of the origin of the workers. Just about all these groups
easier to control an epidemic in Asia virus. Instead, the official Chinese had been fully vaccinated in e.g. Spain
because there was good acceptance reports were simply accepted. and Ireland as well as in Estonia.
2 Hygiene & Medizin | Jahrgang 46 | 2021
Suetens said that it was important to track the variants and mission over a distance of up to 12 metres. Aerosols were a
assess how effective vaccines were against these. For exam- special risk factor under such circumstances. Throughout the
ple, the Pfizer vaccine was less effective against the South history of medicine there were examples of such transmission
African variant, while the same was true for the AstraZeneca as demonstrated by Exner, citing the last smallpox outbreak
vaccine and the British variant. in Meschede, Germany, in 1970.
Suetens next elaborated on infection rates among health- At that time airborne transmission occurred even without
care workers. While these had higher infection rates, there direct contact with infected persons – using smoke tests it
was also some bias since these groups were tested more often. was possible to show how air currents consistent with small-
According to Suetens, the most important protective pox transmission spread in the hospital.
measures in the healthcare setting comprised masks and Looking towards the future, Exner stated that the pan-
gowns. Gloves were not recommended for long-term use demic had already given rise to costs of over 11 billion US$.
since proper hand hygiene was more important. Only 5$ more per person was needed to significantly improve
With respect to vaccination, Suetens said it continued to preparedness for similar scenarios in the future. More inter-
be unclear whether the virus could still be transmitted by national cooperation, rather than fragmentation, was needed
vaccinated persons. to that effect. Infectious diseases posed one of the greatest
Virus variants were causing increasingly more concern, threats, especially in association with climate change. There-
with the British variant B.1.1.7 being more transmissible fore, it was imperative that hygiene/infection control princi-
and possibly also leading to more severe courses of disease. ples should be reinforced and implemented.
Besides, natural and vaccine-induced antibodies were less
effective against the variants that first emerged in South Birgitta Lytsy, Sweden, reported on the Swedish strategy,
Africa and Brazil. Hence, strict compliance with the hygiene which she deemed highly critical. One problem was the wide-
measures was needed. In particular in the healthcare setting, spread fragmentation of competencies. There were govern-
masks should also be worn during work break periods; addi- ment regulations that had to be then implemented locally
tional test strategies with routine rapid tests could increase and regionally.
safety. In Sweden the gastronomy industry had been opened up
for a long time. Only now was there a strict recommendation
Martin Exner reported on German experiences and in his in place in Sweden to work from home. Medical/protective
talk focused on the epidemiology of SARS-CoV-2, on strat- masks were still not mandatory but were recommended when
egies to combat the pandemic and the future prospects. He social distancing could not be observed.
presented statistics on the incidence and mortality rates As regards the outcome of that strategy, Lytsy said that in
among various age groups. Already now, the effects of vacci- the meantime Sweden featured among the dark red countries
nation were coming to light (around 13% of persons in Ger- on the map and, in comparison with the other Scandinavian
many had been vaccinated so far, with priority given to the countries, had the highest infection rates.
higher age groups) – in the meanwhile the incidence among However, there was now a sharp drop in deaths due to
those younger than 60 years was higher than among the vaccination.
elderly age groups. Lytsy focused in particular on outbreaks in healthcare
Exner deemed the new variants to be of concern – they settings; in the Upsala region alone there were more than
were apparently more transmissible and caused more severe 500 different outbreaks since February 2020, mainly among
courses of disease. Often, younger people were affected and healthcare workers, infected by other asymptomatic staff
needed ICU treatment. members who contracted the virus in the community.
The key issue was that a non-immune population was fac- Lytsy said that the knowledge that this transmission
ing a new pathogen. Exner stated that this was considered a existed among healthcare workers was already an important
very dangerous situation by the Robert Koch Institute (RKI). lesson. It also demonstrated that there was a broad chasm
There was also widespread transmission in the commu- between the recommendations and compliance levels.
nity – in the workplace or in communal facilities. Outbreaks It was also expected that the Swedish general public
manifested very differently in various settings – for example, would voluntarily observe the regulations but compliance
they tended to be of a non-explosive nature in schools. was too low.
The latest recommendations, in particular to stay at home,
were not only uncritical – aerosol transmission was also pos- Angel Asensio, Spain, reported on the situation in that coun-
sible in the home. The most important thing was to reduce try: the fourth wave was already underway. In the first wave
contacts, while especially protecting vulnerable persons. there was still too little knowledge of transmission and risk
Exner viewed the RKI immunization recommendations as groups, delaying the lockdown, overwhelming ICUs and
being very good and scientifically sound. resulting in higher mortality rates. In the second wave hos-
But one danger arising in the meanwhile was that vac- pital admission rates were even higher. At the outset, in par-
cines were possibly not fully effective against new variants. ticular, it was the higher age groups that were most affected
What lessons could we now draw from the pandemic and and deaths among the over 80-year-olds were very high. This
for outbreak management? Here Exner called for the crisis to also gave rise to an excess mortality of more than 88,000 cas-
be used to that effect. By way of example he cited the case es, with 80% of the deceased aged over 74 years.
of proven transmission in a restaurant in China as well as The B.1.1.7 variant was now widespread in Spain. The
the outbreaks in the German meat industry. In both cases incidence rate was currently highly variable, also due to
a non-filtered ventilation system was responsible for trans- measures of varying strictness in the different regions.
Hygiene & Medizin | Volume 46 | 2021 3
EVENTS |
Rose Gallagher from the United Kingdom took a close look ple ignored the advice of receiving only one visitor into their
at the impact on carers. She gave an overview of infection home – hence, most cases of infection transmission now also
curves and hospital admissions in the United Kingdom and occurred in private homes.
stressed that even before the pandemic the situation in parts Vos dealt in particular with the safe provision of care
of the care sector was precarious. Now there were also high to non-COVID patients in hospitals. It was possible to make
infection rates among healthcare workers, and long COVID the situation safer with tests, direct separation and special
was common, affecting the availability of healthcare staff masks for persons with suspected infection. Her hospital in
and compounding the situation. Healthcare workers were Rotterdam was lucky to have only single rooms. That meant
urgently advised to take up vaccination. But there were also that visits were also possible – a luxury in these times. For
many unresolved issues around vaccine efficacy and safety, the future it meant hospitals should in principle be designed
as well as, for example, regarding vaccination during preg- with single rooms. Vos stated that this would obviate the
nancy and lactation. need for cohorting. But cohorting made many things easier:
Gallagher said that mental health problems were on the room doors could be left open since all patients were infect-
rise: anxiety, stress and fatigue. It was also difficult to imple- ed and found themselves in the same contaminated environ-
ment certain recommendations in the healthcare setting, for ment. Personal protective equipment (PPE) had of course to
example ventilation, with different provisions and confusion be worn at all times.
regarding airborne transmission. In general, there was no Another pressing question was when isolation could be
uniform policy on various aspects, as borne out by debates discontinued. Often, patients continued to have cough over
among epidemiologists. several months. CT findings played an important role; none-
That made it more difficult to formulate clear recommen- theless, there was uncertainty when isolation could be ended.
dations, especially in occupational settings. That continued to be an important issue for the future.
Sara Romano-Bertrand, France, raised several unresolved Flavia Riccardo, epidemiologist at the Italian Public Health
questions. What indicators should be used to impose a lock- Institute, reported from Italy.
down and who should decide that? Should masks be worn in Italy was affected early on in the pandemic. In principle,
Italy used the “Hammer and Dance Approach” – first, strict
winter?
lockdown, followed by gradual opening up, which like a dance
The speaker described the situation in France, which in
was constantly adapted until enough people had been vacci-
the first wave in the spring of 2020 led to a quick rise in the
nated. In the transition phase it was important to invest in
number of hospitalized patients. In the second wave there
precautionary measures in preparation for similar scenarios in
was less pressure on the ICUs and fewer deaths. The second
the future. Several indicators were used to monitor the situa-
lockdown had proved very effective, during which schools
tion. For the coming winter, for example, model calculations
and universities remained open. But in the third lockdown
and strategies were devised. Among the measures currently
now underway schools were also closed.
applied was the testing of arrivals into Italy. In that way it had
Some 10 million French residents had now been vacci-
been possible for some time to keep the incidence rates lower
nated. The positive test rate was almost between 5 and 10%
than in other European countries, but they then rose again.
nationwide. However, the incidence everywhere reached the
As challenges Riccardo cited the new, more transmissible
“red” level. Romano-Bertrand said that this raised the ques-
variants against which the vaccines were possibly less effec-
tion of whether the incidence was a good indicator.
tive, in addition to the need to continuously adapt protective
There was a consensus that masks would continue to be
measures as well as the vaccination campaign itself. She also
worn in winter because they helped to protect against flu and
stated that investment in preparedness for future pandemics
other respiratory infections; besides, wearing masks was the was of crucial importance.
measure that found most acceptance in France. Romano-Ber-
trand said that social distancing and contact limitations were Another EUNETIPS session, which did not relate to COVID-19,
less commonly observed and there had been many infringe- was held on the second conference day.
ments. Martin Exner, Bonn, focused on how differences in the
She finished off by addressing the hygiene hypothesis. hygiene regulations in European healthcare settings could be
According to that, the COVID-19 pandemic could lend further eliminated. For example, there were marked differences in
impetus to a development already in progress associated with the rates of healthcare-acquired (nosocomial) infections, in
a reduction in the diversity of the microbiome. Social distanc- the number of hospital beds and ICU beds per 100,000 inhab-
ing and meticulous hygiene measures had reinforced that, itants and in nurse-patient ratios in hospitals.
reducing the opportunities for reinoculation. The influence These examples put into sharp relief the efforts still need-
exerted by the microbiome on human health had now been ed to achieve uniform conditions in Europe.
recognized. However, still unresolved, but possibly of critical Exner stated that, in particular, the major differences in
importance, was how the microbiome affected susceptibility antibiotic resistance levels were not acceptable. Citing the
to SARS-CoV-2 infection and equally how preventive meas- case of Italy, ECDC had considered the high rates of antibi-
ures affected the microbiome. otic resistance to pose a major public health threat. In this
respect, ECDC did not mince its words because several fac-
Margaret Vos reported from the Netherlands. There, too, tors, including poor management and control, had given rise
infection curves were similar to those throughout Europe, to such high antibiotic resistance levels that were not being
and the effects of vaccination could be seen. But many peo- kept under control.
4 Hygiene & Medizin | Volume 46 | 2021
What should be the goals for Europe? Exner cited the “Core after patient contact. Compliance improved from 4.8 to 37.3
components of infection prevention and control” formulat- and 56.1%. Accordingly, it was possible to put the spotlight
ed by the WHO in 2016 and containing national guidelines on infection control, and on hand disinfection as its key com-
and institution-specific guidelines. The core components also ponent, throughout the entire hospital, while achieving a sus-
listed surveillance as an essential prerequisite for evaluation tainable and positive impact.
and assessment of measures and considered education and
training to be an important basis for staff competence. Pre- Walter Popp reported on plague in Mongolia. He described
cisely here it was important to check: What is mandatory? the different disease courses of plague, which was still
And how is education and training delivered? What occupa- endemic in certain countries. Bubonic plague was easy to
tional groups are included; for example, should cleaning per- treat with antibiotics. Left untreated, primary pneumonic
sonnel also participate in hygiene and infection prevention plague had 100% mortality.
training courses? The reservoir was rodents such as rats, mice and also mar-
mots, which played a special role in Mongolia, in particular.
Mulugeta Naizgi spoke about the implementation of cost-ef- Marmots could also become diseased and die. Transmission
fective multimodal measures for improvement of hand to humans was via fleas as vectors as well as following oral
hygiene compliance at the Ayder Hospital in Ethiopia. He ingestion or inhalation. There were recent major outbreaks
started by stating that developing countries had 2- to 20-fold in Madagascar and in the Congo, in addition to cases in the
higher healthcare-acquired infection rates than industrial- USA and in Mongolia.
ized countries. In Ethiopia the prevalence was 19.4%. Following diagnosis of cases of plague, isolation, wear-
Hand hygiene was the most effective means of reduc- ing of personal protective equipment and notification to the
ing these infections but there were many barriers. Naizigi health authorities were mandatory. Post-exposure prophylax-
described the baseline situation where in many cases there is was advisable.
were no hand wash basins. Only isolated posters drew atten- A hygiene project was launched in Mongolia in 2010/11.
tion to hand hygiene, and there were no disinfectant dispens- Popp reported on commonly emerging diseases, including
ers. many zoonotic diseases, explained by the fact that 30% of
A joint project with the German hospital Katholisches inhabitants were still herders with close contact to animals.
Klinikum Bochum aimed to improve hand hygiene practic- The National Institute investigated the transmission of
es and compliance. Interventions included the installation at such diseases each year. In 2019 there was a report of a cou-
each patient bedside of homemade hand disinfectant dispens- ple who, contrary to the ban in place since 2014, consumed
ers using the in-house produced disinfectant as well as work- raw marmot flesh – including certain organs, often recom-
shops for staff and new trainees. Besides, the Hand Hygiene mended as traditional medicine. Presumably because of the
World Day was officially celebrated and posters displayed to ban, consumption of marmot flesh was kept secret, causing
remind staff about the measures. a major delay in diagnosis. The husband died at home, his
He concluded by saying that the measures were routinely wife died later in hospital where she had been treated with
evaluated by an interdisciplinary hygiene committee as well antibiotics but nonetheless developed sepsis and multi-organ
as by means of compliance monitoring at baseline and after failure.
seven and 12 months using the WHO protocol. A prize was Yersinia pestis was later isolated from different organs.
awarded for good compliance. Fearing pneumonic plague, the authorities imposed six-day
The outcome of this project was that hand hygiene meas- quarantine throughout the entire region but there were no
ures were implemented significantly more often before and further cases.
Hygiene & Medizin | Volume 46 | 2021 5
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