Management of a large outbreak of COVID-19 at a British Army training centre: lessons for the future.

INTRODUCTION: The COVID-19 pandemic has posed major challenges for infection control within training centres, both civilian and military. Here we present a narrative review of an outbreak that occurred at the Royal Military Academy Sandhurst (RMAS) in January-March 2021, in the context of the circulating, highly transmissible SARS-CoV-2 variant B.1.1.7. METHODS: Testing for SARS-CoV-2 was performed using a combination of reverse transcriptase PCR and Lateral Flow Devices (LFDs). Testing and isolation procedures were conducted in line with a pre-established symptom stratification system. Genomic sequencing was performed on 10 sample isolates. RESULTS: By the end of the outbreak, 185 cases (153 Officer Cadets, 32 permanent staff) had contracted confirmed COVID-19. This represented 15% of the total RMAS population. This resulted in 0 deaths and 0 hospitalisations, but due to necessary isolation procedures did represent an estimated 12 959 person-days of lost training. 9 of 10 (90%) of sequenced isolates had a reportable lineage. All of those reported were found to be the Alpha lineage B.1.1.7. CONCLUSIONS: We discuss the key lessons learnt from the after-action review by the Incident Management Team. These include the importance of multidisciplinary working, the utility of sync matrices to monitor outbreaks in real time, issues around Officer Cadets reporting symptoms, timing of high-risk training activities, infrastructure and use of LFDs. COVID-19 represents a vital learning opportunity to minimise the impact of potential future pandemics, which may produce considerably higher morbidity and mortality in military populations.

Measures of inflammation, complement activation and coagulation in patients with COVID-19

S56 Table 1Table to show measures of complement activation, inflammation and coagulation in patients with COVID-19 stratified by disease severityMildModerateSevereOverall P-ValueMild vs Mod*Mild vs Sev*Mod vs Sev*Number (%)30289----CRP (mg/L)75.5 [28.5,117.25]93.5 [72,143.5]60 [34,157.5]NSNSNSNSFerritin (ug/L)426 [290.5,847.5]728 [381.25,1071.5]857 [443,1607.5]NSNSNSNSPCT (ug/L)0.08 [0.06,0.19]0.16 [0.09,0.49]0.19 [0.12,0.8]0.019NS0.046NSLDH (U/L)708.5 [523.5,903]830 [569,1122]1037 [927.5,1086]0.008NS0.006NSPlatelets (10*9/L)220 [174.75,328.75]255 [203.5, 335]292 [209.5, 329.5]NSNSNSNSINR1.1 [1.08,1.23]1.1 [1.1, 1.2]1.1 [1.1, 1.15]NSNSNSNSAPTR0.9 [0.9,1.0]0.9 [0.9, 1.0]1.0 [0.95, 1.10]NSNSNS0.038D-dimer (ugFEU/ml)0.56 [0.38,0.95]0.74 [0.55, 1.52]0.85 [0.54, 19.2]NSNSNSNSFibrinogen (g/L)4.45 [4.05,5.22]4.7 [4.3, 6.38]4.3 [3.9, 6.0]NSNSNSNSThrombin-AT III Complex ug/L)4.75 [2.65,12.13]8.8 [5.3, 12]14.3 [6.9, 40.7]0.045NSNSNSProthrombin Fragment 1&2 (pMol/L)275 [164.5,380.5]311 [163, 492]301 [258, 709]NSNSNSNSCH50 (U Eq/ml)123.4 [101.75,174.7]113.4[88.68, 153.43]114.7 [74.6,158.9]NSNSNSNSComplement C5a (ng/ml)29 [21.5, 36]36.5[25.5, 48.75]68 [39.5,122.5]<0.0010.0380.001NSComplement C5 (mg/L)270 [235.25,290.5]263[235.25, 279]276 [220,299.5]NSNSNSNSComplement C3 (g/L)1.5 [1.25,1.77]1.48[1.33, 1.71]1.56 [1.16,1.73]NSNSNSNSSC5b-9 complex (ng/ml)1070.46 [836.41,1632.17]1725.48[1092.62, 2403.3]2392.66 [1245.68,5145.88]0.006NS0.019NSComplement Fragment Bb (µg/ml)0.2[0.15,0.27]0.25[0.17, 0.3]0.29 [0.2,0.43]NSNSNSNSComplement C3a ng/ml)296.88[244.33,345.22]325.88[248.33, 484.03]460.23 [282.49,652.1]NSNSNSNS*P-values given a Bonferroni adjustment to allow for multiple testing between subgroupsDiscussionOur findings demonstrated increased levels of complement activity in patients with COVID-19, particularly in those patients requiring non-invasive and mechanical ventilation and those patients that deteriorate requiring increasing ventilatory support. The complement cascade is a key player in protective immunity against pathogens, with its activation orchestrating key immunoprotective and anti-inflammatory effects Increased activation of the complement cascade may contribute to the dysregulated and destructive inflammatory response that leads to multi-organ failure and our findings suggest a potentially important treatment target for COVID-19.

Nosocomial or not? A combined epidemiological and genomic investigation to understand hospital-acquired COVID-19 infection on an elderly care ward.

BACKGROUND: COVID-19 has the potential to cause outbreaks in hospitals. Given the comorbid and elderly cohort of patients hospitalized, hospital-acquired COVID-19 infection is often fatal. Pathogen genome sequencing is becoming increasingly important in infection prevention and control (IPC). AIM: To inform the understanding of in-hospital SARS-CoV-2 transmission in order to improve IPC practices and to inform the future development of virological testing for IPC. METHODS: Patients detected COVID-19 positive by polymerase chain reaction on Ward A in April and May 2020 were included with contact tracing to identify other potential cases. Genome sequencing was undertaken for a subgroup of cases. Epidemiological, genomic, and cluster analyses were performed to describe the epidemiology and to identify factors contributing to the outbreak. FINDINGS: Fourteen cases were identified on Ward A. Contact tracing identified 16 further patient cases; in addition, eight healthcare workers (HCWs) were identified as being COVID-19 positive through a round of asymptomatic testing. Genome sequencing of 16 of these cases identified viral genomes differing by two single nucleotide polymorphisms or fewer, with further cluster analysis identifying two groups of infection (a five-person group and a six-person group). CONCLUSION: Despite the temporal relationship of cases, genome sequencing identified that not all cases shared transmission events. However, 11 samples were found to be closely related and these likely represented in-hospital transmission. This included three HCWs, thereby confirming transmission between patients and HCWs.