Nosocomial SARS-CoV-2 Infections in Japan: A Cross-sectional Newspaper Database Survey

*Correspondence to: Yuta Tani , Email: tyuta0430@gmail.com Copyright: © 2020 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Citation: Tani Y, Sawano T, Kawamoto A, Ozaki A, Tanimoto T. Nosocomial SARS-CoV-2 infections in Japan: a cross-sectional newspaper database survey. Int J Health Policy Manag. 2020;9(10):461–463. doi:10.34172/ijhpm.2020.75 Received: 15 April 2020; Accepted: 16 May 2020; ePublished: 20 May 2020

1 to 128, and the maximum number (52.0%) was found in the Eiju Hospital in Tokyo. This means that nosocomial infections amounted to 141 (13.6%) among the 1040 infected cases in Tokyo. Of the 114 cases with known details of infection, 63 (55.3%) were HCPs, 46 (40.4%) were patients, and five (4.4%) were office workers and their families. Details of the remaining 132 cases have not been identified.
Details of nosocomial infections in the four hospitals were extracted from the newspaper articles at the authors' discretion as representative cases of nosocomial infection in Japan ( Table 2). The causes of nosocomial infection were largely categorized into insufficient patient isolation and HCP protection. A typical example of insufficient patient isolation occurred at the JA Toride Medical Center, wherein an undiagnosed patient infected another patient in the same room. The initial patient was diagnosed with pneumonia, but reverse transcription polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 was not performed upon admission due to the limited capacity of this testing. 6 Similarly, a typical example of insufficient HCP protection occurred at Shin Komonji Hospital, wherein a patient who received emergency surgery before being diagnosed with COVID-19 subsequently infected 16 HCPs who worked with simple personal protective equipment (eg, masks) in the ward.
At least 6.9% of the total number of SARS-CoV-2 cases throughout Japan were reported in newspapers as nosocomial infections, and most occurred in relatively large hospitals. Nosocomial infections of SARS-CoV-2 have been reported in other countries in part as a result of a lack of equipment and poor medical practices, 7,8 and in China, these infections have amounted to 3.8% of all cases. 7 However, Japan's hospital environment may be prone to nosocomial infections because physicians care for many patients and often work at multiple clinics and hospitals due to the relatively small number of physicians in the country. Therefore, if infected, physicians themselves might convey the virus to multiple medical institutions. Furthermore, hospitals usually treat multiple patients in crammed rooms in their wards. In some cases, an initially hospitalized patient who did not have a confirmatory diagnosis at the time of admission subsequently spread the virus to other patients in the same room as well as to HCPs. In Eiju Hospital, 163 infected cases and 20 deaths due to COVID-19 have been reported as of April 11, 2020. 9 Countermeasures against nosocomial infections should be considered based on their primary causes. First, with regard to insufficient patient isolation, a negative pressure ward should be available for patients with suspected, but not confirmed, SARS-CoV-2, and when this is unavailable, frequent ventilation should be encouraged in such a ward as much as possible. 6 Second, with regard to insufficient HCP protection, thorough primary protection, such as standard and droplet precautions, should be employed. 10 When performing invasive procedures for COVID-19 patients, HCPs should undertake secondary protection, namely infection control rules relating to contact with patients, such as wearing gloves, hand hygiene, and wearing a gown. 6,10 Historically, Middle East respiratory syndrome coronavirus (MERS-CoV) infection has caused outbreaks, including through nosocomial infections, in countries such as South Korea. 11 It is crucial to be aware of the risks associated with infected patients because coronavirus infections, including   both SARS-CoV-2 and MERS-CoV, spread via human-tohuman transmission, and SARS-CoV-2 is thought to have a higher basic reproduction number than MERS-CoV (2.24 to 3.58 vs. 0.52 to 1.36). 12,13 Thus, HCPs should follow rigorous practices to deal with SARS-CoV-2; selection, isolation, protection, and observation of medical personnel with appropriate examination routines. 14 In addition, they should observe diagnosis criteria and carry out examination routines for suspected infected patients. 14 Several limitations are present in our study. First, reporting in newspapers can be inaccurate. Second, definitions of nosocomial infections may differ among newspaper companies and articles. Third, our study may have not covered all nosocomial infections due to underreporting.
In conclusion, nosocomial infections of SARS-CoV-2 are common in Japan and have spread among several medical institutions via infected patients and HCPs. HCPs need to develop flexible strategies and action plans to deal with the current pandemic and prevent its further spread.

Ethical issues
Not applicable.