Discussion

By May 31, 2020, several hospitals in Tokyo reported nosocomial transmission of COVID-19 and infected HCP. As elsewhere, COVID-19 infections were common among HCP, who are at high risk of contracting the disease during patient treatment.^{Reference Cheng, Wong and Yuen5–Reference Sikkema, Pas and Nieuwenhuijse7} Apparently, a common route of initial transmission among the HCP at each hospital was community rather than nosocomial transmission, with the remaining cases likely due to nosocomial transmission. In the early phase of the pandemic, close contact with patients with COVID-19 during routine patient care may have led to HCP infections, which might then have been transmitted through sharing common spaces during break times.^{Reference Furuse, Sando and Tsuchiya8} Asymptomatic or minimally symptomatic cases among HCP can also result in transmission.^{Reference Arons, Hatfield and Reddy9} Nosocomial transmission can also be exacerbated by shortages of personal protective equipment and alcohol-based sanitizers.^{Reference Ranney, Griffeth and Jha10,Reference Grimm11}

Unfortunately, a high mortality rate among inpatients with COVID-19 due to nosocomial transmission was observed, in line with other reports.^{Reference Rickman, Rampling and Shaw12} The findings of the present study underscored the importance of preventing the nosocomial transmission of COVID-19.

Moreover, the emergence of infections among HCP and the nosocomial transmission of COVID-19 further deleteriously affected patient care and hospital functions by producing various negative social effects, including verbal abuse of HCP by the public, criticism by the media, and negative patient responses (Appendix 3 online). Verbal abuse of infected HCP has been reported globally.^13–15 Changes in the public mindset and improved understanding of COVID-19 transmissibility are needed to eliminate this sort of behavior.^{Reference Honda14}

In general, inadequate hospital preparedness during the early phase of the pandemic was likely associated with nosocomial COVID-19 transmission. The community spread of COVID-19 began in February 2020, and hospital preparedness by the end of February 2020 serves as an important index of the preparedness mindset prior to the surge in infections. The preparedness planning and organization of committees at the hospitals in this study demonstrated the generally proactive efforts of the hospital leadership. The availability of hospital-wide guidelines to deal with COVID-19 and prompt implementation of infection control practices reflected the general competence of the infection control departments. Moreover, other hospital-wide measures, such as providing special passages for patients with suspected COVID-19 to minimize potential facility-wide contamination, were more common among hospitals without nosocomial transmission.

This study has several limitations. The exact mode of transmission to either HCP or inpatients was unable to be determined due to the lack of a clear definition of nosocomial transmission and community-onset COVID-19 infection. Because the determinations of the transmission mode and infection onset were made by individual infection control personnel and were self-reported by the facility, the data were not validated. Moreover, because the questionnaire depended completely on the respondents’ impression and reports, a response bias may have been introduced. Finally, our study focused solely on hospitals in Tokyo; thus, the findings may not reflect the situation elsewhere.

In conclusion, COVID-19 transmission among HCP and nosocomial transmission to inpatients was common and negatively affected hospital functioning and patient care. Furthermore, to preserve the safety and dignity of HCP with COVID-19, changes in the public’s mindset and better understanding of the transmissibility of COVID-19 are needed.