Racial disparities in health care has been a problem for 

. Last week, Rochelle Walensky, MD, the director of the Centers for Disease Control and Prevention (CDC), went even further, calling those disparities 

 that represents a serious public health threat. Walensky noted that the COVID-19 pandemic helped to underscore health disparities that have become entrenched.

Walensky said in her statement that the “disparities seen over the past year were not a result of COVID-19. Instead, the pandemic illuminated inequities that have existed for generations and revealed for all of America a known, but often unaddressed, epidemic impacting public health: racism.”

Today top officials of the Association for Professionals in Infection Control and Epidemiology (APIC) applauded Walensky’s move.

In a statement, Ann Marie Pettis, BSN, RN, CIC, FAPIC, APIC’s president, and Devin Jopp, EdD, APIC’s CEO, said that “APIC stands ready to work with the CDC and the public health community to confront health inequity and health disparities in our nation. APIC will be focused on conducting research on how health equity and health disparities should be addressed in the field of infection prevention and control including designing interventions that can be deployed nationwide to reduce racial disparities in healthcare-associated infections and improve outcomes.”

Walensky outlined some of those steps in her statement last week.

 of social determinants on health outcomes, expand the body of evidence on how racism affects health, and propose and implement solutions to address this.

 in racial and ethnic minority communities and other disproportionately affected communities around the country, establishing a durable infrastructure that will provide the foundation and resources to address disparities related to COVID-19 and other health conditions.

 to foster greater diversity and create an inclusive and affirming environment for all.

 as part of our ongoing commitment to serve as a catalyst for public and scientific discourse around racism and health, and to be accountable for our progress.”

Echoing Walensky’s call, Pettis and Jopp said that in their statement that “health disparities and long-standing gaps in health care equity have become even more apparent as we have watched the pandemic’s impact within certain segments of our population. Black, Indigenous, and people of color have contracted, been hospitalized, and died from COVID-19 at 

Walensky in her statement last week said that “confronting the impact of racism will not be easy. I know that we can meet this challenge. I know that we can create an America where all people have the opportunity to live a healthy life when we each take responsibility and work together. I am committed to this work. I certainly hope you will lean in and join me.”

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“APIC will be focused on conducting research on how health equity and health disparities should be addressed in the field of infection prevention and control including designing interventions…”

APIC Answers CDC’s Call to Take on Racism in Health Care

In the United States, life for some is rapidly returning to normal with states reopening and people of all walks of life being liberated with vaccinations. The vaccines have been a godsend, they have been reported to be highly effective in the prevention of illness, up to 95% in clinical trials and 90% in real world testing of 

A recent study now affirms that the majority of those previously infected with COVID-19 have lasting antibodies for at least 6 months, 

. Another study has found the vaccine to be 100% effective (although in medicine almost nothing is 100%) in preventing 

. This is welcome news, since according to Anthony Fauci, MD, the director of the National Institute of Allergy and Infectious Diseases, teenagers can be a driver of COVID-19, especially when engaging in activities such as 

Thus, both natural and vaccine immunity appear to provide excellent protection against COVID-19. At least for the original strain or wild-type of the virus.

One must ask, why are some sounding the alarm? Fauci recently has stated that the COVID-19 case rate has creeped up from around 30,000 to 40,000 cases per day to 60,000 cases per day. And he warns we do not want to declare victory prematurely because of the 

Variants which are of special concern contain one of two new spike protein mutations which can evade immunity. These mutations are suspected to empower the virus with the ability to reinfect those with natural immunity. The first is the California variant’s mutation which is suspected to have caused reinfections in California and a resurgence of 

. The second type of spike protein mutation is the E484K or “EeK” mutation. This mutation is found on the South African, Brazilian and New York variants.

Fauci recently testified that previous infection with the wild-type of virus provides “no protection” with the 

. In addition, the Brazilian variant has caused a huge surge in cases in the Amazon city of Manaus, Brazil, during a time that three quarters of the population was carrying COVID-19 antibodies from a 

. To make matters worse a double mutation variant has been found in India and now has been detected in 

. This variant has the escape mutations of the California variant and another one which is very similar to the “EeK” mutation, the implications of this are not good. All of these variants appear to be more infectious and lethal than the original wild-type of coronavirus.

It is also becoming apparent that reinfections can occur in those who have been vaccinated. A recent report from Denmark studied PCR test results by matching individuals with positive tests that were at least 3 months apart. The study found that previous SARS-CoV-2 exposure protected against reinfection 80.5% of the time, but this dropped to 47% in those 

. Severity of illness was not controlled for so a number of these individuals may have had a mild or asymptomatic infection with a blunted immunological response.

Post-vaccination infections can also occur. A recent report from Michigan illustrates that vaccination is not a free pass to return to normal. The 

 reported that the State Health Department has confirmed that 246 vaccinated residents have become reinfected and diagnosed with COVID-19. All patients developed a positive test 14 or more days after vaccination. Three of these patients have died and of the 117 where hospitalization status was known, 11 were 

. However, it is also noted that post-vaccinated infections were more likely to be asymptomatic or mildly symptomatic compared to infections in unvaccinated individuals. In addition, these infections occurred in a state where over a third of the population, almost 3 million residents, have been vaccinated.

But what is worrisome, is that Michigan has gone through a very large surge which appears to equal that of the one they experienced over the holidays. In addition, the Brazilian variant has been recently detected 

Post vaccination infections have also been observed with the South African variant. The Johnson & Johnson vaccine was field tested in South Africa with 6000 individuals where 95% of the cases were found to be due to the South African variant. The vaccine’s efficacy rate 

.(11) An analysis by the United Kingdom’s Scientific Advisory Group on Emergencies (SAGE) concluded that previously infected or vaccinated individuals had a 10-fold decrease in effectiveness of antibodies to the South African variant. This “translates into a potential 30% drop in 

.” However, this is still well above the 50% efficacy goal initially set for COVID-19 vaccine approval. However, post-vaccination infections can still occur.

Disturbingly, no one is tracking reinfections and there is an unknown numerator and denominator. Nor are we doing nearly enough viral sequencing to track the emergence or spread of variants. In this respect, we are flying blind.

Infection preventionists (IPs) are now faced with delivering a difficult message. It is much easier to advocate for vaccinations which prevent disease, than it is for vaccinations which lessen the severity of disease or reduces your chances of becoming infected; especially when advocating to individuals with all or none thinking. To many, reinfections mean the vaccine is not effective and, thus, they do not need to take it. Conversely too many have concluded, that if the vaccine is effective, then why do they still need to wear a mask?

The science behind this conundrum has found that vaccinations will profoundly decrease (by almost 95%) your chances of developing a symptomatic infection from the wild-type of virus. Even just one dose, of a two-dose vaccine, can reduce infections from the wild-type of 

 In addition, research has also shown vaccinations can blunt the illness of the South African variant which has the E484K escape mutation, greatly decreasing hospitalizations and deaths. The Moderna vaccine can boost antibody levels 6.5 to 9 times over that achieved by a natural 

. Theoretically this will provide enough protection to mitigate the disease caused by EeK (E484K) variants.

So, what do IPs tell patients and coworkers? I would suggest using a metaphor. If you do not get vaccinated, you are much more likely to develop COVID-19. Vaccination makes this less likely to happen, but it does not provide complete protection. Similar to driving, if you drink and drive you are more likely to be in a severe car accident, than if you follow public health advice and use a designated driver. But this does not mean that your designated driver cannot be in a car accident. Accidents can still occur.

And everyone needs to wear a mask and follow public health advice after vaccination. You can still become infected with variants and infect others; and even if you become less sick, you can still develop severe post COVID-19 sequela, such as long-haulers syndrome. Granted you are less likely to die, but this is a very low bar to measure success and health of a patient. Finally, even if you are asymptomatic with COVID-19, you need to remember that the more the virus spreads the more it will mutate, potentially into a variant which can totally evade the vaccines.

Vaccine boosters targeted against the E484K variants are being developed and tested by our pharmaceutical giants. Until then, our current vaccines will help slow the spread of this variant. The take-home message for patients is simple, continue following public health advice. If your football team is ahead in the final quarter, no one turns off the TV during the last 4 minutes of the game. Get a vaccine and continue wearing masks.

Infection preventionists (IPs) are now faced with delivering a difficult message. It is much easier to advocate for vaccinations which prevent disease, than it is for vaccinations which lessen the severity of disease or reduces your chances of becoming infected.

COVID-19 Variants Make Road to Normal a Bit Rocky

Things are a bit precarious right now with COVID-19 cases rising in some areas and a race to vaccinate as many as possible. Over 167 million doses have been administered, with 62 million people fully vaccinated within the United States. Of the total population, this accounts for 18.8%, which is a very exciting milestone. Many of the vaccine manufacturers are working to ramp up production as well as 

Effectiveness of mRNA COVID-19 Vaccines in Preventing Infection

One of the big questions we’ve had since the announcement of efficacious vaccines is—will this protect against infection as well as disease? While they are effective against severe disease and hospitalization, what about asymptomatic infection? This continued question is not easy to answer but one that we’re increasingly coming up against.

 (MMWR) assessed both the Pfizer and Moderna vaccines against SARS-CoV-2 infection in health care workers, first responders, and essential workers.

Coined the HERS-RECOVER study, this longitudinal cohort was across 8 locations in the United States that performed surveillance in vaccinated individuals for not only symptoms, but participants also “self-collected a midturbinate nasal swab weekly, regardless of COVID-19–associated illness symptom status and collected an additional nasal swab and saliva specimen at the onset of COVID-19–associated illness.” Investigators noted that “among 5077 participants, those with laboratory documentation of SARS-CoV-2 infection before enrollment starting in July 2020 (608) or identified as part of longitudinal surveillance up until the first day of vaccine administration (240) were excluded. Another 279 were excluded because of low participation (i.e., failed to complete surveillance for ≥20% of study weeks and did not contribute COVID-19–associated illness specimens). Overall, 3950 participants in the vaccine effectiveness analytic sample were analyzed.”

The participants included physicians, nurses, health care personnel, and 62% were female. 75% of the participants received at least one dose during the study period and overall, 5.2% were diagnosed with SARS-CoV-2 infection via RT-PCR.

“During the 116,657 person-days when participants were unvaccinated, 161 PCR-confirmed infections were identified (incidence rate = 1.38/1,000 person-days). During the 13 days after first-dose or second-dose vaccination when immune status was considered indeterminate (67,483 person-days), 33 PCR-confirmed infections were identified and excluded from the outcome. Two sources of partially immunized person-days were reported.”

After studying these frontline responders for 13 weeks across the 8 locations, these 3950 participants helped shed some important insight into protection against infection. Under these real-world conditions, those fully vaccinated had 90% protection against infection regardless of symptoms and even partial immunization yielded 80% protection against infection. More research will be needed, but this is a very promising beginning.

CDC SARS-CoV-2 Fomite Transmission Update

This week the Centers for Disease Control and Prevention (CDC) released a new scientific update on surface transmission and indoor community environments. The topic of “over cleaning” and “hygiene theater” has been used a lot in recent months as we learn more that fomite transmission is possible, but generally lower risk. From the infection prevention and epidemiologist perspective, it’s important to note that when dealing with a novel respiratory pathogen, we treat it like previous ones—fomite transmission is possible and more common in influenza, RSV, and was a concern during previous coronavirus outbreaks.

Hygiene theater and the focus on over cleaning did become an issue as people were bleaching groceries and quarantining mail, but the bigger concern is now how we communicate this. It’s still important to clean and disinfect and use hand hygiene. The CDC reiterates that “people can be infected with SARS-CoV-2 through contact with surfaces. However, based on available epidemiological data and studies of environmental transmission factors, surface transmission is not the main route by which SARS-CoV-2 spreads, and the risk is considered to be low. The principal mode by which people are infected with SARS-CoV-2 is through 

exposure to respiratory droplets carrying infectious virus

.” Cleaning and disinfection are still recommended within 24 hours after an infectious person has been present in an indoor community. The CDC also reiterated that source control (masking) is a great way to avoid contamination, just like hand hygiene and other efforts to avoid bioburden.

Those fully vaccinated had 90% protection against infection regardless of symptoms and even partial immunization yielded 80% protection against infection.

Hot Topics in Infection Prevention: Vaccines Block COVID-19 Infection

’s wide-ranging coverage of the infection prevention and control world. Everything from interviews with known opinion leaders, to the news that infection preventionists and other health care professionals can use on their jobs.

Overprescribing of Certain Antibiotics Might Cause 

The study comes at a time when—despite all the attention and health care resources being thrown at COVID-19—medical experts have begun to turn a wary eye toward bacteriological pathogens.

If COVID Could Talk … But It Does, at the Cellular Level

Joachim L. Schultze, MD: “We decided that the knowledge that we have in immunology, as well as in genomics and single-cell technology, should be used to understand this new disease.”

Infection preventionists are now faced with delivering a difficult message. It is much easier to advocate for vaccinations which prevent disease, than it is for vaccinations which lessen the severity of disease or reduces your chances of becoming infected.

Take 5 minutes to catch up on Infection Control Today®’s highlights for the week ending April 9.

Weekly Rounds With Infection Control Today

What goes on on the cellular level when it comes to COVID-19? To find out, 

 reached across the Atlantic Ocean to the University of Bonn in Germany. Joachim L. Schultze, MD, is a professor of genomics and immunoregulation at the Life & Medical Sciences Institute at that university. Schultze is also the coordinator of the German COVID-19 OMICS Initiative, which seeks to integrate biological and science data with social sciences and the humanities. Schultz’s research focuses on understanding the range of severity of COVID-19 symptoms through an analysis of single cells. His latest research appears to indicate that proteins such as TLR3 and IFN I and II may be useful indicators of disease severity and/or an area to explore for possible therapies. His research also seems to indicate that the heterogeneity of COVID-19 may have to do with three factors: the host, the environment, and the virus itself. Schultze seems to have ruled out the virus. In a wide-ranging discussion with 

, Schultze also discusses the significance of neutrophils in immune response to COVID-19, the immune system’s role in COVID-19 long-haulers, and how the single-cell analysis that can be useful in the diagnose and treatment of COVID-19, can also be used to diagnose, treat, and potentially prevent other kinds of bacterial, viral, and fungal infections.

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Joachim L. Schultze, MD:  “We decided that the knowledge that we have in immunology, as well as in genomics and single-cell technology, should be used to understand this new disease.”

One of the steps hospitals and other health care providers wanting to contain the spread of 

) should be to drastically curtail the prescribing of carbapenems and third- and fourth-generation cephalosporin antibiotics. Patients with 

 are almost twice as likely to have been given those medications, according to a 

. Investigators with Australian National University conducted a meta-analysis of studies from various sources with the data collected from January 1, 2013 to December 31, 2020. In all, the meta-analysis looks at 21 studies published since 2013, as well as 16 studies identified in earlier reviews.

“Eligible studies were those conducted among adult hospital inpatients, measured exposure to individual antibiotics or antibiotic classes, included a comparison group and measured the occurrence of HCFA-CDI [healthcare facility-associated 

 infection] as an outcome,” the study states.

 is the leading cause of health care-acquired infections (HAIs) in modern industrialized nations and is the most common cause of diarrhea in health care facilities. Most of the data were collected from studies conducted in North American and Europe, and the risk that 

 poses may differ from one region to another. It will “depend on the local prevalence of strains that are resistant to the particular antibiotic and a certain degree of heterogeneity is therefore to be expected,” the study states.

What investigators call “modest associations” with 

 were also observed with “quinolones (predominantly fluoroquinolones), lincosamides (namely clindamycin), 2nd generation cephalosporins, and beta-lactamase inhibitor combination penicillin antibiotics.”

Investigators say that one of the limitations of their approach was that antibiotic prescribing and the onset of 

 were not always recorded in an adequate manner, so cause and effect were hard to track. “This could explain the associations found for antibiotics used to treat CDI such as vancomycin and metronidazole (glycopeptide and nitromidazole classes, respectively), although this could not be established in this review, and both are able to incite CDI,” the study states. “Future studies should clearly report the parameters of exposure measurement, including all sources of information on exposure, as it was often unclear particularly in studies with a longer exposure window whether in-hospital prescription only was recorded, or whether prescription in the community setting was included. Information on dose-response relationships is generally lacking and studies investigating the risk of HCF-CDI associated with the timing and duration of antibiotic exposure are needed.”

The study comes at a time when—despite all the attention and health care resources being thrown at COVID-19—medical experts have begun to turn a wary eye toward bacteriological pathogens. The recent launch of an effort by the Centers for Disease Control and Prevention (CDC) to improve antibiotic overprescribing 

 for some conditions and some medicines by 2025, underscores the concern about what havoc bacterial superbugs will wreck in the 

—a possible occurrence that most people don’t want to think about, but which health care providers must be on the lookout for. And just as infection preventionists (IPs) manned the frontlines against COVID-19, they will almost certainly be a part of antibiotic stewardship programs to help stave of any possible bacteriological damage.

As Arjun Srinivasan, MD, the CDC’s associate director for health care association infection prevention programs recently 

: “I think that the key is for the infection preventionists to make sure that they’re connected with their stewardship programs. And I think in almost every instance where I interact with hospitals, that connection is already present, and it’s very strong. But I think these data do help us understand that there are some great opportunities here.”

. (The CDC divides the threat level of the pathogens—aside from urgent, there’s also “serious,” “concerning,” and “watch” lists.)

Overprescribing of Certain Antibiotics Might Cause C Diff

Early in the COVID-19 pandemic, mysteries abounded about this ninja-like disease striking a defenseless populace seemingly out of the blue. Who was most at risk? What were the best steps for protecting the vulnerable—when those were identified? Epidemiologic data on transmission were scarce, consisting mainly of small case reports, cohort studies, and 

.A review of 40 studies suggested 44% of COVID-19 cases worldwide were nosocomial, but many hospitals were still coming to grips with what exactly they could do to 

As the pandemic took hold, some experts warned that rates of health care-acquired infections (HAIs) might rise due to patients with the virus being sicker, with longer lengths of stay, and other COVID-19–related factors. Over time, however, universal masking, “extreme” hand hygiene, and other intensified measures—when properly adhered to—were countering those predictions. Hospitals around the world were seeing striking drops in many HAIs.

A study at Kerman University of Medical Sciences in Iran, for instance, found the total rate of nosocomial infection for all illnesses was 3.7% during the first part of the pandemic, 20% lower than at the same time the 

.3 A hospital in Spain saw the incidence of nosocomial 

 infection drop by 70% from March 11 to May 11, 2020 compared to the same timespan the 

. In Singapore, researchers found enhanced infection prevention and control (IPC) measures had the “unintended positive consequence” of containing respiratory viral infections: Incidence shifted dramatically downward, from 9.69 cases per 10,000 patient days pre 

It is not surprising that intense precautions would also reduce cases of nosocomial COVID-19. A comprehensive infection control program implemented at Brigham and Women’s Hospital in Boston in March 2020 included dedicated COVID-19 units, personal protective equipment (PPE) in accordance with Centers for Disease Control and Prevention recommendations, donning and doffing monitors, universal masking, visitor restriction, and reverse transcription-polymerase chain reaction (RT-PCR) testing of symptomatic and asymptomatic patients.6 Despite the high burden of COVID-19 in the hospital, only 2 patients were identified as having HAIs, one of whom was likely infected by a visiting spouse before visitor restrictions and universal masking. Between March and June of 2020, of 8370 patients with non-COVID-19–related hospitalizations, 11 tested positive for the virus. Only 1 of the 11 was deemed an HAI—but with no known exposures inside the hospital.

The protective precautions have become routine. At Penn State Health Milton S. Hershey Medical Center, in Pennsylvania, limited visitation, screening of all employees and visitors 

Fibi Attia, MD, MPH, CIC
Infection Prevention Coordinator
Penn State Milton S. Hershey Medical Center

upon each arrival, universal mask wearing, contact tracing, hand hygiene, and equipment cleaning “are essential parts of our everyday work,” says Fibi Attia, MD, MPH, CIC, infection control coordinator, and a member of the 

® Editorial Advisory Board. All those measures “are definitely working together to limit any exposure.”

The least, and potentially the best, of these measures is masking. According to Aaron Richterman, MD, et al in 

: “[M]ounting evidence supports the effectiveness of a relatively simple intervention in reducing hospital transmission of SARS-CoV-2: universal use of surgical masks by health care workers (HCWs) and patients”—even when physical distancing is 

It did not take long to find out that masking was a simple but effective measure to flatten the curve of nosocomial COVID-19. From March 15 to June 6, 2020, researchers at Duke Health (a system of tertiary care academic hospitals, community hospitals, and clinics) assessed all HCWs—out of 21,014—who had tested positive for the virus. Of those cases, 38% were community acquired, 22% were health care-associated, and 40% had no clear source. Of note, the investigators say, 80% of the HCWs did not work in 

Of the HAI cases, 70% were related to unmasked exposure to another HCW for more than 10 minutes, less than 6 feet apart; 30% were thought to be secondary (a non-COVID-19 infection) to direct care of patients who tested positive for the virus. However, only 1 week after the hospital system initiated universal mask wearing, the cumulative incidence rate of nosocomial COVID-19 dropped significantly, whereas the community-acquired cases and cases with no clear source continued to mirror the cumulative incidence rates in the communities surrounding Duke Health. At Mass General Brigham in Boston, a study involving more than 75,000 workers also found universal masking could quickly reverse the trajectory of nosocomial spread: Prior to the new rule, new infections among HCWs spiked from 0 to 21%—afterward, the positivity rate declined linearly from 14.65% to 11.46% during a 

Similarly, a study at the German Heart Center in Berlin showed that measures including obligatory surgical face masks for patients and employees, SARS-CoV-2 screening for all patients, and symptom-based testing for employees led to an overall 0.4% prevalence of positive tests (5 of 1128 tests). The incidence of new infections was 0.5%. No nosocomial infections were found, despite a mean number of 14.8 in-hospital contracts. Notably, the investigators say, during the observation period the number of positive SARS-CoV-2 tests sharply increased in Germany.

Nonetheless, “[m]y experience tells me that nosocomial COVID-19 is rampant,” Manoj Jain, MD, an infectious diseases physician and contributing health writer for 

, wrote in a January 2021 op-ed, “and hospitals are not 

His concern was raised about a patient who died of nosocomial COVID-19. Jain was perplexed—how could the virus have reached the patient? It was not lack of handwashing. It was unlikely the virus had come from surfaces; the hospital’s environmental services staff had been diligent. All the family members who had visited the patient had 

That was not the only patient, either. Jain said he had seen 5 other cases of nosocomial COVID-19 in the previous 4 weeks.

Were the staff the reason? Jain said he “armored” himself with N95 masks covered with a surgical mask and a face shield, plastic gown, and gloves. Still, one of his colleagues, who was taking similar precautions, tested positive. Again, there was no discernable cause.

However, Jain notes, in the doctors’ lounge food is served, and health care workers frequently gather, “often taking off their masks to share COVID-19 war stories.”11

When outbreaks have been reported in hospitals that are using universal masking, unmasked exposure to other health care workers is often the cause. Transmissions have been traced to break rooms and cafeterias. Last November, more than 900 Mayo Clinic staff contracted COVID-19 in 2 weeks. Amy Williams, MD, executive dean of clinical practice, in a briefing said 93% of staff contracted the virus in the community. Most of those who contracted it at work had been eating in a break room with a mask off. She later updated that to say they could have been exposed while eating with a mask off in 

One of the ways to prevent these “breaches in now-routine preventive measures,” Richterman et al wrote in 

, would be to provide adequate, well-ventilated and, ideally, dedicated space for breaks and meal times, perhaps staggering times to minimize contact and 

The unprecedented demands of this pandemic call for unprecedented responses. Abbas et al, in their literature review, found that many hospitals are breaking with traditional management of respiratory viral illness, particularly nosocomial outbreaks. In a “paradigm shift,” they say, hospitals are expanding testing criteria: testing asymptomatic patients/residents and health care workers, as well as conducting serial testing or repeat point-prevalence surveys. When Brigham and Women’s instituted liberal universal testing on admission, the researchers observed fewer late-onset cases (patients diagnosed on hospital day 3 or later).

At 2 Minnesota skilled nursing facilities (SNFs), serial testing identified COVID-19 cases among 64% of residents and 33% of health care workers. Following up with genetic sequencing revealed facility-specific clustering of viral genomes from HCW and resident specimens, suggesting intrafacility transmission.

However, such information is not useful by itself: It needs to be supported by action. Although transmission was reduced by early identification of asymptomatic infections and prompt implementation of mitigation efforts, there were challenges. The Minnesota Long-Term Care COVID-19 Response Group found that, in the SNFs, continued SARS-CoV-2 transmission was “potentially facilitated” by “low baseline knowledge of and experience with (IPC) and PPE use,” delays of up to 12 days in receiving half of the HCW test results at one facility, and incomplete 

The Minnesota study is an example of how none of the measures is entirely effective on its own (although masking comes close). For instance, serial testing, investigators say, needs to be done until no new cases are detected after 14 days—along with IPC strengthening. Testing should be accompanied by “IPC education, flexible medical leave, and PPE resources targeted to this 

Researchers at Changi General Hospital, Singapore, developed a prediction model to identify patients at low risk for COVID-19 to better guide 

. They say their risk prediction score would have obviated the need for isolation and testing in up to 41% of patients with pneumonia and acute respiratory infection. Missed cases of COVID-19 are “expected trade-offs” of their risk stratification strategy, they concede, but they point to “reassuring reports” that basic infection control measures (eg, masks, hand hygiene) are effective in minimizing the risks of nosocomial spread.

Crucially, the precautions need to be carried out faithfully—as more viral strains evolve and people relax their vigilance because of the vaccines, more waves of the pandemic are only too possible. Can all this experience benefit hospitals and their workers in a future wave of this pandemic—or in a future pandemic?

Rhee et al say their findings at Brigham and Women’s suggest that “robust and rigorous infection control practices” can minimize the risk of nosocomial spread of COVID-19, and “provide reassurance” as some health care systems reopen services and others continue to 

The basics can also be supplemented with more sophisticated tools. When there was no routine SARS-CoV-2 screening of asymptomatic HCWs, 5 hospitals in the United Kingdom assigned different locations within the hospitals as either green (virus negative) or red (positive) zones, combined with staff bubbles. That tactic helped keep nosocomial infections down. But as patients tested positive even after spending prolonged periods of time in green areas, the investigators realized that there were unrecognized transmission events between the 

They turned to viral genome sequencing as a realistic possibility to track and identify root causes of nosocomial transmissions. They sequenced SARS-CoV-2 genomes for patients and HCWs, obtaining 173 high-quality genomes. They then integrated patient movement and staff location data into the analysis to understand spatial and temporal dynamics of transmission. They identified 8 patient contact clusters with significantly increased similarity in genomic variants, compared with nonclustered samples.

The investigators found that incorporating the location of the HCWs identified additional links in transmission pathways and enhanced identification of outbreak clusters. Looking forward, they say, adopting genomic approaches in real time (eg, within 48 hours) along with consideration of patient movement datasets will enhance rapid identification of linked nosocomial SARS-CoV-2 infections. Their approach, they suggest, could optimize infection control management strategies, lead to targeted interventions, and ultimately prevent avoidable harm.

In his op-ed, Jain said he told his regional Memphis and Shelby County COVID-19 Joint Task Force, consisting of hospital executives and mayors, that hospital staff need to be regularly tested through “the affordable technique of pooling up to 20 test samples.”11 Such PCR gold-standard testing, he says, would amount to the cost of a cup of coffee and a few doughnuts. Without testing, he says, “we are flying blind.”

Like other HAIs, COVID-19 can be prevented, Jain says. “Hospitals should be places where patients come to get better, not sicker; where diseases are treated, not acquired.”

Jan Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

When outbreaks have been reported in hospitals that are using universal masking, unmasked exposure to other health care workers is often the cause. Transmissions have been traced to break rooms and cafeterias.

Keep COVID-19 From Becoming a Health Care-Acquired Infection

 have been urging infection preventionists (IPs) for some time to get more involved in 

, especially when it comes to endoscopes. Well, the Food and Drug Administration (FDA) just gave IPs more reason to jump in and help in the sterile processing effort.

The agency today warns health care providers that some medical devices have caused serious infections in patients. The information comes from numerous medical device reports (MDRs) focusing mainly on endoscope malfunctions. MDRs can be filed by providers, manufacturers, importers, or anybody else who spots a problem.

, the FDA says that the MDRs describe “patient infections and other possible contamination issues associated with reprocessing urological endoscopes, including cystoscopes, ureteroscopes and cystourethroscopes—devices used to view and access the urinary tract. Reprocessing these types of medical devices involves both cleaning and high-level disinfection or sterilization so the devices can be reused.”

The FDA received 450 MDRs from January 1, 2017 through February 20, 2021 that describe how patients were infected with devices post procedure, with the cause likely to be faulty decontamination. Olympus Corporation, a manufacturer of endoscopes, filed 3 MDRs in which patients died from a bacterial infection outside of the United States. (The FDA says that MDRs are not evidence that the infection was caused by a device malfunction.)

“Two of those reports were associated with a forceps/irrigation plug, an accessory component used to control water flow and enable access to the working channel of the endoscope,” the FDA press release states. “Lab tests confirmed the same infectious bacteria was present in both the forceps/irrigation plug and in the patient with the infection. The third patient death report involved a cystoscope that did not pass a leak test, indicating possible damage to the device, which could have been an underlying factor in the infection.”

, Tanya Lewis, who is slated to become the president of the International Association of Healthcare Central Service Materiel Management (IAHCSMM) next month, said that sterile processing no longer solely involves the traditional surgical tools of knife and scalpel, and that it’s the more sophisticated modern devices—such as endoscopes—that really need attention. “They’re a challenge for us,” Lewis said. “And that’s why it’s so important for us to make sure that we get our instructions for use from the manufacturer. Because we can never just guess. We’re not ever going to guess on how we would clean an item, or a camera, or a scope, or anything of that sort. We have to have that information. And we have to be able to do it according to the manufacturer’s instructions because if we don’t, then we’re setting our patients up to fail.”

Jeff Shuren, MD, JD, the director of the FDA’s center for devices and radiological health, said in the press release that “while some reports indicate the potential causes could be inadequate reprocessing or device maintenance issues, we’re also evaluating other possibilities, including device design or the reprocessing instructions in the labeling. Although we believe that the risk of infection is low based on available data, we’re reminding health care providers how important it is to follow the labeling and reprocessing instructions to properly clean and reprocess the devices, including accessory components.”

Linda Spaulding RN, BC, CIC, CHEC, CHOP, a member of 

’s Editorial Advisory Board, warned in an 

 in January that a lot can go wrong in sterile processing. She told of a time when she was working for a hospital accreditation company and inspected hospitals “where they didn’t even track their scopes. They didn’t know what scope was used on what patient or…that a particular scope kept breaking down. And that’s the same one they kept sending out, because their tracking programs just aren’t there.”

There’s a solution though, Spaulding said. The Healthcare Infection Control Practices Advisory Committee (HICPAC), which is under the Centers for Disease Control and Prevention, published a document called “

Essential Elements of a Reprocessing Program for Flexible Endoscopes—Recommendations of the Healthcare Infection Control Practices Advisory Committee

“Not only does it give you good information related to scopes and processing, but if you don’t have a strong program setup, it gives you everything to put that program in place,” Spaulding said. “It gives you a policy format [and] audit tools. It gives you a competency verification tool so you can make sure your people are competent, [and]…an inventory repair and maintenance log, so you can log every single time a scope breaks and when it goes out.”

The letter the FDA sent to providers today “provides recommendations for reprocessing and using these devices, including following the reprocessing instructions, not using a device that has failed a leak test, developing schedules for routine device inspection and maintenance, and discussing the potential benefits and risks associated with procedures involving reprocessed urological endoscopes with patients,” according to the FDA press release.

The FDA’s concern about contamination of medical devices has grown in recent years. In 2015, the FDA issued instructions about how to properly 

 and urges manufacturers to make all or parts of 

The FDA wants providers to know about “contamination issues associated with reprocessing urological endoscopes, including cystoscopes, ureteroscopes and cystourethroscopes—devices used to view and access the urinary tract.”

Endoscopes Causing Infections, FDA Warns Providers

US deaths from COVID-19 have now exceeded more than 550,000 as of 

. As a result of this pandemic, we have seen a faster progression in how health care is being delivered and who delivers it. Some of these changes have been a result of emergency orders by the federal or state governments. Pharmacists lead the charge in delivering health care services in various settings throughout this pandemic. Health system pharmacists have managed numerous drug shortages emerging throughout the pandemic, evaluated and often used novel therapies for patients hospitalized for COVID-19, and changed workflow to secure and preserve valuable personal protective equipment (PPE). Community pharmacists have increased the accessibility of medications by delivering medications and supplies, implemented curbside pickup, increased the use of telehealth services, and have taken lead roles in administering COVID-19 testing and the great task of vaccination. Infection preventionists (IPs) have always had a good handle of the operations of pharmacy inside of the hospital setting. As the pandemic evolved, IPs have had to step outside of the hospital to provide guidance to local health departments, school districts and businesses. Getting to know the local pharmacists—in fact developing a professional rapport with those pharmacists—should be on an IP’s to-do list. Also, IPs should know the story of how community pharmacists’ roles have evolved because of COVID-19

Over the course of the pandemic, the government attempted to remove barriers for pharmacists that prevented them from actively taking care of patients. The act that removed the most barriers was the Public Readiness and Emergency Preparedness Act (

 by expanding the ability for licensed pharmacists and eventually pharmacy interns, pharmacy students, and pharmacy technicians with appropriate training to administer all ACIP approved immunizations in patients 3 and over. Subsequent to the discussion of the magnitude of the task at hand and realization of the sheer need for vaccinators, some pharmacy boards also changed regulations to allow pharmacists with valid license from out of state to begin to assist by making the process simple, and technician abilities have been expanded as well during the pandemic.

As part of the US government efforts to increase access to COVID-19 vaccinations and get "more shots in arms," the US Government, in coordination with the Centers for Disease Control and Prevention (CDC), began implementing its plan for community pharmacies to administer COVID-19 vaccines. The plan implements a collaboration between the federal government, states, territories, 21 national pharmacy partners, and independent pharmacy networks to increase access to COVID-19 vaccination across the US. The program is being 

, starting with just a few large chain store pharmacies, hospitals, and some select independent pharmacies, and is expanding with adjustments made as additional 

 become more readily available. Efforts initially 

, partnering with national chains CVS and Walgreens and some independents with efforts focused on nursing home patients at high risk and then expanding to select retail locations 

. The program will expand to include more than 40,000 pharmacies in the United States as additional vaccine products with less stringent storage requirements continue to 

One big advantage of pharmacist expanding role has been the partnership with public health efforts in underserved areas. Pharmacists have been able to help cover large areas that require more providers, especially in the rural area. In many of those areas, pharmacists already have personal relationships with local health departments, and they have been able to easily augment local health department efforts by expanding the number of access points and the hours that immunizations are available. As most pharmacies are already familiar with immunization providers, these pharmacies have many resources and can help achieve public health goals in these areas. We should also consider that one health department often covers a large geographic area.

As the pandemic continues, there has been a substantial amount of misinformation and a large amount of distrust in government efforts promogulated in the vaccines’ approval. Education needs to continue to occur with health professionals and the public on the advantages of receiving vaccines. The CDC and the AD Council have recently started promoting a large-scale public-facing messaging campaign which will support the Biden administration’s immunization completion goals. This campaign starts with health professionals, and the CDC will offer educational programs along with 

. As health professionals are trained, they can begin working with different groups such as churches and community centers to get the word out and decrease vaccine hesitancy, especially amongst minority groups. Several steps can be taken to overcome hesitancy, which can include education for the individual or caregiver and those that 

. There are several ways that pharmacists will be working with officials to extend messaging efforts, dispel misinformation, and to increase immunization rates. They include:

.Employers play a key role in getting information about vaccines to their employees, and pharmacists can help employers reassure the vaccines' safety profile and promote the short-term advantage. In addition, some work-related activities may require an employee to have received 

 is committed to getting word to the public about the safety of the vaccines and how the FDA followed protocol as it refers to side effects and duration of effects related to vaccine administration and needs to reduce fear and concern 

. Working with the FDA, pharmacists can direct patients to published information that is evidence-based.

Providing Evidence-Based Information that is Easy for Patients to Understand: 

In addition to general vaccine fears, the vaccines 

 have been manufactured using different methods, and as such, questions will arise related to the type of vaccine received and 

 (e.g., mRNA vs. adenovirus vaccine). For example, the two mRNA have an efficacy rate of 94%-95%, while the viral vector showed an efficacy of 66%, according to the CDC. This has caused some confusion among the public related to 

. Pharmacists will help to reassure a skeptical patient population.

Prior to expanding the community pharmacy channel for increased access points, pharmacies were involved in working with state and local health departments to immunize our nation’s most vulnerable patients. This involved use of mobile clinics where pharmacists and other public health officials took their services directly to the residences of these patients, helping with transportation, storage of vaccine product, monitoring of vaccine cold chain, ensuring proper storage of vaccine, aiding in the proper preparation of drugs, and assisting in public announcements of product to protect them in the first round of immunization efforts. These efforts have helped to mitigate outbreaks in these vulnerable populations.

Pharmacists have been thoroughly trained in ensuring appropriate drug storage and cold-chain integrity. Pharmacists have been involved in these efforts to ensure adequate transportation of vaccine products working with local and state-level health officials. They have been integral in using coolers/refrigeration/freezers, in proper monitoring and storage of drugs, in aiding local and state officials in immunization preparation and administration, helping with public service announcements, with scheduling patients, and with social media efforts, including word of mouth advertising, bag flyers, advertisements, etc. to help get the word out especially in underserved and rural communities.

Many pharmacists have been actively involved with the Federal Emergency Management Administration

FEMA). Healthcare professionals who will jump in and help as needed with emergencies. Also, FEMA and state officials have developed registries for health care workers that want to volunteer and serve during emergencies both during the pandemic and in other emergencies such as floods, hurricanes, acts of terrorism, etc. Many pharmacists have signed up for these corps and have continued to work as partners in these efforts.

Pharmacies that want to participate early have two ways to participate. Each state is handling their vaccine supply slightly differently. First, pharmacists can obtain vaccines directly by working through the state health department to get allotment from the state supply, and the state health department allocates directly to immunizing pharmacies part of their supply. The second method is working through the federal network to obtain vaccine products. Only about 9000 of the 40,000 pharmacies receiving vaccine in March will go through this method but it will become more common to allow an adequate national supply.

When we consider the COVID-19 immunization program, it is of a massive scale never seen before. Ultimately, we must vaccinate the entire world’s population in the shortest time possible. 

Pharmacists are a competent workforce embedded in the community, trusted by patients, and can rapidly expand access points to patients to receive the COVID-19 

. Other than increasing access points, pharmacists are trained to counsel patients, administer the vaccine, provide vaccine education, and pharmacies are readily accessible in communities, with most Americans living within 5 miles of a pharmacy. Because of these access points to care, the pharmacy will play an integral role and drive immunizations to help achieve herd immunity if that target is 

. With efforts already underway, we are beginning to see numbers of cases, hospitalizations, and deaths come down albeit it not in a straight line from their peak, although this is not a straight line, and we are not out of the woods in this pandemic with many experts worrying about a possible resurge with loosening 

. Many retailers are adding pharmacists and technician support staff on a part-time or full time basis to support efforts. The US pharmacy retailer Walgreens has recently announced they plan to add 25,000 personnel to 

While there is no debate about expanding access points to pharmacies, using community pharmacies to greatly expand access points is a huge logistical endeavor. The community pharmacy part of this COVID-19 immunization program will be an ongoing rollout to increase access points everywhere an immunizing pharmacy or pharmacist is available. It will expand based on vaccine availability and will initially be provided to patients at no cost. Implementation and delivery will be greatly aided now with the emergency use authorization approval, and the 3rd major vaccine’s availability by J&J/Janssen completed on March 1, 2021.

The J&J vaccine has different storage and administration considerations that are a game-changer for expanding the community pharmacy channel’s efforts. The first two available vaccines from Moderna and Pfizer were mRNA vaccines and, while very effective, required stringent management of storage and supply chain. The Johnson and Johnson/Janssen vaccine is a viral vector vaccine. The Janssen COVID-19 Vaccine storage is simply standard refrigeration between 2°C and 8°C (36°F and 46°F) for up to the expiration or beyond use date (BUD). After first puncturing the vial, the vial should be held between 2°C and 8°C (36°F and 46°F) for up to 6 hours 

 at room temperature (up to 25°C [77°F]) for up to 2 hours. Also, this 

. Due to these relaxed storage requirements and single dosing, this is a much easier vaccine to deliver in the community pharmacy setting.

As the community pharmacy COVID-19 immunization program scales up through April and May, it will eventually include COVID-19 immunization at more than 40,000 community pharmacy locations. This means more hours to access, access points, and more practitioners helping administer the immunizations very quickly. The Biden administration has promised that by the end of May 2021 that 

During the COVID-19 pandemic, pharmacists have been very quick to adapt with innovative ideas and have emerged as leaders in providing care in many settings and IPs would to well to seek out their professional assitance. As the pandemic evolved, pharmacists continued to play critical roles at various stages and are essential to ending the pandemic through immunizations. Pharmacists have helped ensure testing availability, drug supply chain, alternative treatments, patient care, and expanding access points throughout the pandemic. Now the profession is poised to make an impact on one of the greatest immunization efforts ever. As the community pharmacy immunization program expands, intense community outreach will be critical to educate people about the importance of vaccination and where vaccines are available in the communities, and pharmacies will be 

Craig Kimble, PharmD, MBA, MS, BCACP is the director of experiential learning and the manager of clinical support services as well as an associate professor of pharmacy practice at Marshall University School of Pharmacy.

Alberto Coustasse-Hencke, DrPH, MD, MBA, MPH, is the professor in the health care administration program management and health care administration division of Lewis College of Business at Marshall University.

Kenneth Maxik, MBA, MBB, is the vice president of operations support at CompleteRx, Ltd.

Getting to know community pharmacists—in fact developing a professional rapport with those pharmacists—should be on an infection preventionist’s to-do list.

Pharmacists Have Delivered During the COVID-19 Pandemic

Some weeks are busier than others in the world of infection prevention and global health. The United States sits on a precarious position as we race to vaccinate as many as possible to combat the growing case counts and hospitalizations. It’s a worrisome sign when Rochelle Walensky, MD, the director of the Centers for Disease Control and Prevention (CDC), pleads with 

people to maintain vigilance in COVID-19 prevention efforts. More and more the goal of passing the finish line is used, but the truth is that we keep having to push back this line with our rush to reopen and return to “normal.” From a global health and infection prevention perspective, “normal” is what got us here—a state of poor preparedness, underfunded health departments, and neglected hospital preparedness for a pandemic. There are several things though, that we should keep a close eye on that will likely come in up infection prevention rounds.

 that their COVID-19 vaccine has shown preliminary efficacy and safety in children aged 12-15 years.While more data is being collected, analyzed, and many are calling for antibody results, this is an exciting bit of news. A timeline for distribution though could be prior to the next school year. The current Pfizer vaccine is already available for those aged 16 years and older, so this new insight would expand the vaccine eligibility and hopefully decrease transmission as older children appear to have more similar transmission dynamics as adults. Overall, this will be a welcome advancement in COVID-19 response, especially in the face of novel variants and an increasing need for school re-openings.

The World Health Organization (WHO) just released its 

From a global health and infection prevention perspective, “normal” is what got us here—a state of poor preparedness, underfunded health departments, and neglected hospital preparedness for a pandemic.