Unique Challenges in Investigating a Cluster of COVID-19 Cases in an Inpatient Rehabilitation Unit

BACKGROUND: The SARS-CoV-2 virus that causes Coronavirus Infectious Disease 2019 (COVID-19) is primarily spread via droplets and aerosols when individuals are in proximity, and to a lesser degree through fomite contamination. In a six-day timeframe in January 2021 our inpatient rehabilitation unit experienced an outbreak of SARS-CoV-2 among five patients and one healthcare worker METHODS: A formal outbreak investigation commenced in the setting of one hospital-acquired case of COVID-19 and evidence of transmission from a previously identified case. The investigation included contact tracing, control measures, source testing, and a descriptive epidemiology study. Testing of 26 patients and 39 employees was conducted to determine the extent of transmission. Mid-turbinate or nasopharyngeal specimens were run on QIAstat-Dx real-time reverse transcription polymerase chain reaction (RT-PCR) platform. Inpatient specimens were collected by nursing staff. Employee specimens were collected at an Urgent Care center affiliated with the health system. RESULTS: Three additional positive patients were discovered, one asymptomatic and two who developed symptoms. Patient activities in common included a shared dining room, shared shower facilities since many in-room showers could not accommodate a wheelchair or walker, and a physical therapy gym. One positive employee was identified through asymptomatic testing. This employee had extensive contact with the index case while the patient had cough, vomiting and diarrhea. The employee was not yet vaccinated; this was prior to implementation of an organizational vaccine requirement policy. Control measures included immediately closing shared spaces, unit-level enhanced symptom screening and employee education. CONCLUSIONS: Patients receiving physical, occupational and/or speech therapies have unique infection risks due to shared equipment of varying materials that may be difficult to clean, needing to be observed during meals for swallow safety, and removing masks during meals in the common dining room. No additional cases were identified following interventions targeted at common spaces and enhanced staff screening and education.