114


Sebastian Schulz-Stübner et al


Fig. 1. Organisms involved in 94 outbreaks related to infections, infections and colonization and colonization only. The following specific items were identified from the outbreak


reports as areas of concern or potential for improvement in outbreaks affecting HCWs:


∙ Overcrowding and staff shortage (influenza) ∙ High staff turnover rate and lack of specifically assigned personnel caring for infected patients (influenza, norovirus)


∙ Mishandling of personal protective equipment, especially during doffing of gowns and gloves (influenza, norovirus)


∙ Lack of influenza vaccination (influenza) ∙ Return to work while still symptomatic, infecting colleagues and patients and resulting in prolonged outbreak situations (influenza, norovirus)


∙ Continuing to work while symptomatic but undiagnosed (scabies) ∙ Lack of awareness of symptoms (scabies) ∙ Lack of compliance with preemptive treatment (scabies) ∙ Diagnostic uncertainty of staff screening results (MRSA)


Discussion


Highly contagious viral diseases like norovirus and influenza were the main cause of HCW illness during outbreak situations in our registry. Although the rate of HCW influenza vaccination is slowly increasing in Germany,2 much improvement is needed, which cannot be compensated by distribution of antiviral medi- cations during outbreak situations, even though the early use of those medications might help to limit the outbreak.3


Mishandling of personal protective equipment remains a


problem that can be exacerbated by stress at work, overcrowding, and understaffing. Furthermore, understaffing and obligation toward third parties contribute to presenteeism, which can create a vicious circle of continuous transmission, prolonging the outbreak. Based on our analysis of the outbreak reports, the fight against presenteeism4,5 might be of utmost importance, especially during influenza and norovirus outbreaks. Broad information about signs of symptoms of scabies and


screening for symptoms by occupational health and preemptive treatment of HCWs with unprotected contact with affected patients6,7 is needed. Lack of preemptive treatment compliance or application failure might be improved by using ivermectin rather than topical treatment,8 as demonstrated in scabies outbreaks without staff involvement in our registry. Staff screening seems only be indicated in MRSA outbreaks


with a possible epidemiological link to staff. However, the results need to be interpreted with caution, and molecular analysis or whole-genome sequencing should be readily available to prove or disprove the connection to the outbreak. Otherwise, there is the chance of following a wrong track and missing the real causes of the outbreak. Incidental findings of colonization9 are possible, as demonstrated in 1 of our cases. Avoiding stigmatization of affected staff is an additional challenge that needs to be addressed in advance by a clear institutional policy regarding screening, communication of screening results, and measures to be taken in case of a positive screening result.10


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