Frank Diamond has been with Infection Control Today since November 2019. He has more than 30 years of experience working for magazines, newspapers, and television news. 

A newly discovered variant of COVID-19 contains as many as 30 mutations and some scientists worry that that variant—B.1.1.529, also called Omicrom, after the 15th letter in the Greet alphabet—might be able to evade antibodies produced by previous infection or vaccines. In other words it could be—

” that keeps medical experts up at night.

As scientists around the world scramble to get a handle on Omicrom—there’s really not that much data on it, yet—the actions of countries seem to indicate that the variant represents a serious health threat, and a possible new tragic chapter in the COVID-19 saga.

’s Editorial Advisory Board, says that “although there is scant data being shared with the public to draw definitive conclusions, the swift actions taken by governments throughout the world indicate an extremely high level of concern.”

Those actions include issuing travel bans from other countries. The United States has banned travel from South Africa (where Omicrom was first spotted), Botswana, Zimbabwe, Namibia, Lesotho, Eswatini, Mozambique and Malawi, as 

. The action is being taken on the advice of Anthony Fauci, MD, the chief medical advisor to the White House.

Meanwhile, the World Health Organization (WHO) has already labeled Omicrom a variant of concern (VOC), which might be the fastest a COVID-19 variant has reached that threat level since being first discovered and labeled, says Kavanagh.

Scientists with South Africa’s National Institute for Communicable Diseases (NICD) sounded the alarm on Monday about B.1.1.529 and yesterday posted a 

“This lineage possesses a high number of mutations previously seen in other SARS-CoV-2 variants of interest (VOI) or variants of concern (VOC) but also other mutations which are novel,” says the NICD. “One of these changes can be detected through standard diagnostic tests that target the S gene, which allows detection of this lineage in South Africa without sequencing data.”

The NICD states that Omicrom shares some similarities with the Alpha and Delta variants, but there are elements to it that make it “distinctively different” than any other variant of COVID-19 so far. Currently, B.1.1.529 doesn’t seem to cause different symptoms among infected individuals and, as with other variants, people who are asymptomatic can spread the disease.

But, again, so far little is known. The NICD states that “we are being cautious about the implications, while we gather more data to understand this lineage.”

In addition, the NICD says that “work is already under way to look at the immune escape potential of B.1.1.529 in the laboratory setting. We are also establishing a real time system to monitor hospitalization and outcome associated with B.1.1.529. Based on our understanding of the mutations in this lineage, partial immune escape is likely, but it is likely that vaccines will still offer high levels of protection against hospitalization and death.”

Kavanagh says that while scientists strive to find out more about Omicrom, “initial reports are that it is more transmissible, possibly more lethal and is highly mutated having a plethora of different immunity escape mechanisms.”

Kavanagh also points to the reaction to the variant by the WHO, the US, and other nations.

“It is evident by actions, that world governments have grave concerns,” says Kavanagh. “The World Health Organization has just classified this variant as a ‘variant of concern’, only the fifth time it has 

What made the Delta variant so deadly was its infectiousness. Omicrom, says Kavanagh, “appears to be spreading fast and has been already found in Hong Kong, Belgium and Israel. Travel restrictions have been imposed by the United Kingdom, European Union along with Japan and Singapore have ordered travel bans on travelers from southern Africa,” says Kavanagh.

The South Africa Minister of Health Joe Phaahla made the announcement yesterday about Omicrom. It is unknown where it first emerged. “Initially it looked like some cluster outbreaks, but from yesterday, the indication came from our scientists from the Network of Genomic Surveillance that they were observing a new variant,” Phaahla said.

The emergence of Omicrom serves as a reminder of the actions the public needed to take before the vaccines came along: hand hygiene, social distancing, and masking.

“We expect new variants to continue to emerge wherever the virus is spreading. Vaccination remains critical to protect those in our communities at high risk of hospitalization and death, to reduce strain on the health system, and to help slow transmission” the NICD states. “This must be in conjunction with all the other public health and social measures, so we advise the public to remain vigilant and continue to follow COVID-19 protocols by: ensuring good ventilation in all shared spaces, wearing masks (which cover your nose, mouth and chin), keeping 1.5m distance from others as much as possible and washing or sanitizing your hands and surfaces regularly and keeping 1.5m distance from others as much as possible. These non-pharmaceutical interventions (NPIs) are still proven to prevent the spread of all SARS-CoV-2 viruses.”

This article contains details first reported by 

Articles

Although not much has been disclosed about Omicrom so far, its appearance made the WHO label it a variant of concern and caused a cascade of travel restrictions around the world.

Enter Omicrom: New COVID-19 Variant Spreads Alarm

Two people need a lung to live. One has been vaccinated against COVID-19. The other refused to get vaccinated, got the disease and needs a lung as a result. “These are ethical questions that are 

’s Editorial Advisory Board. “There’s no real good right or wrong answer.” Which doesn’t mean that there won’t be some system developed to deal with one of the many long-term problems created by the pandemic. For instance, Kavanagh says it’s possible that an arm of the health care system might be created just to deal with problems resulting from COVID-19 in people who refused to be vaccinated. Also, the unvaccinated might have to pay more for health care coverage. In this wide-ranging interview, Kavanagh also talks about gain-of-function research. Some of it might be worthwhile, but most of it should be discontinued, he says. For instance, avian flu doesn’t usually infect humans, but when it does, there’s a 60% fatality rate. In one gain-of-function project, scientists crossed avian flu with influenza. “So, imagine if that code got out or if that virus was made and spread,” says Kavanagh. “You’d have a virus that would spread like the flu, and it would have a 60% fatality rate. I mean, it’s just to me baffling why this this type of research is being done.”

 reports on a smallpox scare and showed that dangerous pathogens need to be closely monitored. In that article, you also wrote that George Washington ordered his troops to get the smallpox vaccine. And in those days, vaccination against smallpox was serious business. It could get you really sick, correct?

Correct. And the vaccines back then weren’t safe. They were trying whatever they can do to avert this disease that can cause a 30% fatality rate. Back then 90% of the armed forces deaths were sometimes due to infections. They weren’t necessarily due to combat. And so infectious disease was a huge problem. And for us to really ignore this problem and say, “Hey, look. We’re not going to get vaccinated. We’re not going to mandate vaccines for our armed forces and have them susceptible to this illness. I think that is unconscionable, and it puts our nation at risk. These are concepts that go back centuries. And infectious diseases are national security problems, especially ones like SARS-CoV-2 that cannot be easily controlled.

[Anthony Fauci, MD, White House chief medical advisor] has said the same thing. But you don’t expect the holidays to be as horrible as last year’s holidays, right?

Well, they may well [be just as horrible]. And that gets into the spread of the virus and whether or not people get boosters. Even if you’re vaccinated, you can spread the virus, but you’re not as likely to spread the virus. First of all, if you become infected, that’s a prerequisite to spreading the virus. And if you’re vaccinated, you’re not as likely to become infected. If you are infected, you spread the virus for a shorter period of time. And that’s good for the community. 

So, if you have an unvaccinated person spreading it for nine days, a vaccinated person spreading it for one day, you go out in the community, you’d expect much less community spread. But when you talk about close contacts, and family contacts, they are exposed in an indoor setting to a much higher rate of virus. And when you go visit your friends on the holidays, and you stay, let’s say, for a week, it doesn’t matter whether you expose those people for nine days or one day, they’re still going to get COVID-19. And if you have older individuals there that haven’t had their boosters, or people that are immunosuppressed, you are placing them at then grave risk. So, we may have a significant rise in both cases and hospitalizations. If you look at some of the graphs that are coming out of Germany, out of France, and the start in rising cases that you’re seeing in Iceland and Ireland, this is very concerning. Because again, it’s like compound interest. You go through one wave, then you go through another, you go through another. You have to constantly keep up your guard. And that means we can’t ignore the virus. But we have to change the way that we live so that we can live safely with the virus.

I have a feeling that your answer this next question will be: There’s no real way of knowing. But I have family and friends who didn’t get the vaccine. I’m sure you that have family and friends who didn’t get the vaccine. Now there are some people out there who you could call diehard anti-vaxxers. They just don’t believe in it and are kind of militant about not getting it. There are other people who just don’t seem to care, or just kind of like bump along and not really think about it. Do you see that divide too?

Well, I do. I think that there are some people who really don’t think that this is serious enough to act. And, again, that’s some of the disinformation and the idea of compound interest that “well, you know, we’re not seeing a whole lot of change this year so it’s not something we have to worry about.” Then there are other people who are anti-vaxxers and who are actually scared of the vaccine. On our last meeting that we had with our 

 group, we had a presentation and it was a very good one. And it was a presenter who described one of her family members who is 33 years old. Just put off getting vaccinated. Wasn’t an anti-vaxxer. Just didn’t get around to it, and wound up getting severe COVID-19, intubated, almost died. Wound up having to have ECMO [extracorporeal membrane oxygenation] in order to recover. And this was someone who’s 33. So yes, you do see it. And this virus can affect the young and so everybody needs to become vaccinated. And everybody who’s had a previous infection should also become vaccinated. And I would view that as a booster. So, after you’ve recovered from the infection, and you are able to get a vaccine, I would recommend doing that.

Do you see hospitals United States dealing with the problem of 

 among health care workers in unique ways?

Well, definitely. I think that there will definitely be a lot of carrots out there and examples to try to encourage people to get vaccinated. On the other hand, I’m seeing some sticks starting to emerge. And that is, if you’re not vaccinated, you may not have the same coverage, or the same safety net that vaccinated people do. So, if you’re unvaccinated, you’re going to be at risk of not having maybe timely access to funds that can give you good medical care. Singapore is starting to implement that with no longer paying for COVID-19 related illnesses that occur in people who voluntarily are unvaccinated. And I think you’re also going to see not only problems with health care coverage, but time off of work, etc. At some point, people are going to say, “Look, we can’t keep affording to pay for the amount of death and disability that’s coming about from people who are unvaccinated.” And, also, you have a huge problem of access to health care with people who have non-COVID-19 diseases. One person with COVID-19 can spend months in the ICU, which would prevent 10 or 20, non-COVID-19 cases from going to the ICU, whether it’s for a coronary bypass, or just angioplasty, or getting a cancer procedure. You have 10 or 20 times the number of patients that can’t get care for other serious illnesses. One of the most debated points at this time is lung transplants. These are very rare, and at the moment almost all the lungs can go to COVID-19 patients who weren’t vaccinated. So, should someone who needs a lung transplant that was vaccinated and needs it for a non-COVID reason; should they be at the end of the line for someone who chose not to be vaccinated? These are ethical questions that are starting to be debated. There’s no real good right or wrong answer. I do think at some point, if this virus doesn’t go away, we may have to set up a separate health care arm for COVID-19 patients. In other words, we had that in the past, for example, with TB hospitals. And have infectious disease hospitals and start to allocate resources just for COVID-19. But a large portion of that, and something that is just critical, is to try to get as many people vaccinated as possible. Because this does decrease the chances of developing long COVID, of getting hospitalized, and of dying. Let alone decreases the chances of spreading an infection. If we don’t do that, I don’t feel we’re going to get control of the health care costs. And even getting our health care system back up and running to the point where we can take care of everybody as efficiently and quickly as they need to be taken care of.

And finally, Doctor, in your smallpox article you write that the recent scare highlighted some of the possible dangers of gain-of-function research. Can you describe in layman’s terms for this beat reporter what gain-of-function research is and what lessons should we take from the recent scare?

For me, gain-of-function research is making a virus more dangerous to people. Now, the NIH [National Institutes of Health] may have their own definition. But if you’re doing research and a virus becomes more dangerous in the process that’s problematic. Because if that virus gets released, it will then go throughout the community, and it can cause great harm and sometimes irreparable harm. As you know, there was an article that was written I believe about gain-of-function with the Delta variant or with the SARS coronavirus where they came up with a virus that could completely escape immunity with the idea of “well, then we can know about it, developed vaccines, etc.” Although that’s a dangerous experiment, you could argue that that had some benefit. However, I myself haven’t noticed any change in behavior or vaccines developed or anything else based upon the research. So, if the research isn’t actionable, it shouldn’t be performed. And I don’t think at this point, that you need to have vials that say “smallpox” on them sitting around in freezers. Now luckily, the follow-up is these were actually vaccine vials and not vials that had the active virus. But either way, they were sitting in there, no one knew that they were there, no one knew what was in them, and they had smallpox on the vials. These type of lab mistakes can be made anywhere, and there are repositories that still have the live smallpox virus. I think it should be completely eliminated. You know the genetic code so if you had to make the virus, you could actually print it out and make it, make a vaccine for it, and be good to go. There’s no reason to have these dangerous things floating around in freezers or even sitting in a very secure area. Because as you know, one of Murphy’s Laws is anything that can go wrong will go wrong. And it’s mutating like you can’t believe. But some of the research that I read on the SARS-CoV-2 virus, and in coronaviruses in general, is very scary. You’re talking about making 10 or 20 types of immunity-evading viruses that are made in the lab. Some viruses that are more infectious, etc., and then publishing genetic codes. That’s scary. For example, one of the scariest research projects that has taken place has to do with the avian flu virus. Avian flu seldom affects people. But when it does, it’s about a 60% fatality rate. But it doesn’t infect people. Well, they have made an avian flu virus crossed with a human flu virus that will readily infect people. So, imagine if that code got out or if that virus was made and spread. You’d have a virus that would spread like the flu, and it would have a 60% fatality rate. I mean, it’s just to me baffling why this this type of research is being done. If it has to be done, I prefer it to be done on some remote island someplace with no access to the outside world where if the virus got out, you could hit a red button and just kind of incinerate the whole place. Kind of like what you see on TV and the movies. But it shouldn’t be done in a lab that’s sitting in the middle of a highly populated area. That’s a setup for disaster if you do have a lab leak or something happens. And when I say something happens, it could be an earthquake, it can be hit by a tornado. I mean all sorts of scenarios that may be unplanned and nobody’s fault but still result in a disastrous release of a very dangerous pathogen.

This interview has been edited for clarity and length.

Kevin Kavanagh, MD: “One person with COVID-19 can spend months in the ICU, which would prevent 10 or 20, non-COVID-19 cases from going to the ICU, whether it’s for a coronary bypass, or just angioplasty, or getting a cancer procedure. You have 10 or 20 times the number of patients that can’t get care for other serious illnesses.”

Who Gets the Lung? Vaccinated or Unvaccinated?

One of the groups hesitant to get the COVID-19 vaccine is pregnant women. As 

 last month when the Centers for Disease Control and Prevention (CDC) issued an advisory to health care providers faced with vaccine hesitancy among pregnant women or women who’ve just given birth, misinformation might be fueling that hesitancy. Infection preventionists (IPs) have been urged to fight misinformation about COVID-19 among the public and even their fellow health care professionals. As 

 reported last month, IPs know the reliable sources and are familiar with reading scientific studies and being able to translate those findings to staff in an understandable way.

One of those reliable sources is the Cleveland Clinic, and investigators at the Clinic sought to understand the clinical and immunological implications of COVID-19 on maternal-to-fetal health.

“We know that pregnancy increases maternal risk for COVID-19, but relatively little is known about the long-term consequences of in utero exposure for infants,” said Jae Jung, PhD, director of the Cleveland Clinic Global Center for Pathogen and Human Health Research.

included 93 mothers with COVID-19 and 45 of their infants who were exposed to the virus. The investigators compared maternal blood specimens collected close to the original date of COVID-19 infection and throughout pregnancy and delivery. They studied immune profiles for over 1400 cytokines and other inflammatory proteins from the subjects’ peripheral and cord blood samples.

At delivery, the women had dysregulated levels of many cytokines associated with pregnancy complications, such as MMP7, MDK, ESM1, BGN and CD209. The infants expressed induction of T cell-associated cytokines IL33, NFATC3, and CCL21. While most births were healthy, there was high incidents of certain complications like fetal growth restriction and preeclampsia.

Jung reported, “Our findings show that COVID-19 infection during pregnancy leads to distinct immune alterations in mothers and babies, highlighting how important it will be for long-term follow-up after pregnancy to catch and hopefully prevent any unforeseen long-term health conditions related to prenatal infection.”

The investigators found different immune signatures between pregnant women with asymptomatic and severe COVID-19 infection. The mothers with severe disease had significantly more inflammation and elevated levels of the protein interferon lambda 1 (IFNL1) and its binding receptor, IFNLR1.

“This increase in interferon lambda signaling may help explain why we see relatively little direct transmission of COVID-19 between mother and baby during the period right before or after birth—what we call vertical transmission,” said Suan-Sin (Jolin) Foo, PhD, the study’s co-first author.

There was no robust data suggesting vertical transmission, but the investigators found COVID-19 infection altered the mothers’ immunity at delivery, and gestational COVID-19 exposure alters the immunity of the newborns.

“More research will be necessary to determine if increased expression of IFNL1 and IFNLR1 does in fact block vertical transmission,” Foo said.

Perhaps another reason why pregnant women should get the COVID-19 vaccine? Investigators found COVID-19 infection altered the mothers’ immunity at delivery, and gestational COVID-19 exposure alters the immunity of the newborns.

Immune Changes in Mothers, Infants Linked to COVID-19 Infection

The move toward stronger ties between infection preventionists (IPs) and sterile processors was well on the way before COVID-19 struck. Now, with the COVID-19 vaccines adding to the growing hope that the disease will stop being a pandemic and become endemic, the focus on IPs taking a more active role in the sterile processing continues. La’Titia Houston MPH, BSN, RN, CIC, is a senior IP at a large hospital in Dallas. Houston was one of the presenters at the Cleaning, Disinfection, and Sterilization Conference hosted by the Association for Professionals in Infection Control and Epidemiology—APIC—earlier this month. Her presentation was titled Traceability: High Level Disinfection Challenges Met by Using Available Resources. The main hurdle to providing better traceability, as Houston sees it, is that the technology has not kept up with the demand for traceability pushed by the Joint Commission, the Centers for Medicare and Medicaid Services, and the Association for the Advancement of Medical Instrumentation. Still, IPs and sterile processors can follow the guidelines anyway. “Think outside the box,” Houston tells 

. “There are processes that we can easily use in order to become compliant with whatever it is that they’re requesting from us.”

 What’s the main thing that you want your fellow infection preventionists to take away from your presentation?

One of the things that we want to make sure that everyone understands is that it’s not the time for us to just get so nervous due to the fact that technology has not kept up with the demands or the requirements that the Joint Commission or CMS [Centers for Medicare and Medicaid Services] is requiring when it comes to our sterile processing. One of the things that they are requiring is the traceability of instruments and those instruments are the ones that are high-level disinfected. With that being stated, right now, the majority of all of our sterile instruments are traced and we can see where each instrument 

actually has touched a patient. And once the procedure is completed, those instruments go to sterilization. And there’s already a program that is available for those particular instruments. But for our high-level disinfection instruments, it’s totally different. There are a lot of hands that are interchanging with these particular instruments. It is the patient with the physician, and then once it leaves that area, it goes to a decontamination area which is owned by sterile processing. And then once sterile processing does that particular decontamination of the instrument or the scope or the device that is high-level disinfected, then it has to go into another machine, which actually does the high-level disinfection if you are doing the automated reprocessing. Or you can also do the manual reprocessing whenever it is that if you’re going to do that. [But neither] the automated nor the manual are able to capture that last bit where it’s like, “OK. We’re no longer in the electronic mode anymore.” One of the things that we at our facility had to come up with was a process that was able to capture all the information that is required when it comes to sterile processing, when it comes to high-level disinfection and traceability.

A two-part question. When you talk about some complicated instruments, we here at 

 have published a number of articles about 

. Are those examples of the instruments that you’re talking about? And we here at 

 have also published a number of articles about how important it is for the infection prevention department and the sterile processing department to 

. Is that what you’re talking about as well?

Yes, it is. So, for the endoscope process. Yes. This was one of the things that AAMI, which is the Association for the Advancement of Medical Instrumentation; they are more or less stating that all of the high-level disinfection instruments—and I’m pretty sure it was due to an 

 of Carbapenem-resistant Enterobacterales back in the day, which is CRE…. I’m pretty sure this is the reason why they are now wanting that traceability but not only just for that reason, but also for chemicals. It’s more or less [about] quality assurance. If the chemicals actually are no longer effective as far as when it comes to the high-level disinfection of those instruments, we now have a log of that particular lock number for that chemical that was used on this particular endoscope. And if the endoscope did get used on a patient, then we’re also able to select what patient that endoscope was used on. Now as far as us working hand-in-hand with sterile processing—the department that I work with, our sterile processing department, they are awesome. We work, again, just like they are in my office, and I’m usually in their office. That’s what happened on the ground.

Initially, what I would do is I would just make up a scenario … and I would tell them, “Hey, you know, there’s a recall on a chemical and it was two weeks ago.” And I could actually pull this lot number up of that particular chemical due to the fact that we are in automated reprocessing of the machine itself. I could actually go to them and say, “Hey. I want to see all the patients that were run on this particular lot.” And they would have access in the automated property processor to be able to pull all the information. And they will also be able to go inside of the electronic medical record program that we use and actually pull the patient procedures that were performed, who the clinician was, what date it was performed on, did this patient have a biopsy? That way we can also see if there were any other invasive procedures when they had that particular procedure.

Was this system upgrade begun before COVID-19? Did COVID-19 cause it to stall? Or did it make it accelerate? And where is it now?

The traceability actually was implemented right before COVID-19. We had our Joint Commission survey back in 2016, 2017. And we implemented the traceability program at that time. Because, again, this was one of the recommendations or the requirements based upon AAMI and also CMS and the Joint Commission, which are the ones that will actually come out and do these audits. But when COVID-19 came, it was somewhat of a delay due to the fact that we were still trying to understand: Is COVID in the stool? And do we need to hollow disinfect the endoscopes at least two times versus one? And when science proved that it was not a concern, we more or less just did it once. And we continued with our program then moving forward. But initially, during COVID-19 it was: “OK. We are not going to use these scopes that were reprocessing twice on someone that is not COVID positive so that way we can actually do a traceability on those that are COVID versus those who are not COVID?”

Could you tell us a more about who you might cooperate with?

We collaborate not only with sterile processing, but also the areas that actually are performing these procedures. And so, in our organization sterile processors are not the ones who are actually at the bedside. We do work with the nursing staff. They are also doing all of the precleaning that’s required at the bedside once the procedure is complete. And the transporting of those instruments to sterile processing department at that time. And the endoscopes only have a certain amount of time that they can actually sit without being decontaminated. We work not only with the bedside nurses and the sterile processors, but even with our clinicians, our physicians. They want a timeout before the procedure is even performed because they want to ensure that the scope did pass during the high-level disinfection procedure. This was just another quality check that they wanted. So, it’s not just sterile processing. It’s all of us at one. One big happy family.

And God bless us, everyone, hopefully. Do you ever come across health care professionals who are a little bit wary of this sort of cooperation and how do you win them over?

No. No. Actually, once we implemented the traceability, they were all on board with this. Especially the chief gastroenterologist. He was like “Oh, this would be great.” Due to the fact that we not only implemented the traceability, but we also had started ATP [adenosine triphosphate] testing at that same time. His concerns as far as any of his patients being infected or being contaminated by another patient previous that was using this particular scope, anything that we as infection prevention recommended, and the GI department was receptive to it, he was very much on board with it.

When I first contacted you via email to ask you to do this interview, one of my possible questions began with “Now that COVID-19 is dying, where do we go from here?” And of course, within that short time, there’s talk now of a 

. Hopefully, the fifth wave won’t cause as many deaths because of the vaccines. But I guess I’ll ask this question now: When COVID-19 finally becomes 

Currently, we are purchasing some more automated processes. Not only just endoscopes will have hollow disinfection. The other items that are hollow disinfected in our organization are also the endocavity probes, proctoscopes, or cystoscopes. With that being stated, we are going to implement those same automated processes which were already working in with that particular area, which is our sonography department. And they’re rating, because they have been doing a lot of manual rating as far as when it comes to traceability. But as far as our endoscopes, we will continue with that process, and just start our automated process with our endocavity probes.

Is there something that I neglected to ask you that you think is pertinent that you want your fellow professional infection preventionists to know about your presentation at the conference or this subject in general?

I would just like to just restate that although the technology is not there, that sometimes we choose not to even go forward with a lot of the things that are required or recommended by AAMI or the Joint Commission. Think outside the box. There are processes that we can easily use in order to become compliant with whatever it is that they’re requesting from us.

One quick follow-up question. When you said that the technology’s not there what do you mean? What technology do you see on the horizon that you’d like to see implemented quickly?

OK, so what the Joint Commission and AAMI would like for us to be able to have all of this information in one thing. So, the decontamination: There are some items that are in place where you can scan the scope. But then at the same token, there are a lot of things where the organizations as far as when it comes to patients’ information…. Some of these programs are not secure for them to be able to have access to the patient’s demographics. It’s still a lot of information where you’re having to piecemeal just so that you can get that patient’s information available whenever it’s required when it comes to that traceability. So that you can have the patient information to connect it to that particular item that you’re using on the patient. And there’s no technology that is out there at this moment where it can actually securely be implemented into your electronic medical records.

This interview has been edited for clarity and length

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La’Titia Houston MPH, BSN, RN, CIC: “We work not only with the bedside nurses and the sterile processors, but even with our clinicians, our physicians. They want a timeout before the procedure is even performed because they want to ensure that the scope did pass during the high-level disinfection procedure.”

Traceability: Challenges IPs Face Keeping an Instrument Decontaminated

The innumerable problems with the health care systems in the United States and the rest of the world exposed by COVID-19 continue to keep medical investigators busy, as they peel away layers to find yet more dimensions to the pandemic that stomped about since March 2020. For instance, in the beginning months of the pandemic experts struggled to understand just how the virus spreads. Paula J. Olsiewski, PhD, a contributing scholar at the Johns Hopkins Center for Health Security, told 

, that it “took the [Centers for Disease Control and Prevention and the World Health Organization] a long time to recognize that this virus lingers in the air as an airborne virus.”

But COVID-19 can also spread by droplets. It isn’t either/or.

 Michael Klompas, MD, MPH, a professor of population medicine at Harvard Medical School and an infectious disease expert, and his colleagues argue that division of droplet and aerosol transmission is misguided and needs to be retired.

There are viruses like influenza and mumps that spread by relatively large droplets produced by coughing and sneezing and that fall to the ground relatively quickly. Doctors, nurses, and other clinicians are advised to wear face masks to block the droplets.

Another group of pathogens are aerosolized, spreading via minute respiratory particles that people produce when they talk and breathe. Aerosols tend to stay suspended in the air for much longer periods of times than droplets and travel much farther.

 in October 2020, perhaps the best analogy for COVID-19 would be how cigarette smoke might linger and spread in an enclosed setting, like a bar (back when smoking was allowed in those establishments). In such a situation, 6-foot social distancing offers very little protection.

Measles and tuberculosis have also been held up as two exemplars of viruses that spread this way. Precautions against aerosols include N95 masks, negative-pressure rooms, ventilation and high-efficiency particulate air (HEPA) filters.

Klompas and colleagues argue that research into COVID-19 and the virus that causes it, SARS-CoV-2, demonstrates that people generate the full range of respiratory particles, not either droplets or aerosols. Droplets can stay aloft for long periods like aerosols and respiratory viruses are not picky about the size of particle that they hitch a ride on, although aerosols may account for most transmission, partly because people produce aerosols just by talking and breathing.

The governing factor of transmission, wrote Klompas and his colleagues, is “infectious dose”—the amount of virus a person is exposed to. Infectious dose is product of time and exposure concentration, or how much virus is in the air, the review says.

Poor ventilation can allow virus-laden aerosols to accumulate and increase the exposure concentration and, as a result, the infectious dose. Good ventilation, HEPA filters and ultraviolet disinfection can decrease the amount of virus floating in the air. Time is a factor because the longer a person spends breathing in air that has contaminated aerosols, the greater the infectious dose.

“Source strength”—or how much virus an infected person is spewing into the air in respiratory particles—is another factor in the complicated question, the reviewers explained.

Klompas and his colleagues—Chanu Rhee, MD, MPH, and Meghan Baker, MD, ScD, who are at Harvard with Klompas; Donald Milton, MD, DrPh, of the University of Maryland School of Public Health; and Surbhi Leekha, MBBS, MPH., of the University of Maryland School of Medicine—discuss some of the implications of the current understanding of respiratory virus transmission for infection control policies and programs.

Here is a list of potential policy responses included in the 

Consider creating a uniform set of respiratory precautions for all respiratory pathogens rather than differentiating between airborne vs. droplet pathogens

Consider using higher-level respiratory protection (e.g., N95 respirators) in the care of all patients with active respiratory viral infections

Allocate airborne-infection isolation rooms for pathogens historically associated with long-range transmission and for patients with high viral loads

Reinforce minimum ventilation standards for nonclinical spaces

Consider using higher-level respiratory protection such as N95 respirators for all prolonged, face-to-face encounters when the community incidence of SARS-CoV-2 is high

Consider using upper-room or 222-nm ultraviolet air disinfection or HEPA filters to decrease transmission risk in inadequately ventilated spaces.

Consider retiring the concept of aerosol-generating procedures

Risk-stratify patients instead on the basis of viral load, severity of illness, or anticipated duration of an encounter and proximity to the respiratory tract.

Recent research into COVID-19 suggests that health care systems need to move beyond the idea that pathogen spread happens either via droplets or aerosolized particles. Patients can generate the full range of respiratory particles.

COVID-19 Spread: Droplets or Particles? It’s Not an Either/Or

Americans traditionally go home for the holidays, but public health officials hope to ensure that they don’t bring an uninvited guest—COVID-19—along with them. Nobody’s forgetting what happened last holiday season, as the vaccines stumbled out of the gate while health care systems dealt with a 

. This year, about 60% of the US population has gotten 2 doses of the vaccine, but medical experts warn that that might not be enough on two counts. First, while the Centers for Disease Control and Prevention (CDC) appears to be 

 a fixed vaccination rate needed to ensure herd immunity—it has varied throughout the course of the pandemic from 70% to 85%—medical experts say that there’s still too many Americans who remain unvaccinated. Second, the definition of being 

 may be shifting to having 3 doses of the vaccine.

, some experts claim. The CDC last Friday 

 that agency officials hope will streamline the message. Under the new guidance, anybody 18 or older can get a booster if they’re 6 months out from getting the double-dose of either the Pfizer/BioNTech or Moderna vaccines. Those who got the single-dose Johnson & Johnson vaccine, can get a booster 2 months out. In addition, everybody can mix and match vaccines.

“After critical scientific evaluation, today’s unanimous decision carefully considered the current state of the pandemic, the latest vaccine effectiveness data over time, and review of safety data from people who have already received a COVID-19 primary vaccine series and booster,” Walensky said in a statement. “Booster shots have demonstrated the ability to safely increase people’s protection against infection and severe outcomes and are an important public health tool to strengthen our defenses against the virus as we enter the winter holidays. Based on the compelling evidence, all adults over 18 should now have equitable access to a COVID-19 booster dose.”

In addition, Walensky wants Americans 50 and older to get the booster shot. The CDC 

 on booster shots says that “people ages 50 years and older should get a booster shot. The risk of severe illness from COVID-19 

 and can also increase for adults of any age with underlying medical conditions.”

CDC adviser Matthew Daley, MD, of Kaiser Permanente Colorado, tells the 

 that “It’s a stronger recommendation. I want to make sure we provide as much protection as we can.”

Confusion surrounding just who should get COVID-19 booster shots addressed in latest guidance from the Centers for Disease Control and Prevention. 

COVID-19 Booster Shots Urged for Anyone 50 or Above

By now, almost all medical experts agree that COVID-19 is here to stay. It’s endemic. By now, many medical experts expect that humans will deal with COVID-19 the way we deal with other seasonal maladies such as the cold or influenza. Kevin Kavanagh, MD, agrees that COVID-19 is endemic (he 

 back in January), but warns that it’s still much more problematic than the cold or flu. Yes, the COVID-19 vaccines should ensure—as we face a 

 of COVID-19—that not nearly as many people will die from the disease as did this time during last year’s holiday surge. Kavanagh points out that “death is a pretty low bar for public health. Long COVID, mild [COVID-19] illness can cause devastations to our society.” These could come back to haunt society and overburden the health care system in the decades to come. There’s also the matter of animal infection. That means that the virus has innumerable hosts in which it can thrive and mutate, possibly into an iteration that can shake off the antibodies created by prior infection or vaccines in humans. For these problems, Kavanagh uses the compound interest analogy in banking. “When you look at it short term, it doesn’t seem like it’s doing much. But long term, this may be a real problem and a real toll to our society.”

I’m going to ask you to gaze into your crystal ball again, Doctor Kavanagh. You’ve written about a 

. And you’ve written many articles about the importance of booster shots. Why don’t we just start there?

Well, I think this virus is entering into a phase of becoming endemic. And we need to adjust our behavior. And one of those is this, we need to get a booster shot. Now boosters may actually be just a third course of the vaccine, and it may be part of the normal vaccine course that we’ll have in the future. But at least for right now, it is of utmost importance that people get boosters. If you look at some of the countries in Europe, some of these countries are highly vaccinated. For example, Iceland—also, Ireland and Gibraltar—where over 90% of the adults are vaccinated. Yet they’re going through huge surges. And what’s happened there is two 

things: one is that these were some of the countries to first get the vaccine and to get their populations vaccinated. And unfortunately, they have not been very efficient at rolling out boosters. Some of them are just doing it now. And that’s allowed the COVID-19 virus to reemerge as immunity has waned. The other factor is when we talk about people who are infected with COVID-19. And whether or not you can get herd immunity, and you talk about numbers of vaccinations within the community, you need to realize that, to a large extent, it’s not homogenous on how people are distributed who are vaccinated and not. Those who are not vaccinated, tend to clump or gather together in their own social groups, which I like to sometimes call death cults because they go around spreading disinformation regarding vaccines. But in those groups and in those meetings and gatherings, you don’t have any herd immunity. They will readily spread the virus. And this is indeed one of the big problems that I think that we have. One is just because 90% of a country is vaccinated doesn’t mean that virus won’t spread and won’t have outbreaks, because we have whole segments of our society which are anti-vaccine. And that is I think posing a huge problem. And of course, as we’ve discussed before, you’ve got the problem of the virus being in animals and animal hosts. And you can get virus spread from people to animals, and also the reverse. Just last week, there was report of three snow leopard deaths at the [Lincoln Children’s Zoo] in Lincoln, Nebraska. And this was from COVID-19. And, also, there’s an updated report out of—I believe it was Iowa—where 80% of the whitetail deer were COVID-19 positive. And this follows a report which we discussed in 

, where the deer from Illinois, Michigan, Pennsylvania, and New York had a positivity rate of around 40% for SARS-CoV-2. This virus unfortunately has also found animal hosts and that’s going to make it even more difficult to eradicate. I think at this point we need to plan to live with the virus and to adjust the way that we live so that we can do so as safely as possible.

What is it with the snow leopards? You told me about a case of snow leopards getting it 

Yes. And the large cats tend to be very susceptible to the virus. And this includes small cats and pets. And it’s possible to pass the virus between the handlers and the people who take care of the animals. You know, these cats will cough and sneeze, they don’t wear masks, and they can easily spread the virus to those people who are feeding the cats or who are within a closed space, especially during the winter when they may be indoors. You know, they have indoor settings in the zoos where the caretakers are in with the animals. And as we’ve discussed many times before, this virus can aerosolize. Gorillas and other primates are very susceptible to the virus as are minks and guinea pigs. There’s a whole variety of animal hosts that this virus has besides man, which again, is going to make if very problematic in getting it eradicated. It’s also a little scary because, as you know, on an evolutionary scale, this virus doesn’t need people to survive. And so that means we need to really take this virus seriously.

Does the virus actually kill the animals?

Well, with the snow leopards and the larger animals, yes. On some of the smaller animals, they can get sick, but it may not kill them. For example, we haven’t heard of a large amount of deer deaths that have been occurring. The deer apparently live with COVID-19 quite well, but, yet rapidly spread it amongst the herds. And that’s actually very problematic, because if it finds a host that it doesn’t make sick, but yet it can mutate and change and then reinfect other animals and plus mankind, that is one of the worrisome scenarios that could take place. It’s something that we need to watch very carefully. At some point the Department of Agriculture may advise on culling the deer herd to try to decrease the numbers so that [humans are not in as close contact with deer] and it may not be as easily spread between areas and regions. That to me will be a warning sign that this may be something that is becoming more serious.

, the analogy between COVID-19 and influenza doesn’t pan out. 

. When you hear people say if we get 60% of the population with both doses of the vaccine, we’re at least not going to get the death rate that we’ve gotten before. Do you agree with that? And do you think that’s germane to the discussion?

Well, I agree with it, but I’m not sure how germane this should be as a major goal, because death is a pretty low bar for public health. Long COVID, mild [COVID-19] illness can cause devastations to our society. And one of the things that frustrates me is that people really do not understand math. They don’t understand long-term effects. It’s mainly short sighted and their views are very simplistic. And let’s compare SARS-CoV-2 to smallpox. Smallpox will come into a community. It’s a DNA virus. It doesn’t mutate, doesn’t change very rapidly. And it will have a 30% fatality rate. Other members of the community tend to become immune, oftentimes for life with long-term immunity. It’s almost like—if you talk about banking—it’s almost like going out and paying for something in one lump sum. You pay for it. You get it over with. SARS-CoC-2 is more like compound interest. Very difficult to understand. It may just be a small toll in the beginning. And when I say small tool, I’m talking about a 1% fatality rate, maybe 5% or 10% disability rate, which is really a pretty large tool, but compared to smallpox, it’s not as large. But this virus is mutating, immunity’s waning, and it’s coming back year after year, wave after wave. I mean, who would have thought we’d be entering our fifth wave of this virus, which really makes the idea of herd immunity just becoming absolutely discredited. We’ve had too many people exposed to the virus. We have too many people [unvaccinated] And all indications are immunity is not long lasting. So, that we have to keep either getting boosters, or we have to keep up our anti-viral strategies, so that we can try to slow down this pandemic. At a minimum, we’ve got to keep our health care system from being overrun. We can’t have 14.5% increases in Medicare B premiums every single year. I mean, that’s at a minimum. And then we need to look at trying to get the rates of infection down low enough so that people feel more secure in going out and mingling in society, maybe going indoors, shopping, etc. And right now, we’re not there. People are still fixated on droplet spread. They have not upgraded ventilation to any big degree. At least in my region where I live, you don’t see a lot of people wearing masks. And there’s just a tremendous amount of misinformation, both on the severity of the disease, and the effectiveness of both vaccines and of wearing masks. This to me is a setup for disaster. And again, it gets back into more of the compound interest model. When you look at it short term, it doesn’t seem like it’s doing much. But long term, this may be a real problem and a real toll to our society.

Kevin Kavanagh, MD: “The deer apparently live with COVID-19 quite well, but, yet rapidly spread it amongst the herds. And that’s actually very problematic, because if it finds a host that it doesn’t make sick, but yet it can mutate and change and then reinfect other animals and plus mankind, that is one of the worrisome scenarios that could take place.”

Animal Kingdom: COVID-19 Has So Many Hosts to Choose From

On September 24, Rochelle Walensky, MD, the director of the Centers for Disease Control and Prevention (CDC) took the highly 

 of overruling the CDC’s Advisory Committee on Immunization Practices and made COVID-19 booster shots available for health care professionals (HCPs) on the frontlines of the pandemic. The move 

 and speculation as to why Walensky took that action, but perhaps a new study on vaccine uptake among HCPs might shed some light. By mid-September vaccine uptake among HCPs had stalled significantly, according to a huge 

In what’s being touted as the most comprehensive examination of the problem of vaccine hesitancy among HCPs, investigators with the 

 collected data from 2086 health care facilities with about 3.3 million HCPs. Vaccine uptake among this population seemed to be going well, rising from 36% to 60% between January 2021 (when the rollout began with a 

) and April 2021 (after the initial rollout problems were fixed).

The study states that “as of September 15, 2021, among 3,357,348 HCP in 2,086 hospitals included in this analysis, 70% were fully vaccinated. Additional efforts are needed to improve COVID-19 vaccine coverage among HCP.”

, infection preventionists (IPs) will most likely 

. IPs often take the lead in vaccination efforts in hospitals and other health care settings—not only for COVID-19, but also for 

 study arrives as medical experts and the mainstream media focus on the waning of the COVID-19 vaccines that brings both the CDC and the Food and Drug Administration (FDA) close to authorizing that COVID-19 booster shots be 

. It also comes as the holiday season fast approaches and both the CDC and FDA face criticism about 

 when it comes to the importance of COVID-19 booster shots that would help fuel a 5th wave of the pandemic that seems to have already begun.

Hannah Reses, MPH, the lead author of the 

 that “our analysis revealed that vaccine coverage among U.S. hospital-based HCP stalled significantly after initial uptake. Additional efforts are needed now to improve HCP vaccine coverage and reduce the risk of SARS-CoV-2 transmission to patients and other hospital staff.”

To underscore that IPs will most likely play a crucial role in those efforts, the press release also contains a statement by Ann Marie Pettis, BSN, RN, CIC, FAPIC, the president of the Association for Professionals in Infection Control and Epidemiology (APIC), the lobbying organization representing IPs. (

“Hospital-based HCP play a critical role in influencing community uptake of vaccines and are also at increased risk of both acquiring and transmitting COVID-19 in health care settings,” Pettis says in the press release. She adds that “the findings from this analysis suggest that vaccine mandates as well as investment in additional educational and promotional activities could help increase vaccine coverage among HCP to better protect public health.”

But vaccine mandates must be handled with care. As 

 reported in its October issue, there are 

 of HCPs at a time when there’s already a 

CDC investigators looked at HCP vaccine uptake at children’s hospitals, short-term acute care hospitals, long-term acute-care hospitals, and critical access hospitals.

Vaccine uptake for HCPs was highest at children’s hospitals with a confidence interval (CI) of 95% between 75.8 and 77.3, followed by short-term acute care hospitals (95% CI: 70.1, 70.2) long-term acute care hospitals (CI: 68.2, 69.3) and critical access hospitals (95% CI: 63.8, 64.3). Uptake was highest in health care facilities in metropolitan counties (95% CI: 70.9, 71.0), followed by rural counties (95% CI: 64.8, 65.3), and non-metropolitan urban counties (CI: 63.1, 63.5).

“HCP who did not want to be vaccinated often reported low trust in regulatory authorities and the government; notably, trust in information received from medical professionals was higher, suggesting an important role of professional societies and medical organizations in enhancing vaccine uptake among HCP and combating misinformation that might impact uptake,” the study states.

 relates that peer education was one of the methods used in a large hospital system to bring HCP vaccination rates up to 90%. In that study, investigators with Narayana Health in Bengaluru, India, used role models. First in line to get vaccinated were senior physicians, and health care facilities administrators. They also relied on the adage that when it comes to battling vaccine hesitancy, a picture might be worth a thousand words.

“Photo booths were erected where everyone getting vaccinated was encouraged to take themselves photographed and use it as their display profile in different social media platforms,” the study states. “This seemed to reassure the other HCWs and may have played an important role in the high uptake seen in all these institutions.”

 study by the CDC investigators notes that the ramifications of strong COVID-19 vaccine uptake among HCPs can extend far beyond the walls of a hospital.

“HCP play a critical role in advising patients and communities and influencing vaccine decisions,” the study states. “Several studies have found that vaccinated HCP were more likely to recommend vaccination to patients, friends, and family, suggesting that broader uptake of the COVID-19 vaccine among HCP might lead to improved coverage in the general population. HCP are also at increased risk for acquiring and transmitting COVID-19 in health care settings.”

Health care professionals were getting vaccinated at a steady clip. Then came the drop-off. Now, only about 70% are fully vaccinated. Infection preventionists to the rescue?

COVID-19 Vaccine Uptake Among Health Care Workers Hits Wall

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

Click here to download the December BOTM.

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. 

Bug of the Month: I Think I’m Scarier Than COVID-19

KEVIN KAVANAGH, MD, is the founder of the patient advocacy group Health Watch USAsm and a frequent contributor to 

The news of COVID-19 surging in Eastern Europe is a dire warning to the United States. Austria with 65% of its population fully vaccinated and Germany with 68% of its population fully vaccinated are entering a fifth 

. The vast majority of vaccines administered in Germany were Pfizer/BioNTech along with Moderna. Few individuals in Germany have 

. Austria just started to rollout boosters on 

Even Iceland and Ireland with over 90% of their adult population fully vaccinated are 

. Ireland has had a significant delay in 

This does not bode well for the US which has only 59% of its population fully vaccinated.

Because of waning immunity Israel started offering boosters to those over 60 years of age on July 30, 2021, and then extending this to all adults over 50 a 

. By August 28, 2021 children as young as 12 were being encouraged to 

In contradistinction, the US offered boosters starting on October 21, 2021 to those over the age of 65 and those having underlying medical conditions or at high risk of 

. At the same time many policy advisors were downplaying the risks of COVID-19 in individuals who were not at risk for hospitalization or death. This strategy ignored the fact that many of the so called “mild” cases often progress to long COVID-19 or can later develop cardiac abnormalities as a result of 

The delayed and restricted use of boosters in the US was the result of guidance by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) and blunted an effort by the White House to offer boosters to everyone. The CDC at one time considered changing the definition of “

.” There is growing evidence that fully vaccinated should be defined as having 3 doses of an mRNA vaccine. Some states, including California and Colorado, have overridden CDC guidance and are currently offering boosters to all 

Not only is the US at risk because of absent or incomplete immunization in a large percentage of its population, but about 1 in 30 individuals have an immune deficiency. Those with organ transplants and hematological malignancies are at a significant risk of not having protective immunity after vaccination. Only about 20% of solid organ transplant patients have measurable antibodies after a second vaccine dose. The good news is that a Moderna booster (third vaccine dosage) has been reported to produce an immunological response in 49% of those who did not develop a response after the 

It also needs to be remembered that vaccination rates and the percentage of dead-end hosts which will stop viral spread are not homogeneously distributed throughout a state or country. The unvaccinated are part of a social group with similar thinking and tend to congregate together promoting viral spread (and mutations) even in regions with high vaccination rates.

The low percentage of the US population who have received at least 2 doses of an mRNA vaccine is not only an embarrassment but also a reflection of the dysfunction in our country. It is placing our nation in great peril. We have fallen behind 50 other countries, including third world countries such as Cambodia where 80% of the population is “fully vaccinated.” It is apparent that a booster is also needed in most of our population to protect against infection and mitigate spread. Unfortunately, our nation is set up for another surge of Delta over the winter holidays. Scott Gottlieb, MD, the former head of the FDA, stated that “the confusing message around the boosters … may end up being one of the biggest missed opportunities in this pandemic…. [W]e now see very clear evidence of declining vaccine 

Finally, the CDC needs to provide comprehensive real-time data on the status of the COVID-19 pandemic in the US. Currently, data on immunization status of patients with infections and hospitalizations is over 

. We also need data on reinfections and expanded viral sequencing in order to detect the emergence of variants. This will enable us to not only better predict the trajectory of the pandemic but to regain the trust of the public by giving more accurate guidance which can have a profound impact on their daily lives.

The toll of this pandemic on the US has been profound. Over 750,000 deaths directly related to COVID-19, along with many other non-COVID-19 patients who have not been able to obtain timely medical care for potentially life-threatening diseases because hospitals were filled. The strain also is placing an economic toll on many, exemplified by the Medicare announcement of an over 14.5% increase in Part B 

The evidence is clear, and the path evident, we must expand our efforts to stop viral spread, including the upgrading of indoor ventilation along with the use of masks by all in public settings and expansion of home testing. But above all we need to offer boosters to all adults who are more than 5 to 6 months post receiving an mRNA vaccine.

There is growing evidence that fully vaccinated should be defined as having 3 doses of an mRNA vaccine. 