Risk of Coronavirus Transmission in Classrooms, Clinical Settings, and the Community

A female medical student attending a school lecture raises her hand to ask a question. The multi-ethnic group of adult students is wearing medical scrubs and protective face masks to prevent viral infection during the Covid-19 pandemic.

Many colleges are reopening for in–person learning after major shutdowns during the spring and fall of 2020 to mitigate transmission of the novel coronavirus. Reopening is especially important for nursing education because there is already a substantial nurse shortage both in the United States and globally (Snavely 2016). An important question is whether nurses and other students can be safely educated during a global pandemic. Nursing training includes both classes and clinical training in healthcare settings.

Risk of Transmission in Classrooms
Classrooms are controlled environments and, at most colleges in the United States, in order to prevent COVID-19 transmission all students and faculty are now required to wear masks and practice physical distancing. There is some evidence–based research providing insight into whether or not transmission is occurring in college classrooms. At Indiana University during the fall 2020 semester, epidemiologists found that the more classes a student took in person, the lower the likelihood they became infected with the SARS CoV-2 virus (Dbeibo et al. 2020). A study analyzing testing and contact tracing data at Duke University found that there was no evidence that there was any transmission associated with in–person classes (Denny et al. 2020). Syracuse University reported that when analyzing contact tracing data, not a single case could be attributed to classroom transmission (Hartocollis and Hubler 2020). The University of Arizona also reported that there were no cases of SARS CoV-2 transmission in a classroom or laboratory (Zalaznick). While there is growing evidence that transmission is not happening in college classrooms, during the fall 2020 semester many campuses were COVID-19 hotspots. The transmission, however, was likely almost exclusively outside classrooms and laboratories in congregate living environments and social settings.

Risk of Transmission in a Clinical Setting
Nursing education involves not only courses in the classroom but also clinical rotations in a healthcare setting. While the COVID-19 pandemic is the worst public health emergency in more than a century, hospitals and other clinical settings have experience with infection prevention and control for any airborne pathogen (Brown et al. 2019). The U.S. Centers for Disease Control (CDC) has also provided supplemental recommendations beyond standard infection control practices for COVID-19 (CDC 2020). These enhanced practices include universal personal protective equipment (PPE) use throughout healthcare facilities including breakrooms and common areas, use of N95 masks for patient care, SARS CoV-2 testing of patients regardless of symptoms, testing of staff, engineering controls to improve indoor air quality (e.g., ventilation, closing doors to separate areas), and restricting visitors and managing the movement of visitors, staff and patients. These enhanced practices should limit the spread of coronavirus in clinical settings and they are recommended for all health care workers and healthcare professional students. The recommendations will prevent transmission not only during close contacts with diagnosed COVID-19 patients, but also from undiagnosed or subclinical infectious patients and staff. Training and adherence to recommendations is essential to prevent transmission in healthcare settings.

Transmission in a Clinical or Community Setting?
Healthcare workers and student trainees who are infected with coronavirus can be infected in healthcare settings, in their home environments, or in the community and it is difficult to determine where transmission occurs. There has been some research that can provide insight into whether healthcare workers have been infected with SARS CoV-2 in healthcare settings. Early in the pandemic in China and Europe, there is evidence that transmission occurred in healthcare settings (Shah et al. 2020; Wang et al. 2020). Much less was known about the virus in this early period and there were shortages of PPE in some regions and healthcare facilities. One study of transmission of healthcare workers in eight hospitals around the world found that 57% did not use PPE and while a total of 4.7% of the workers were infected after exposure events, there were no cases of transmission for those who used PPE (Gómez-Ochoa et al., 2020). A study in China found that PPE use prevented transmission and that transmission risk was highest for doctors conducting procedures that induced coughing for prolonged periods of time and lower in nurses and nursing assistants (Chen et al., 2020).

A study in 14 U.S. states, early in the pandemic (March 1–May 31, 2020) found that six percent of adults hospitalized with COVID-19 were healthcare workers, the highest proportion in nurses (Kambhampati et al. 2020). About 73% of those hospitalized healthcare workers were obese and 90% had one or more underlying condition for severe COVID-19 disease. However, the study did not differentiate between workplace versus community–acquired exposure. Community exposure among healthcare workers has been identified in several studies (Kluytmans et al. 2020). One study in the Netherlands concluded that most of the transmission among healthcare workers was in the community and not hospitals (Sikkema et al. 2020). A study in England found no difference in the proportion of healthcare workers who were infected with the virus who had direct patient contact versus those who did not, which suggests that they were being infected in their communities, homes, or at their workplaces but not during patient interaction (Hunter et al. 2020).

Resuming Clinical Rotations is Essential
While existing evidence suggests that much of COVID-19 prevalence in healthcare workers is not due to occupational exposure and that PPE is effective in preventing and controlling infection, further research is needed that is specifically designed to differentiate between occupational and community transmission dynamics in healthcare workers and settings. However, there is clear evidence that enhanced COVID-19 prevention and control procedures, especially the universal use of PPE including masks, can prevent transmission. It is essential that training resumes for nursing and other healthcare professional students so that the worker shortages are not exacerbated when frontline healthcare professionals are needed most. With proper guidance and procedures, their training can be done safely both in the classroom and in clinical rotations.

written by Dr. Michael E. Emch

Brown L, Munro J, Rogers S. 2019. Use of personal protective equipment in nursing practice. Nurs Stand. 34(5):59-66.

Centers for Disease Control (CDC). 2020. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.  www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. November 4, 2020.

Chen Y, Tong X, Wang J, et al. 2020. High SARS-CoV-2 antibody prevalence among healthcare workers exposed to COVID-19 patients. J Infect. 81(3):420-426.

Dbeibo L, Rosenberg M, and the Indiana University Medical Response Team. 2020. Safety of in-person courses at Indiana University supported by new analysis: Data shows no evidence of increased COVID-19 risk with classes taught in person. news.iu.edu/stories/2020/11/iu/releases/20-analysis-supports-safety-of-in-person-courses.html.

Denny TN, Andrews L, Bonsignori M, et al. 2020. Implementation of a Pooled Surveillance Testing Program for Asymptomatic SARS-CoV-2 Infections on a College Campus – Duke University, Durham, North Carolina, August 2-October 11, 2020. MMWR Morb Mortal Wkly Rep. 69(46):1743-1747.

Gómez-Ochoa SA, Franco OH, Rojas LZ, et al. 2020. COVID-19 in Healthcare Workers: A Living Systematic Review and Meta-analysis of Prevalence, Risk Factors, Clinical Characteristics, and Outcomes. Am J Epidemiol. Online preprint.  kwaa191. doi:10.1093/aje/kwaa191

Hartocollis A and Hubler S. 2020. Some Colleges Plan to Bring Back More Students in the Spring. New York Times, December 6, 2020.

Hunter E, Price DA, Murphy E, et al. 2020. First experience of COVID-19 screening of health-care workers in England. Lancet. 395(10234): e77-e78.

Kambhampati AK, O’Halloran AC, Whitaker M, et al. 2020. COVID-19-Associated Hospitalizations Among Health Care Personnel – COVID-NET, 13 States, March 1-May 31, 2020. MMWRMorb Mortal Wkly Rep. 69(43):1576-1583.

Kluytmans-van den Bergh MFQ, Buiting AGM, Pas SD, Bentvelsen RB, van den Bijllaardt W, van Oudheusden AJG, van Rijen MML, Verweij JJV, Koopmans MPG, Jan A.J.W. Kluytmans JAJW. 2020. SARS-CoV-2 infection in 86 healthcare workers in two Dutch hospitals in March.  medRxiv doi: https://doi.org/10.1101/2020.03.23.20041913

Shah ASV, Wood R, Gribben C, et al. 2020. Risk of hospital admission with coronavirus disease 2019 in healthcare workers and their households: nationwide linkage cohort study. BMJ. 371: m3582.

Sikkema RS, Pas SD, Nieuwenhuijse DF, et al. 2020. COVID-19 in health-care workers in three hospitals in the south of the Netherlands: a cross-sectional study. Lancet Infect Dis. 20(11): 1273-1280.

Snavely TM. 2016. A Brief Economic Analysis of the Looming Nursing Shortage In the United States. Nurs Econ. 2016 34(2): 98-100.

Wang D, Hu B, Hu C, et al. 2020. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020; 323(11):1061-1069.

Zalaznick M. 2020. A look at 5 schools expanding in-person classes. University Business, October 6, 2020.

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