Summary
Background
In contrast to the beginning of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), pandemic, more and more hospital issues are now regulated by policy.
Aim
To identify differences between expert recommendations and legal requirements regarding infection prevention and control (IPC) strategies.
Methods
A cross-sectional study was conducted between 29th September 2022 and 3rd November 2022 addressing 1319 members of the German Society for Hygiene and Microbiology. The response rate was 12%. This paper reports the expert recommendations on different IPC strategies.
Findings
The majority (66%) of experts recommended universal mask usage, with 34% recommending it seasonally, even after the SARS-CoV-2 pandemic. Medical microbiology (MM) experts were more likely to recommend continuing to wear the masks indefinitely compared with IPC experts. Concerning the mask type, medical masks were recommended more frequently by IPC experts (47.3%), while FFP2 masks were preferred by MM experts (31.8%). The majority (54.7%) of experts recommended universal screening of employees, mainly in settings with extremely vulnerable patients and if regional incidence rates were high, at a frequency of twice per week. The dominant advice (recommended by at least 50% of experts) for employees exposed to SARS-CoV-2 was daily testing and wearing a mask, regardless of the length of exposure.
Conclusions
Expert recommendations deviate from the legal requirements and appear to be more differentiated and proportional. The influence of specific experience and expertise on mask recommendations should be investigated in more detail. For relevant policy decisions, a quick, focused and broad-based consultation of expertise could be of added value.
Keywords
Introduction and background
Infection prevention and control (IPC) strategies are at the heart of efforts to contain the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic [
[1]
]. During the pandemic, the German Infection Protection Act (IfSG) [[2]
] underwent a profound amendment to adapt to the rapid changes. Politicians made room for measures ranging from minor to major interventions. Regarding infection prevention in hospitals, IfSG summarizes the current policies.Robert Koch Institut. Infektionsschutzgesetz – IfSG. Berlin: Robert Koch Institut; 2021. Available at: https://www.rki.de/DE/Content/Infekt/IfSG/ifsg_node.html [last accessed December 2022].
The IPC strategies concerning SARS-CoV-2 differ, at least in part, between employees, patients and visitors; however, all have to adhere to a complex system of regulations that build on each other. At federal level, the uniform IfSG, specifically § 28b, lays the foundations, but not all regulatory needs can be represented there in a specific and timely manner; therefore, local laws in each of the states and hospitals also provide their own guidelines [
[2]
]. Within the ‘legislative competence for infection control’, it was specified in 2020 that ‘the states have the power to legislate in the area of concurrent legislation as long as and to the extent that the federal legislature has not exercised its competence by means of a law’ [Robert Koch Institut. Infektionsschutzgesetz – IfSG. Berlin: Robert Koch Institut; 2021. Available at: https://www.rki.de/DE/Content/Infekt/IfSG/ifsg_node.html [last accessed December 2022].
[3]
]. IPC strategies against SARS-CoV-2 in hospitals can include a vast array of measures [Deutscher Bundestag Gesetzgebungskompetenz für den Infektionsschutz. WD 3 – 3000 – 081/20. 2020. Available at: https://www.bundestag.de/resource/blob/691276/d7b39e76d5cd2649a5ffe3e6596df907/WD-3-081-20-pdf-data.pdf [last accessed April 2022].
[4]
], including airing [[5]
], mask mandates [[6]
] and visitor restrictions [Robert Koch Institut. Organisatorische und personelle Maßnahmen für Einrichtungen des Gesundheitswesens zum Schutz vor SARS-CoV-2-Infektionen. Berlin: Robert Koch Institut; n.d. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Getrennte_Patientenversorgung.html%3Bjsessionid=00A15D0EFF58358162571857448AE740.internet102?nn=2444038 [accessed 14 December 2022].
[7]
], and their effects are under constant scrutiny by the scientific community [8
, 9
, 10
]. The federal law states that employees have to wear either FFP2 (EN 149:2001+A1:2009), KN95 (GB2626-2006) or N95 (42 CFR Part 84) masks in hospitals. No state regulation may overrule that (§ 28b Nr.3 a IfSG). The law further states that exceptions are possible if wearing a mask hinders medical procedures. Employees have to be tested for SARS-CoV-2 at least three times per week; in this case, the state laws have the freedom to determine the frequency and scope of documentation (§ 28b Nr.3 b IfSG).- Grote U.
- Arvand M.
- Brinkwirth S.
- Brunke M.
- Buchholz U.
- Eckmanns T.
- et al.
Maßnahmen zur Bewältigung der COVID-19-Pandemie in Deutschland: nichtpharmakologische und pharmakologische Ansätze [Measures to cope with the COVID-19 pandemic in Germany: nonpharmaceutical and pharmaceutical interventions].
Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2021; 64: 435-445
Every person entering a hospital – patients, visitors and different service providers – has to wear a mask (FFP2 or comparable) and has to provide a test certificate in accordance with § 22a Nr. 3 IfSG [
[11]
]. Exceptions are possible for patients, if, for example, the mask hinders medical procedures, or if a person is deaf or hearing/speaking impaired; other reasons are also admissible [Bundesministerium der Justiz. Gesetz zur Verhütung und Bekämpfung von Infektionskrankheiten beim Menschen (Infektionsschutzgesetz-IfSG) § 28b Besondere Schutzmaßnahmen zur Behinderung der Verbreitung der Coronavirus-KRankheit-2019 (COVID-19) unabhängig von einer epidemischen Lage von nationales Tragweite bei saisonal hoher Dynamik. Berlin: Bundesministerium der Justiz; n.d. Available at: https://www.gesetze-im-internet.de/ifsg/__28b.html [last accessed December 2022].
[12]
]. There are no visitor restrictions by law at the time of writing (3rd January 2023). However, as stated above, each state and hospital is allowed to extend the regulations when necessary in this regard.Bundesministerium für Gesundheit. Änderung des Infektionsschutzgesetzes. Bonn: Bundesministerium für Gesundheit; n.d. Available at: https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/ifsg.html [last accessed December 2022].
Targeted implementation of the laws, especially in the hospital setting, is by no means trivial. A study from 2021 [
[13]
] reported that IPC strategies for patients and visitors are not implemented in full in German hospitals, which are influenced by the structural conditions of the hospital and assessments of the needs and safety of patients. Another challenge in implementing these IPC strategies is to assign additional responsibilities to hospital employees, which can lead to massive workloads.As such, knowledge and experience from experts in the respective fields are needed. This will benefit the development and improvement of IPC policies [
[14]
,[15]
].The question arises whether some of these measures could become the ‘new normal’ even after the pandemic, or when the most suitable time for a staggered withdrawal could be. The heightened regulatory restriction could lead to less ‘natural’ development of recommendations due to decreased room to manoeuvre. However, the importance of situational decisions and expert-based decisions of IPC measures has been reported [
[16]
,[17]
]. It is therefore not easy to grasp what recommendations the experts in the field would give without these regulations in place. The research question was posed as follows: What recommendations would IPC and/or medical microbiology (MM) experts make for infection prevention given the current SARS-CoV-2 pandemic?Methods
An observational cross-sectional study was conducted from 29th September 2022 to 3rd November 2022. The aim of this survey was to identify expert opinions regarding IPC strategies in German hospitals, independent of political regulations. All members (N=1319) of the German Society for Hygiene and Microbiology [Deutsche Gesellschaft für Hygiene und Mikrobiologie (DGHM)] were invited to participate in this study, and their expert opinions on mask usage, testing and procedures in the event of exposure of employees, visitor restrictions and admission screening of patients were surveyed.
The questionnaire was designed and developed within the Scientific Working Group ‘Infection Prevention and Control and Antimicrobial Resistance’, the Standing Committee of the ‘General and Hospital Hygiene’, and board representatives of DGHM. The questionnaire is available in Appendix A2 (see online supplementary material).
The survey was conducted using the online platform, Limesurvey (https://www.limesurvey.org/). Before this survey was distributed, pre-tests were conducted on experts (N=7) with expertise in infection control, infectious diseases, microbiology, virology or public health. The invitation to participate in this survey, including the link to Limesurvey, was sent and advertised via e-mail within the DGHM mailing list. In addition, two e-mail reminders were sent to all members on 4th October 2022 and 26th October 2022. A further description of survey participation is provided in Appendix A1 (see online supplementary material).
Participation in the survey was voluntary and completely anonymous; no personal data were collected. Therefore, ethical approval was not required committee. Each expert agreed to the data protection regulations and gave informed consent.
Data analysis
Responses to the questionnaire were analysed using frequency and percentage. The participants were asked to state their profession and primary role, and grouped accordingly as MM experts and hygiene/IPC experts. The purpose of this categorization was not to compare different opinions of experts with different backgrounds, but to investigate how opinions from different perspectives could be justified scientifically as well as experientially. Additionally, respondents were asked to state whether or not they held a leadership position. The analysis was performed using Microsoft Excel 2016 (Microsoft Corp., Redmond, WA, USA) and SPSS 28 (IBM Corp., Armonk, NY, USA).
Results
Participant characteristics
In total, 159 of 1319 DGHM members participated in this survey (response rate 12%). Table I show the participant characteristics. The participants came from different institutions, with the majority working in university hospitals (40.3%) and non-university hospitals (29.6%). At least 50% held a leadership position and most of them had a medical background.
Table IParticipant characteristics
| Characteristic | N (%) |
|---|---|
| Institution | |
| University hospital | 64 (40.3) |
| Non-university hospital | 47 (29.6) |
| Private laboratory, private consulting firm | 21 (13.2) |
| Public health service | 11 (6.9) |
| Other | 16 (10.0) |
| Leadership position | |
| Director/head of department or acting director/head of department | 92 (57.9) |
| Not in a leadership position | 67 (42.1) |
| Profession of director/head of department or acting director/head of department | |
| Chief physician | 33 (35.9) |
| Senior physician | 24 (26.1) |
| Scientist/working group leader | 16 (17.4) |
| Others | 19 (20.6) |
| Profession of non-director/head of department | |
| Senior physician | 20 (29.9) |
| Specialist physician | 16 (23.9) |
| Scientist | 15 (22.4) |
| Assistant physician | 11 (16.4) |
| Others | 5 (7.4) |
| Area of expertise | |
| Medical microbiology | 85 (53.5) |
| Hygiene/infection prevention and control | 74 (46.5) |
Recommendations for hospital employees
The results of the survey concerning the preferred IPC strategy for hospital employees can be found in Table II. The table shows the suggestions made for mask mandates, universal screening processes, contacts with positive persons, and recommendations for employees with mild cold symptoms.
Table IIRecommendations of experts with background expertise in medical microbiology (MM)/infection prevention and control (IPC) or leadership positions in IPC strategies for healthcare workers
| Area of expertise | Leadership position | Total N=159 | 95% CI | |||
|---|---|---|---|---|---|---|
| MM N=85 | IPC N=74 | Leader N=92 | Non-leader N=67 | |||
| Extent of mask mandate | ||||||
| Long-term | 10 (11.8%) | 3 (4.1%) | 6 (6.5%) | 7 (10.4%) | 13 (8.2%) | 3.9–12.5 |
| Seasonal, even after SARS-CoV-2 pandemic | 26 (30.6%) | 29 (39.2%) | 39 (42.4%) | 16 (23.9%) | 55 (34.6%) | 27.2–42.0 |
| Until the end of SARS-CoV-2 pandemic | 16 (18.8%) | 17 (23.0%) | 20 (21.7%) | 13 (19.4%) | 33 (20.8%) | 14.5–27.1 |
| Do not recommend wearing mask | 31 (36.5%) | 23 (31.1%) | 24 (26.1%) | 30 (44.8%) | 54 (33.9%) | 26.5–41.3 |
| Other | 2 (2.3%) | 2 (2.6%) | 3 (3.3%) | 1 (1.5%) | 4 (2.5%) | 0.1–4.9 |
| Mask type | ||||||
| Medical mask (EN 14683:2019–10) | 20 (23.5%) | 35 (47.3%) | 37 (40.2%) | 18 (26.9%) | 55 (34.6%) | 27.2–42.0 |
| FFP2 mask (EN 149:2001+A1:2009) | 27 (31.8%) | 12 (16.2%) | 23 (25.0%) | 16 (23.9%) | 39 (24.5%) | 17.8–31.2 |
| No preference | 3 (3.5%) | 3 (4.1%) | 4 (4.3%) | 2 (3.0%) | 6 (3.8%) | 0.6–6.4 |
| Do not recommend wearing mask | 31 (36.5%) | 23 (31.1%) | 24 (26.1%) | 30 (44.8%) | 54 (34.0%) | 26.6–41.4 |
| Other | 4 (4.7%) | 1 (1.3%) | 4 (4.3%) | 1 (1.5%) | 5 (3.1%) | 0.4–5.8 |
| Activities and processes in which a mask should be worn | ||||||
| Generally | 15 (17.6%) | 6 (8.1%) | 11 (12.0%) | 10 (14.9%) | 21 (13.2%) | 7.9–18.5 |
| All activities in patient care | 18 (21.2%) | 17 (23.0%) | 17 (18.5%) | 18 (26.8%) | 35 (22.0%) | 15.6–28.4 |
| Only in direct patient contact | 13 (15.3%) | 20 (27.0%) | 28 (30.4%) | 5 (7.5%) | 33 (20.8%) | 14.5–27.1 |
| Only for activities traditionally considered as aerosol-producing | 5 (5.9%) | 5 (6.8%) | 7 (7.6%) | 3 (4.5%) | 10 (6.3%) | 2.5–10.1 |
| Do not recommend wearing mask | 31 (36.5%) | 23 (31.1%) | 24 (26.1%) | 30 (44.8%) | 54 (34.0%) | 26.6–41.4 |
| Other | 3 (3.5%) | 3 (4.0%) | 5 (5.4%) | 1 (1.5%) | 6 (3.7%) | 0.8–6.6 |
| Universal screening for employees for SARS-CoV-2 (multiple answers possible) | ||||||
| As long as the pandemic persists | 13 (15.3%) | 13 (17.6%) | 15 (16.3%) | 11 (16.4%) | 26 (16.4%) | 10.6–22.2 |
| When regional incidence rate is high | 20 (23.5%) | 23 (31.1%) | 24 (26.1%) | 19 (28.4%) | 43 (27.0%) | 20.1–33.9 |
| Employees in specific areas (e.g. particularly vulnerable patient groups) | 34 (40.0%) | 30 (40.5%) | 34 (37.0%) | 30 (44.8%) | 64 (40.3%) | 32.7–47.9 |
| Unvaccinated employees | 13 (15.3%) | 9 (12.2%) | 12 (13.0%) | 10 (14.9%) | 22 (13.8%) | 8.4–19.2 |
| When new VOC or VOI occurs | 11 (12.9%) | 16 (21.6%) | 17 (18.5%) | 10 (14.9%) | 27 (17.0%) | 11.2–22.8 |
| Do not recommend universal screening for employees | 35 (41.2%) | 26 (35.1%) | 37 (40.2%) | 24 (35.8%) | 61 (38.4%) | 30.8–46.0 |
| Frequency of universal screening for employees for SARS-CoV-2 | ||||||
| Three times per week | 6 (7.1%) | 5 (6.8%) | 6 (6.5%) | 5 (7.5%) | 11 (6.9%) | 3.0–10.8 |
| Two times per week | 22 (25.9%) | 22 (29.7%) | 22 (23.9%) | 22 (32.8%) | 44 (27.7%) | 20.7–34.7 |
| Once per week | 4 (4.7%) | 3 (4.1%) | 3 (3.3%) | 4 (6.0%) | 7 (4.4%) | 1.2–7.6 |
| Depending on the vulnerability of the patient group | 11 (12.9%) | 14 (18.9%) | 17 (18.5%) | 8 (11.9%) | 25 (15.7%) | 10.0–21.4 |
| Do not recommend universal screening for employees | 35 (41.2%) | 26 (35.1%) | 37 (40.2%) | 24 (35.8%) | 61 (38.4%) | 30.8–46.0 |
| Other | 7 (8.2%) | 4 (5.4%) | 7 (7.6%) | 4 (6.0%) | 11 (6.9%) | 3.0–10.8 |
| Employee contact with SARS-CoV-2-infected person, short duration | ||||||
| Quarantine for X days, resumption of work after negative test | 2 (2.4%) | 1 (1.4%) | 2 (2.2%) | 1 (1.5%) | 3 (1.9%) | -0.2–4.0 |
| Quarantine for X days, resumption of work without negative test | 1 (1.2%) | 0 (0.0%) | 1 (1.1%) | 0 (0.0%) | 1 (0.6%) | -0.6–1.8 |
| Work with daily testing | 2 (2.4%) | 3 (4.1%) | 2 (2.2%) | 3 (4.5%) | 5 (3.1%) | 0.4–5.8 |
| Work with daily testing and wear medical/FFP2 mask | 38 (44.7%) | 41 (55.4%) | 47 (51.1%) | 32 (47.8%) | 79 (49.7%) | 41.9–57.5 |
| Wear medical/FFP2 mask | 17 (20.0%) | 11 (14.9%) | 15 (16.3%) | 13 (19.4%) | 28 (17.6%) | 11.7–23.5 |
| Work without conditions | 10 (11.8%) | 6 (8.1%) | 10 (10.9%) | 6 (9.0%) | 16 (10.1%) | 5.4–14.8 |
| Decision depends on type of activity, vulnerability of patient group | 15 (17.6%) | 12 (16.2%) | 15 (16.3%) | 12 (17.9%) | 27 (17.0%) | 11.2–22.8 |
| Employee contact with SARS-CoV-2-infected person, long duration | ||||||
| Quarantine for X days, resumption of work after negative test | 5 (5.9%) | 6 (8.1%) | 6 (6.5%) | 5 (7.5%) | 11 (6.9%) | 3.0–10.8 |
| Quarantine for X days, resumption of work without negative test | 1 (1.2%) | 0 (0.0%) | 0 (0.0%) | 1 (1.5%) | 1 (0.6%) | -0.6–1.8 |
| Work with daily testing | 5 (5.9%) | 2 (2.7%) | 5 (5.4%) | 2 (3.0%) | 7 (4.4%) | 1.2–7.6 |
| Work with daily testing and wear medical/FFP2 mask | 45 (52.9%) | 48 (64.9%) | 55 (59.8%) | 38 (56.7%) | 93 (58.5%) | 50.8–66.2 |
| Wear medical/FFP2 mask | 9 (10.6%) | 7 (9.5%) | 7 (7.6%) | 9 (13.4%) | 16 (10.1%) | 5.4–14.8 |
| Work without conditions | 5 (5.9%) | 6 (8.1%) | 10 (10.9%) | 1 (1.5%) | 11 (6.9%) | 3.0–10.8 |
| Decision depends on type of activity, vulnerability of patient group | 15 (17.6%) | 5 (6.8%) | 9 (9.8%) | 11 (16.4%) | 20 (12.6%) | 7.4–17.8 |
| Employee with mild cold symptoms (multiple answers possible) | ||||||
| Always wear medical/FFP2 mask | 54 (63.5%) | 41 (55.4%) | 57 (62.0%) | 38 (56.7%) | 95 (59.7%) | 52.1–67.3 |
| Wear medical/FFP2 mask when working with patients | 11 (12.9%) | 14 (18.9%) | 17 (18.5%) | 8 (11.9%) | 25 (15.7%) | 10.0–21.4 |
| If possible, work from home | 28 (32.9%) | 24 (32.4%) | 32 (34.8%) | 20 (29.9%) | 52 (32.7%) | 25.4–40.0 |
| Work after testing negative for SARS-CoV-2 | 15 (17.6%) | 14 (18.9%) | 17 (18.5%) | 12 (17.9%) | 29 (18.2%) | 12.2–24.2 |
| Work after testing negative for SARS-CoV-2 and influenza | 20 (23.5%) | 23 (31.1%) | 29 (31.5%) | 14 (20.9%) | 43 (27.0%) | 20.1–33.9 |
| Work and parallel testing for SARS-CoV-2 | 15 (17.6%) | 17 (23.0%) | 19 (20.7%) | 13 (19.4%) | 32 (20.1%) | 13.9–26.3 |
| Work without testing for SARS-CoV-2 | 2 (2.4%) | 1 (1.4%) | 1 (1.1%) | 2 (3.0%) | 3 (1.9%) | -0.2–4.0 |
| Avoid working in the clinic | 3 (3.5%) | 2 (2.7%) | 1 (1.1%) | 4 (6.0%) | 5 (3.1%) | 0.4–5.8 |
SARS-CoV-2, severe acute respiratory syndrome coronavirus-2; VOC, variant of concern; VOI, variant of interest; CI, confidence interval.
Subgroup proportions outside of the 95% confidence interval for the entire sample are presented in bold type.
Mask policies
The majority of the experts (66%) recommended any type of universal mask wearing as an IPC measure against SARS-CoV-2 for employees in hospitals. Approximately one-third of the experts did not recommend universal mask wearing for employees for this purpose.
The suggested duration for wearing a mask varied, with the most prevalent recommendation being to continue mask usage indefinitely on a seasonal basis [34.6%, 95% confidence interval (CI) 27.2–42.0]. The same opinion was expressed by experts who held a leadership position (42.4%). Regarding the type of mask, medical masks (EN 14683:2019–10) were recommended by 34.6% of the responding participants and most of those who held a leadership position (40.2%). There was a marked difference between IPC experts (47.3%, 95% CI 27.2–42.0) and MM experts (31.8%, 95% CI 17.8–31.2).
When considering under which circumstances and for which specific processes healthcare workers (HCWs) in hospitals should wear masks, most experts in the study recommended continuous usage during all processes in patient care (22%), followed by employees in direct patient contact (20.8%). For the latter, this was recommended by one-third of the experts in leadership positions. Wearing a mask for aerosol-generating procedures alone was advised by <10% of participants.
Universal screening of hospital employees
Approximately one-third of the experts recommended that employees should not be universally screened. Most experts recommended universal screening for SARS-CoV-2 via rapid antigen or polymerase chain reaction (PCR) tests for employees (54.7%). The dominant advice was to screen HCWs working in departments with extremely vulnerable patient groups (40.3%), followed by screening when regional incidence rates were high (27%). The frequency of twice per week was recommended by the experts. Additionally, some experts recommended determining the frequency based on the vulnerability of the patient group (15.7%).
Hospital employees as contact person
The most recommended strategy for employees exposed to SARS-CoV-2 was daily testing and wearing a mask, regardless of the duration of exposure (49.7% for short contacts and 58.5% for long contacts). Particularly for long contacts, MM experts were more likely than IPC experts to consider the strategy depending on employee responsibility and vulnerability of the patient group (17.6% MM experts and 6.8% IPC experts). In addition, some experts in leadership positions recommended working without any additional measures in this situation (10.9%).
Hospital employees with cold symptoms
For mild cold symptoms, the majority of experts (59.7%) recommended that employees should wear a mask universally. At least one-third of the experts recommended that the employees should work from home if possible.
Restrictions for patients and visitors
Table III provides results of the survey regarding the preferred IPC strategies for patients and visitors. The table shows the recommendations for universal screening and hospital visit regulations.
Table IIIRecommendations of experts with background expertise in medical microbiology (MM)/infection prevention and control (IPC) or leadership positions in IPC strategies for patients and visitors
| Area of expertise | Leadership position | Total N=159 | 95% CI | |||
|---|---|---|---|---|---|---|
| MM N=85 | IPC N=74 | Leader N=92 | Non-leader N=67 | |||
| Universal screening of patients for SARS-CoV-2 (multiple answers possible) | ||||||
| All inpatients | 12 (14.1%) | 24 (32.4%) | 20 (21.7%) | 16 (23.9%) | 36 (22.6%) | 16.1–29.1 |
| All inpatients and selected outpatients | 21 (24.7%) | 16 (21.6%) | 24 (26.1%) | 13 (19.4%) | 37 (23.3%) | 16.7–29.9 |
| Patients in specific areas (e.g. oncology, intensive ward) | 38 (44.7%) | 32 (43.2%) | 44 (47.8%) | 26 (38.8%) | 70 (44.0%) | 36.3–51.7 |
| Patients with increased risk of severe disease progression (e.g. underlying disease, planned surgery, unvaccinated, old age) | 31 (36.5%) | 27 (36.5%) | 38 (41.3%) | 20 (29.9%) | 58 (36.5%) | 29.0–44.0 |
| When regional incidence is high | 21 (24.7%) | 25 (33.8%) | 29 (31.5%) | 17 (25.4%) | 46 (28.9%) | 21.9–35.9 |
| When new VOC or VOI occurs | 21 (24.7%) | 22 (29.7%) | 30 (32.6%) | 13 (19.4%) | 43 (27.0%) | 20.1–33.9 |
| Takeover patients from abroad | 12 (14.1%) | 14 (18.9%) | 15 (16.3%) | 11 (16.4%) | 26 (16.4%) | 10.6–22.2 |
| Do not recommend universal screening for patients | 20 (23.5%) | 8 (10.8%) | 13 (14.1%) | 15 (22.4%) | 28 (17.6%) | 11.7–23.5 |
| Implementation of visit restrictions | ||||||
| Yes | 1 (1.2%) | 0 (0.0%) | 0 (0.0%) | 1 (1.5%) | 1 (0.6%) | -0.6–1.8 |
| Visits under certain regulations | 60 (70.6%) | 61 (82.4%) | 73 (79.3%) | 48 (71.6%) | 121 (76.1%) | 69.5–82.7 |
| No restrictions | 24 (28.2%) | 13 (17.6%) | 19 (20.7%) | 18 (26.9%) | 37 (23.3%) | 16.7–29.9 |
| Specification of restrictions on visits (multiple answers possible) | ||||||
| Limited number of visitors per patient | 36 (42.4%) | 42 (56.8%) | 56 (60.9%) | 22 (32.8%) | 78 (49.1%) | 41.3–56.9 |
| Limited visiting hours | 25 (29.4%) | 20 (27.0%) | 30 (32.6%) | 15 (22.4%) | 45 (28.3%) | 21.3–35.3 |
| Compulsory testing for visitors | 32 (37.6%) | 26 (35.1%) | 38 (41.3%) | 20 (29.9%) | 58 (36.5%) | 29.0–44.0 |
| Mask mandate, medical/FFP2 mask | 54 (63.5%) | 56 (75.7%) | 68 (73.9%) | 42 (62.7%) | 110 (69.2%) | 62.0–76.4 |
| Specific regulations depending on department | 18 (21.2%) | 18 (24.3%) | 21 (22.8%) | 15 (22.4%) | 36 (22.6%) | 16.1–29.1 |
| Mask type for visitors | ||||||
| Medical mask (EN 14683:2019–10) | 27 (31.8%) | 39 (52.7%) | 41 (44.6%) | 25 (37.3%) | 66 (41.5%) | 33.8–49.2 |
| FFP2 mask (EN 149:2001+A1:2009) | 28 (32.9%) | 15 (20.3%) | 26 (28.3%) | 17 (25.4%) | 43 (27.0%) | 20.1–33.9 |
| No preference | 1 (1.2%) | 1 (1.4%) | 2 (2.2%) | 0 (0.0%) | 2 (1.3%) | -0.5–3.1 |
| Do not recommend wearing mask | 27 (31.8%) | 18 (24.3%) | 20 (21.7%) | 25 (37.3%) | 45 (28.3%) | 21.3–35.3 |
| Other | 2 (2.3%) | 1 (1.4%) | 3 (3.2%) | 0 (0.0%) | 3 (1.9%) | -0.2–4.0 |
| Extent of mask mandate for visitors | ||||||
| Long-term | 14 (16.5%) | 7 (9.5%) | 10 (10.9%) | 11 (16.4%) | 21 (13.2%) | 7.9–18.5 |
| Seasonal, even after SARS-CoV-2 pandemic | 28 (32.9%) | 26 (35.1%) | 39 (42.4%) | 15 (22.4%) | 54 (34.0%) | 26.6–41.4 |
| Until the end of SARS-CoV-2 pandemic | 15 (17.6%) | 20 (27.0%) | 20 (21.7%) | 15 (22.4%) | 35 (22.0%) | 15.6–28.4 |
| Do not recommend wearing mask | 27 (31.8%) | 19 (25.7%) | 21 (22.8%) | 25 (37.3%) | 46 (28.9%) | 21.9–35.9 |
| Other | 1 (1.2%) | 2 (2.7%) | 2 (2.2%) | 1 (1.5%) | 3 (1.9%) | -0.2–4.0 |
SARS-CoV-2, severe acute respiratory syndrome coronavirus-2; VOC, variant of concern; VOI, variant of interest; CI, confidence interval.
Subgroup proportions outside of the 95% confidence interval for the entire sample are presented in bold type.
Universal screening of patients
Universal screening of patients refers to screening every patient at admission regardless of symptoms or exposure. The majority of the experts recommended a form of universal screening for SARS-CoV-2 for patients (82.4%). However, there was a marked difference in the preferred settings. While 32.4% of the IPC experts recommended generalized universal screening, 23.5% of MM experts advised against any form of universal screening. However, 44% of all experts recommended universal screening of patients in high-risk settings where either the individual or the setting is vulnerable.
Visitor regulations
Most experts recommended hospital visitation with certain regulations (76.1%). When specifying the circumstances, the experts showed a tendency to suggest mandatory mask wearing during hospital visits and limiting the number of visitors per patient.
Different preferences regarding mask type for visitors were found, with IPC experts tending to recommend wearing a medical mask (52.7%, 95% CI 33.8–49.2), and MM experts tending to recommend wearing an FFP2 mask (32.9%, 95% CI 20.1–33.9). Interestingly, the answers of participants in leadership positions varied in equal proportions, with one-third recommending medical masks, one-third recommending FFP2 masks, and one third not recommending general mask wearing. One-third of the experts recommended that masks should continue to be worn seasonally, even after the pandemic.
Discussion
There are differences between other European countries and Germany regarding the existing and preferred measures, as well as the legal regulations that are currently in place. The results are discussed here in reference to the regulations in place in Germany. It is remarkable that, with regards to several issues relevant to patient care and the daily routines of HCWs, expert assessments deviate significantly from the current legally regulated requirements. This allows at least a few questions or interim evaluations.
Table IV shows a small number of experts aligned in their opinions with the current legal requirements concerning employees; however, more expert opinions were aligned with the requirements concerning patients and visitors. This reflects the experience and additional evidence gained in the context of the pandemic, with these measures being universal measures against different pathogens when there is a high risk of transmission. This also suggests that it can by no means be dichotomous decision-making, but that further data and insights into effect sizes in different constellations are needed. Differences between experts working in medical microbiology and in IPC could be due to their diverse primary area of responsibility in everyday life. IPC experts create the hospital-specific regulations for masks, and may therefore be more familiar with the practical limitations and questions of feasibility and acceptance. Differences between experts in leadership positions with decision-making power and those who are not in leadership positions could be due to a higher level of experience because of their longer professional career, or because they, as taskforce members, have to present and/or defend the decisions directly to hospital management and clinicians.
Table IVProportion of expert opinions that align fully with the legal requirements
| IPC measure | Legal requirement | Expert opinion |
|---|---|---|
| Masks for employees | Universal, FFP2 mask | 24.5% |
| Screening of employees | Universal screening three times per week | 6.9% |
| Employees after contact of short duration | Quarantine, return after negative test | 1.9% |
| Employees after contact of long duration | Quarantine, return after negative test | 6.9% |
| Employees with cold symptoms | Daily testing, 5 days, FFP2 mask | 49.7% |
| Patient screening | Universal | 82.4% |
| Visitor regulation | FFP2 mask Compulsory testing | 27% 36.5% |
a The specific legal requirements and exceptions can be found in the German Infection Protection Act.
b The specific answers and diverse recommendations are reported in the results section and can be viewed in detail in the online supplementary material.
Some deviations could arise because the experts must include the logistical effort of the measures in their assessment, as well as the lack of these capacities for direct patient care. In addition, there is also the psychological aspect of the increased demands on the people who bore much of the burden of illness during the pandemic. The latter must be considered in particular if all requirements in public life are relaxed or no longer apply.
For inpatient settings, it is reasonable for most experts to suggest at least periodic universal screening of HCWs and patients in vulnerable settings, and additional screening when regional incidence rates are high. Perhaps this is based on the knowledge that the risk of SARS-CoV-2 transmission in hospitals can be high [
[18]
]. However, the current evidence for decreasing transmissions by screening is low in general, and is only higher for high incidence constellations, certain risk settings and certain patient groups. Moreover, the additional burden of work for HCWs has to be taken into account [[19]
]. Regarding the frequency of screening, the current legislation requires hospital employees involved in patient care to be tested three times per week [[11]
]. This survey found that most experts recommended a screening frequency for hospital employees of twice per week, which is in line with the recommendation from the European Centre for Disease Prevention and Control [Bundesministerium der Justiz. Gesetz zur Verhütung und Bekämpfung von Infektionskrankheiten beim Menschen (Infektionsschutzgesetz-IfSG) § 28b Besondere Schutzmaßnahmen zur Behinderung der Verbreitung der Coronavirus-KRankheit-2019 (COVID-19) unabhängig von einer epidemischen Lage von nationales Tragweite bei saisonal hoher Dynamik. Berlin: Bundesministerium der Justiz; n.d. Available at: https://www.gesetze-im-internet.de/ifsg/__28b.html [last accessed December 2022].
[20]
]. A modelling study reported that twice-weekly testing with a rapid antigen test could reduce an outbreak by 67% compared with symptomatic-only testing [[21]
]. However, screening is an additional task for HCWs during the pandemic. Staff workload, efficiency and feasibility could explain why the experts recommended a lower frequency of screening.Regarding hospital employees who have been in contact with persons positive for SARS-CoV-2, regardless of the duration of exposure, the national public health authority ‘Robert Koch-Institute’ recommends reducing contact, especially with those at risk of severe illness, and daily testing for 5 days after exposure [
[22]
]. The experts in this study expressed the same opinion, and recommended daily testing and wearing a mask. Their opinion reflects their expertise in this area, as the testing strategy alone aims at early detection but may not provide additional protection for others. Combining this with the mask strategy could increase the protection of employees and patients from disease transmission [[23]
,[24]
].Limiting the number of patient visitors, another preferred suggestion, may depend on experience, as this strategy can reduce contact [
[25]
] and therefore prevent the transmission of many diseases, especially during the pandemic and winter seasons.In the late phase of the pandemic, with good evidence and extensive experience of the experts who advise and work in hospitals, a one-fits-all top-down solution does not seem to be the most suitable.
Strengths and limitations
The survey instrument was developed and pre-tested in an iterative process with experts from the fields of virology, immunology, infectious medicine, hygiene and medical microbiology. The participants provide expertise in different hospital settings, work in various professions and hold leadership positions in Germany, which were positive aspects of the survey. The response rate was low, which could represent selection bias. However, it should be borne in mind that the denominator overestimates the potential population. All persons listed as members of DGHM were invited to participate, regardless of whether or not they already had a degree, were active in this area, or were retired. It is important to point out that many members of DGHM are not (yet) involved directly in health care but are laboratory researchers. It can be assumed that they did not feel addressed by the survey due to their distanced position, which could explain, in part, the low response rate. It should be emphasized that half of the participants were in leadership positions. These are the experts who would be actively consulted and have decision-making powers and authority. It could be suggested that this study represents a subgroup of those active in the field, based on the low number of scientists within the respondents, and the high rate of those in managerial positions, thereby reducing the limiting effect of the low response rate.
In the introduction to the survey, respondents were asked to choose IPC strategies under conditions free from legal requirements and other restrictions. However, it cannot be known whether the answers given were based on perception or evidence. As participation in this survey was anonymous, it is expected that this anonymity will have increased the quality of answers provided by respondents who were selected based on their expertise and experience.
Regarding the screening of employees, patients and visitors, no direct questions were asked about whether the experts recommended the use of a rapid antigen test or a PCR test. Therefore, no conclusions can be drawn from this survey in this regard.
The survey results only show a snapshot of the rapidly changing pandemic situation. Repeated inclusion of expert opinions in decision-making processes, and surveying these experts, could be of great interest to policy makers.
In conclusion, this survey showed differences between the current legal requirements and expert assessments. For future policy decisions, a quick, focused and broad-based consultation of expertise, comparable to this, could be of added value.
The survey showed that experts showed an overall tendency to recommend wearing masks, favouring medical masks over FFP2 masks. Interestingly, IPC experts tended to be less strict regarding mask wearing recommendations than MM experts, suggesting that those with less experience in IPC measures and effectiveness before the pandemic tend to recommend stricter measures to be ‘on the safe side’. This may not always be preferable, if all pros and cons are weighed carefully.
Screening measures were also recommended by the experts, with the clear tendency to focus on vulnerable groups or during periods with high incidence rates rather than a universal generalized approach. This is currently also what the scientific evidence suggests; however, legal requirements still recommend major screening efforts, which may not reduce transmission. The added negative effect of burdening HCWs with tasks on top of their existing challenges has to be taken more seriously.
Acknowledgements
The authors wish to thank Lina Zimmermann from the Department of Infection Control and Infectious Diseases, University Medical Centre Göttingen, for assistance.
Appendix A. Supplementary data
The following is the Supplementary data to this article.
- Multimedia component 1
Conflict of interest statement
None declared.
Funding source
This study received funding from the project ‘PREPARED’ (PREparedness and PAndemic REsponse in Germany) (Grant No. 01KX2121) in the frame of the BMBF programme ‘Netzwerk Universitätsmedizin, 2. Förderphase’.
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Article info
Publication history
Published online: April 13, 2023
Accepted:
April 3,
2023
Received:
January 4,
2023
Identification
Copyright
© 2023 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
