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Is SARS-CoV-2 RNA found in aerosols in hospital break rooms and nurses stations during a nosocomial outbreak?
In this cohort study, SARS-CoV-2 genome sequences in air samples collected at a nurses station were identified in all particle sizes and were identical to human samples from a nosocomial outbreak. Detection of aerosol-borne SARS-CoV-2 was statistically less frequent on units under surveillance (7 of 240 samples) than without surveillance (24 of 270 samples).
These findings suggest that nosocomial infection may result from aerosol-borne SARS-CoV-2 introduced by employees and patients into common hospital areas; surveillance may help reduce the introduction of SARS-CoV-2 into aerosols.
Aerosol-borne SARS-CoV-2 has not been linked specifically to nosocomial outbreaks.
To explore the genomic concordance of SARS-CoV-2 from aerosol particles of various sizes and infected nurses and patients during a nosocomial outbreak of COVID-19.
Design, Setting, and Participants
This cohort study included patients and nursing staff in a US Department of Veterans Affairs inpatient hospital unit and long-term-care facility during a COVID-19 outbreak between December 27, 2020, and January 8, 2021. Outbreak contact tracing was conducted using exposure histories and screening with reverse transcriptase–polymerase chain reaction (RT-PCR) for SARS-CoV-2. Size-selective particle samplers were deployed in diverse clinical areas of a multicampus health care system from November 2020 to March 2021. Viral genomic sequences from infected nurses and patients were sequenced and compared with ward nurses station aerosol samples.
Main Outcomes and Measures
The primary outcome was positive RT-PCR results and genomic similarity between SARS-CoV-2 RNA in aerosols and human samples. Air samplers were used to detect SARS-CoV-2 RNA in aerosols on hospital units where health care personnel were or were not under routine surveillance for SARS-CoV-2 infection.
A total of 510 size-fractionated air particle samples were collected. Samples representing 3 size fractions (>10 μm, 2.5-10 μm, and <2.5 μm) obtained at the nurses station were positive for SARS-CoV-2 during the outbreak (3 of 30 samples [10%]) and negative during 9 other collection periods. SARS-CoV-2 partial genome sequences for the smallest particle fraction were 100% identical with all 3 human samples; the remaining size fractions shared >99.9% sequence identity with the human samples. Fragments of SARS-CoV-2 RNA were detected by RT-PCR in 24 of 270 samples (8.9%) in units where health care personnel were not under surveillance and 7 of 240 samples (2.9%; P = .005) where they were under surveillance.
Conclusions and Relevance
In this cohort study, the finding of genetically identical SARS-CoV-2 RNA fragments in aerosols obtained from a nurses station and in human samples during a nosocomial outbreak suggests that aerosols may have contributed to hospital transmission. Surveillance, along with ventilation, masking, and distancing, may reduce the introduction of community-acquired SARS-CoV-2 into aerosols on hospital wards, thereby reducing the risk of hospital transmission.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: April 22, 2022.
Published: June 8, 2022. doi:10.1001/jamanetworkopen.2022.16176
Correction: This article was corrected on June 30, 2022, to fix an error in the placement of a row of Ward B breakroom data in Table 3, which also affected some other summed values in the text and table; to clarify the number of individuals involved in the outbreak in the Outbreak Investigation section (the original text misleading said that 108 HCP and patients were involved, when in reality 11 HCP and 8 patients were infected); and to add a missing funding source for Dr Stern from the National Institute of Environmental Health Sciences.
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Stern RA et al. JAMA Network Open.
Corresponding Author: Eric Garshick, MD, MOH, Veterans Affairs Boston Healthcare System, 1400 VFW Pkwy, West Roxbury, Boston, MA 02132 (firstname.lastname@example.org).
Author Contributions: Drs Stern and Garshick had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Stern, Charness, Gupta, Koutrakis, Martins, Lemos, Dowd, Garshick.
Acquisition, analysis, or interpretation of data: Stern, Charness, Gupta, Linsenmeyer, Madjarov, Martins, Lemos, Dowd, Garshick.
Drafting of the manuscript: Stern, Charness, Gupta, Garshick.
Critical revision of the manuscript for important intellectual content: Stern, Charness, Koutrakis, Linsenmeyer, Madjarov, Martins, Lemos, Dowd, Garshick.
Statistical analysis: Stern, Gupta, Linsenmeyer, Garshick.
Obtained funding: Koutrakis, Garshick.
Administrative, technical, or material support: Stern, Gupta, Koutrakis, Linsenmeyer, Martins, Dowd, Garshick.
Supervision: Stern, Gupta, Garshick.
Conflict of Interest Disclosures: Dr Charness reported having stock in Pfizer and receiving royalties from UpToDate outside the submitted work. Dr Gupta reported holding stock in Pfizer, Moderna, and Abbott Laboratories and receiving royalties from UpToDate outside the submitted work. Dr Garshick reported receiving royalties from UpToDate outside the submitted work. No other disclosures were reported.
Funding/Support: This project was supported by Coronavirus Aid, Relief, and Economic Security Act funds from the Department of Veterans Affairs (Dr Garshick). Dr Stern was supported by US Environmental Protection Agency (EPA) grant RD-835872 to the Harvard/Massachusetts Institute of Technology Air, Climate & Energy Center and by the National Institute of Environmental Health Sciences, National Institutes of Health grant T32 ES007068.
Role of the Funder/Sponsor: The US Department of Veterans Affairs and EPA were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The contents are solely the responsibility of the grantee and do not necessarily represent the official views of the US Department of Veterans Affairs, EPA, or US government. Furthermore, the EPA does not endorse the purchase of any commercial products or services mentioned in the publication.
Additional Contributions: We thank Stephen Ferguson, Mikhail Wolfson, and Joy Lawrence for assisting with sampler production and the sampling protocol. We also thank Erin McHugh, Emma Busenkell, and Cathy L. Zhang for assistance with conducting sampling. We gratefully acknowledge the leadership and clinical staff of VABHS for assistance and advice. There was no financial compensation for these contributions.
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