key: cord-334867-ohw0chbg
authors: Ma, Hui; Zhu, Jiangong; Liu, Jianfei; Zhang, Xin; Liu, Yunxi; Song, Hongbin
title: Hospital biosecurity capacitation: Analysis and recommendations from the prevention and control of COVID-19
date: 2020-05-27
journal: J Biosaf Biosecur
DOI: 10.1016/j.jobb.2020.05.001
sha: 
doc_id: 334867
cord_uid: ohw0chbg

The outbreak of COVID-19 epidemic in December 2019 has highlighted issues with hospital biosafety capacitation in the People’s Republic of China, although the epidemic has been controlled now. This study examined the primary issues, including an absence of hospital emergency system, inadequate management and control of nosocomial infection, limited hospital laboratory capacity, and poor hospital admission capacity. Accordingly, the study put forward the following countermeasures and suggestions for hospitals to deal with future biosecurity events, such as a major epidemic: first, there is a need to build biosecurity management systems and emergency response mechanisms in hospitals; second, the investment and guarantee mechanisms for hospital biosecurity construction should be improved; third, the capacity building of biosecurity incident treatment needs attention in general hospitals; and fourth, comprehensive plans need to be developed for the integrated construction of medical treatment and prevention facilities through disease-control systems.

In December 2019, the coronavirus disease 2019 was detected in Wuhan City, Hubei Province, People's Republic of China, and rapidly spread to many provinces and cities across the country. At 24:00 on April 21, 2020, the National Health Commission reported a total of cumulative 82,788 confirmed cases of COVID-19, including 4,632 deaths, and 77,151 cured cases, from 31 provinces (autonomous regions and municipalities); in the Hubei Province, there were 68,128 confirmed cases, 4,512 deaths, and 68,128 cured cases [1] .

In contrast to the severe acute respiratory syndrome (SARS) and influenza A virus, subtype H1N1 (H1N1), infections that respectively occurred in 2003 and 2009 in the People's Republic of China, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes COVID-19 is a new pathogen characterized by the following features: unknown animal origin, strong transmissibility, high susceptibility of the general population, and uncertain mortality rates in high-risk populations. The lack of an effective treatment for severe COVID-19 has contributed to the considerable destructive power of the disease with regard to its effects on the society and economy [2, 3, 4] . Moreover, the epidemic has exposed inadequacies of biosecurity governance. A greater concern is that the slow early warning of the epidemic has seriously undermined the effectiveness of prevention and control measures as well as treatment in the later stages of the infection. Thus, from the perspectives of ensuring the people's health, safeguarding national security, and maintaining the long-term national stability, it is essential to incorporate biosecurity into the national security system, systematically plan the construction of a national biosecurity risk-control and governance system, and comprehensively improve the national biosecurity governance capacity [2] .

After the outbreak of the COVID-19 epidemic, the People's Republic of China set up a leading group for a timely response to the epidemic. The state, the army, and local governments at all levels responded forcefully, and the military-civilian joint prevention and control mechanism was rapidly established to undertake decisive measures to prevent the import, spread, and transmission of the epidemic and thus block the nationwide transmission of the SARS-CoV-2 [3] [4] [5] . The majority of military and civilian medical workers have fought hard at the frontline to reach the phased goals of "double increases" (increased treatment rate and cure rate) and "double decreases" (decreased infection rate and mortality rate), to achieve remarkable results in epidemic prevention and control [6] . However, in the fight against the COVID-19 epidemic, we found many issues that emerged in local hospitals in the response to a major epidemic. These issues indirectly reflected that hospitals have many shortcomings and weaknesses in the prevention and treatment of infectious diseases as well as with regard to hospital biosecurity construction [7] . Therefore, we aimed to evaluate those issues and develop suitable countermeasures.

After the outbreak of the COVID-19 epidemic, all provinces (autonomous regions and municipalities) across the country initiated first-level responses to public health emergencies to ensure the momentum of the epidemic was effectively contained. Nevertheless, medical institutions at all levels, especially hospitals, demonstrated a weak response to the epidemic in the early stages, which was attributable to the following four reasons. First, the emergency response force for biosecurity was insufficient. Although hospitals set up infection control or disease prevention department, due to the shortage of personnel skilled in biosecurity and lack of professional knowledge and skills, such as surveillance and early warning, sample collection, disinfection and quarantine, and protection training, the clinicians who had a poor understanding of the disease implemented inappropriate measures in the early stage, and thereby missed the best timepoint for disease control [8] . Second, the interactive emergency response mechanism did not function smoothly. With the large number of patients visiting hospitals, the poor information exchange among medical institutions, disease control institutions, and scientific research institutions caused doctors to have scant knowledge of the epidemiological characteristics, transmission patterns, and human-to-human transmission of SARS-CoV-2 infection, with the consequence of disappointing treatment results [9] . Third, the emergency reserves were inadequate. Owing to the defective emergency reserve system and the large number of people quarantined for prevention and protection purposes, there was a nationwide shortage of masks, goggles, protective clothing, and quarantine clothing in hospitals [10] . Fourth, the hospital infectious disease monitoring network system does not play an early warning role in the early stage. Since 2003, the People's Republic of China has successively established direct epidemic reporting system, pathogen surveillance system, unknown pneumonia case surveillance system, and symptom surveillance system, in order to facilitate early detection of new emerging infectious diseases. However, judging from the response to the epidemic, many of these systems did not play an adequate role in early warning [11] .

COVID-19 is transmitted from the carrier to the infected mainly through droplets and close unprotected contact, and there is a possibility of airborne transmission due to aerosols produced during medical procedures [3] . Thus, COVID-19 can be detected in ambient air of medical institutions [12] , which everyone is generally susceptible to [13] . It has been confirmed that there is human-to-human transmission and medical staff infection [13, 14, 15, 16] . By February 20, 2020, a total of 2,055 medical staff in 476 hospitals were reported to have contracted the SARS-CoV-2 infection [3] , and most (88%) were from the Hubei Province and diagnosed in the early stage of the outbreak in Wuhan. Therefore, the biosecurity protection of medical staff is of particular significance. Because patients in the incubation period could not be detected in time at the outset of the epidemic, the medical staff failed to implement graded protection and standard prevention protocols [15] , which resulted in nosocomial infections. After identifying the confirmed cases, the shortage of protective materials or gear and the lax implementation of hospital rules and regulations on nosocomial infections further exposed medical staff to the risk of nosocomial infection. In addition, nosocomial cross-infection among ordinary patients was not given due importance.

Cross-infection among patients or between doctors and patients is caused by poor conditions at the fever clinic or inadequate management of nosocomial infection. In particular, in the treatment of COVID-19, the vast majority of non-infectious and respiratory professionals had limited knowledge of the disease and its prevention and control, which contributed to the growth of the nosocomial infection rate, accounting for a large proportion of COVID-19 cases. One example of this is the earliest nosocomial event at the Department of Neurology in Wuhan Union Hospital [17] .

One of the gold standards for confirming the diagnosis of patients with SARS-CoV-2 infection is the etiological evidence, namely nucleic acid testing through real-time fluorescent polymerase chain reaction [13] . However, the COVID-19 epidemic has exposed several problems with regard to laboratory conditions and capabilities. First, there is a lack of bio-secure laboratories in hospitals. The COVID-19 test needs to be carried out in secondary biosecurity laboratories [18, 19, 20] , which are unavailable at many hospitals; moreover, hospitals that have these laboratories may be unable to obtain the testing qualification from relevant state departments in time, with a resultant failure to in timely detection and delay in the diagnosis and treatment of the disease. Second, there is a lack of hospital testing materials.

Due to improper sampling, non-standard protocols, and issues with the stability and reliability of many hastily developed new kit products at some hospitals, the rate of positive detection was low. In addition, some patients had residual viral loads detected in stool samples after discharge from the hospital, which resulted in "re-positivity" [4] and a risk of infection re-spread.

During the epidemic, several hospitals faced difficulties with expanding capacities for quarantine and admission purposes in a short period. As of February 20, 50,000 patients received treatment across the country, and hospitals strived to expand hospital bed capacity [3] .

The first difficulty was the limited capacity for housing patients with infectious diseases. For instance, weeks after the outbreak, although there were 45 designated hospitals in Wuhan, a large number of patients were waiting for beds. Two hospitals were temporarily built, and 10 square cabin hospitals were quickly set up; therefore, the bed capacity increased sharply, which greatly relieved the pressure with regard to hospitalization of patients. The second challenge was the limited emergency treatment capacity. During the epidemic, many general hospitals undertook the tasks of emergency admission and treatment of patients with COVID-19 and quarantine of suspected patients. However, most hospitals were apparently inexperienced at reforming medical institutions for segregated diagnosis and treatment, complete quarantine of confirmed and suspected cases, effective interruption of the route of transmission, and diagnosis and treatment of the disease [6, 21] . Moreover, the lack of treatment capacity delayed the treatment of other patients with tumors or traumatic infection.

The third challenge was poor conditions at fever clinics. During the SARS outbreak of 2003, many hospitals set up fever clinics,, but some were put on hold for a long time, and their infrastructure could not fulfil the biosecurity requirements for SARS-CoV-2. The COVID-19 epidemic necessitated resumption or construction of temporary fever clinics and improvement of the facilities and conditions. Moreover, these fever clinics strictly followed the observation and diagnostic protocols during quarantine, which subsequently increased the time to detection and hospitalization admission, thereby contributing to long wait times.

At the core of the national medical treatment system, hospitals play a major role in biosecurity defense. In recent years, hospitals have gained remarkable achievements in responding to new outbreaks of infectious diseases such as SARS, H1N1, Ebola, and COVID-19 [22, 23] . Therefore, it is of immense importance to clarify the status and role of hospitals in the national biosecurity system. First, it is recommended that future biosecurity laws or implementation regulations should clearly define the functions and roles of hospitals at all levels, from the national level onward, to legally define and safeguard the responsibilities of hospitals. Second, it is necessary to call on hospitals at all levels to establish leading groups for biosecurity management and define their responsibilities and tasksnamely, undertaking emergency response to biosecurity emergencies in wartime and enhancing leadership and supervision over biosecurity work in hospitals in peacetime. Third, it is essential to refine and improve emergency plans for different types of biosecurity emergencies [24] . Special attention should be paid to the following aspects: the establishment of a regional joint prevention and management mechanism; the overall planning of biothreat assessment, surveillance and early warning, emergency treatment, and disease treatment; the whole-chain link and process of restoration and reconstruction; and the coordination of the organization and command; talent; disease treatment; information platform; and material and equipment systems [25, 26] . Particularly, it is imperative to strengthen the setting up of symptom surveillance sentinel points, such as fever clinic and intestinal clinic, in hospitals; integrate the symptom surveillance and pathogen surveillance systems; enhance the ability to identify unknown pathogens; and improve the early identification and early warning capabilities of biothreat hospital outposts [28] .

As the epidemic swept through the country, all levels and types of hospitals across the country participated in COVID-19 treatment, and nosocomial infections occurred in some hospitals for non-communicable diseases in Wuhan and Beijing. This suggests that general hospitals for non-communicable diseases can encounter biosecurity incidents and face serious risks similarly as hospitals for infectious diseases. Therefore, it is suggested that, under the unified planning and guidance of the competent authorities, a biothreat treatment system should be developed at the national level, and funding support and specialist training should be reinforced. First, it is essential to increase investment in specialized hospitals such as those for infectious diseases. According to the proportion of the resident urban population, it is necessary to increase the number of hospitals that specialize in infectious diseases and set up biosecurity laboratories to meet the need for medium-scale treatment of infectious diseases.

Second, it is important to increase investment in public health and epidemic prevention in general hospitals. Sufficient number of infectious diseases specialty and standardized fever clinics should be established in accordance with the construction requirements. The negative pressure isolation wards should be increased or modified to fulfil the requirements for accepting and treating patients with respiratory infectious diseases, which are normally used for the general hospitalization of patients in "peacetime" and for quarantine and emergency treatment in "wartime" [27, 28] . Drawing on effective practices in the United States, bio-control training and treatment wards should be set up in hospitals for ready-to-use purposes. Third, it is necessary to improve the guarantee mechanism for emergency materials. It includes improving the national emergency materials reserve system, optimizing the production capacity guarantee and regional layout of important emergency materials, and unblocking the emergency procurement and supply channels [29, 30] , in order to ensure the supply of emergency materials and outfit, such as medicines, vaccines, antibodies, masks, protective clothing, disinfectants, and goggles, for ready-to-use availability in critical conditions.

The emergency treatment capacity of biosecurity incidents is related to the effectiveness of the treatment of biosecurity incidents, the health of the people, and national security and stability. First, it is necessary to establish and improve the biosecurity incident treatment system. Relying on the medical treatment alliance and graded diagnosis and treatment, we should establish and improve the classification, stratification, and diversion of biosecurity incident treatment mechanism, unblock the conversion mechanism in peacetime and wartime, and urgently authorize non-public medical institutions and laboratories to rapidly expand their detection and treatment capabilities in "wartime." The application of 5G and artificial intelligence image-assisted technologies can help to carry out remote consultation on major infectious diseases and other biological events. It is vital to better the construction of medical personnel, encourage all medical staff to acquire the knowledge and basic skills of infectious diseases and biosecurity protection, and lay stress on the training on protection knowledge and skills of infectious diseases and biosecurity among non-infectious medical staff and grass-roots medical staff with low seniority and professional titles [31, 32] . Second, the technical standards and quality management standards of diagnosis and treatment need to be improved [29] . The intervention measures for the prevention and control of infectious diseases should be strictly implemented, and the strategic pass should be moved up to achieve the "four early" (early detection, early reporting, early quarantine, and early treatment). In particular, priorities should be given to the medical treatment of mild patients to reduce the transition from mild cases to severe ones, as well as to the treatment of severe cases to reduce the mortality rate. Third, scientific and technological researches, such as developing robot delivery systems and UAV sterilization devices, upgrading medical emergency vehicles, negative-pressure quarantine stretchers, and negative-pressure first aid devices, and accelerating the research and application of novel technologies and treatments, including convalescent plasma treatment and blood purification treatment need to be carried out. It is vital to advance laboratory detection and diagnosis and establish on-site rapid detection technologies such as isothermal amplification, mass spectrometry, to improve the ability of rapid detection of pathogens [28] .

Disease-control systems and medical institutions are crucial components of national biosecurity construction. Through a dynamic integration of and cooperation between these two components, it is possible to ensure population health and construct better biosecurity systems. However, the problems of "attaching importance to treatment but neglecting prevention" and "separating treatment from prevention" are ubiquitous in the country. The lessons learned from the epidemic are extremely profound. Therefore, greater effort should be invested to integrate medical and preventive forces and form a pattern of integrated construction of treatment and prevention facilities. First, it is necessary to further promote reforms of the disease-control system [33] . The tripartite forces of disease-control institutions; general and specialized hospitals; and grassroots medical and health units should be coordinated to establish an interdependent "trinity" of disease-control systems characterized by division of labor, cooperation, and interdependence on each other's strengths [34] . This would further intensify the role and function of hospital disease-control departments. In key and sensitive departments such as the emergency department, disease-control experts should be assigned and conferred adequate governance authority in terms of rights and responsibilities to enhance the ability of hospitals to deal with biosecurity incidents represented by public health emergencies. Second, it is vital to improve the emergency response mechanism for integrated treatment and prevention. We recommend improvement of the effective interaction of mechanisms for scientific research, disease control, and clinical treatment, as well as coordination of research, assessment, decision-making, and prevention and control capabilities for major biosecurity risks; facilitation of interregional and interinstitutional exchanges [35] ; examination and clarification of institutional responsibilities; and development of interaction protocols for various types of biosecurity emergencies to facilitate information and communication, timely assistance for investigations, and provision of mutual assistance and support [5, 36] . In particular, it is of special significance to establish an institutional mechanism for full participation in the organizational command network for public health emergencies to ensure timely response and effective outcomes.

Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19)

Guidance for Corona Virus Disease 2019: Prevention, Control, Diagnosis and Management

People's Medical Publishing House, WHO Health Information and Publishing Cooperative Organization

Analysis of epidemiological characteristics of COVID-19

Comprehensively improve the ability of prevention, control, and governance and the national public health emergency management system pursuant to law

Jianqing Ding et al. Thinking on the COVID-19 epidemic

Thoughts on the countermeasures of turning the emergency treatment stage into the continuous prevention and control stage at epidemic peak

Expert Panel on Prevention and Control of COVID-19 of Chinese Preventive Medicine Association. The latest understanding of epidemiological characteristics of COVID-19

How to improve "information transmission" to respond to public health emergencies

Hubei provincial governor: medical protective clothing masks and other protective materials are still in particular shortage

A major epidemic warning is the race between the government and the virus incubation period

Clinical Data on Hospital Environmental Hygiene Surveillance and Medical Staffs Protection during the Coronavirus Disease

Diagnosis and Treatment Protocol for COVID-19 (trial version 6

Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia

Infection prevention and control during health care when COVID-19 (nCoV) infection is suspected. Interim Guidance

What Healthcare Personnel Should Know about Caring for Patients with Confirmed or Possible 2019-nCoV oV

Witnesses: The whole story of the infection of medical staff in the Central Hospital of Wuhan

General Office of the National Health Commission

Laboratory Testing Technology Guide for COVID-19

Laboratory testing for 2019 COVID-19 (2019-nCoV) in suspected human cases Interim guidance 17

Investigation on the status of purification and air-conditioning systems in operating rooms of 158 hospitals in Hunan Province during COVID-19 epidemic

Thinking on China's biosecurity situation and countermeasures. Infectious Disease Information

Enlightenment of SARS, Ebola, and influenza A H1N1 on COVID-19 epidemic

New progress in biosecurity medical treatment and clinical diagnosis and treatment of major infectious diseases

Biosecurity discipline construction and capacity development in China

Speed up the development of biosecurity science and technology in China with capacity building at the core

Thoughts on the countermeasures of turning the emergency treatment stage into the continuous prevention and control stage at epidemic peak

Suggestions on the reform of China's public health prevention system in COVID-19 epidemic

Study on collaborative management of emergency supply chain of COVID-19 epidemic

Study on dynamics of interregional collaborative allocation of emergency supplies for major infectious diseases

Investigation on the core emergency capabilities of among medical staff in major infectious diseases

Emergency research agenda for COVID-19: strategies for transmission and non-drug relief

Analysis of the functional positioning of Chinese public health professionals under the new situation

Thoughts and suggestions on modernization of disease prevention and control system

Risk communication and community engagement (RCCE) readiness and response to the 2019 COVID-19 (2019-nCoV) interim guidance v2

Regional joint prevention and control of major diseases

Not applicable

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study. 

The authors have no competing interests to declare.

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

This work was supported by Medical Innovation Project (18CXZ038), Logistics Scientific Research Project (ALB19J003) and National Social Science Foundation (15GJ003-155).

None.

MH and SHB conceived and wrote the manuscript.ZJG, LJF,ZX and LYX critically reviewed and revised the manuscript. All authors have read and approved the final manuscript.