We’ve made tremendous strides against coronavirus disease 2019 (COVID-19), and that can be seen just in how the mortality rate has plummeted and how doctors around the world have polled data to share the best methods for treating those most severely infected. Monica Gandhi MD, MPH, an infectious disease expert and a professor at the University of California, San Francisco, wants people to know that we will indeed get out pre-COVID lives back, but it’s going to take some time. Still, her message for infection preventionists and everybody else who may be listening is a hopeful one. “I think we’ll be going to movies,” Gandhi tells 

. “That people will be going to the theater. People will be going to sports events will hug each other, will hang out. We’re going to get back to normal, but it’s going to take a year and a half.”

What has surprised you the most about the COVID-19 pandemic?

What has surprised me about SARS-CoV-2 is the range of clinical manifestations that you can get. You can be completely asymptomatic, as shown by antibody studies that people have had it, they had no idea. And then how ill people can get. And I think what this has revealed to me is that we have to think about that interplay between host and pathogen better. And how to decrease and mitigate any viral factors that could be contributing to the severity of disease. And also, how to protect hosts that are more vulnerable. I think there are ways to decrease the severity of this infection by working on both virus and host.

Where do infection preventionists fit in here?

I think when you said treatments; by the time we get to treatments, the cat is out of the bag in the sense that obviously someone already has SARS-CoV-2 and the only treatments we have right now are for very severe disease. That’s why outpatient treatment, we don’t have anything yet. It really is about—speaking of infection control—it really is about all of these public health mitigation measures to even prevent people from getting to that point of getting infected. This is all about five things now. They’re very rote. They’re very tiresome. It’s very hard to do all of this. But it’s about social distancing. It’s about universal facial masking. It is about isolation and quarantine if you do get sick. It’s about contact tracing at that point, if there is someone who is exposed to someone who gets sick. And it’s about selective testing. And finally avoiding large problems. With these techniques, we can keep ourselves in some sort of equilibrium until we get to the vaccine. Because by the time we get to treatment, someone is very ill. And that’s what we want to prevent.

What are some of the hurdles with contact tracing? That that can be a pretty difficult thing to do.

Actually, that’s why I'm so much more interested in facial masking to not even get to contact tracing, because again, by the time we get to contact tracing someone’s been infected. But you’re right, it is a huge hurdle to contact trace. And what’s going on in the White House right now is a very good example that you don’t know how long someone’s been infectious. You don’t know when they started having symptoms, because symptoms can be subtle, or people may not want to tell you. And all those reasons, it’s hard to trace back who could have been exposed. One thing we’ve been working on is this concept that the dose that you get, or the viral inoculum, how much virus you get, is related to how sick you get. And there’s evidence for that. We’re putting out a paper now that’s showing that masking may be decreasing the severity of illness you get. Our idea is let’s work on how we keep away from each other and wear our masks and block viral particles from getting in so that you may not even get to that point where you get sick. You’re right that contact tracing is hard, and we can’t do it on everyone, which is why we’re asking so many people to stay home.

Is it true that mortality figures are going down even as the number of people who have it are going up? And does that give you any hope?

I definitely think the mortality is going down from the infection. Why? I think there are six possible reasons. I think that one is that people are getting exposed and infected at younger ages. They’re less likely to die from it and get very sick. The second is that I do truly believe that we are doing a better job at infection control and universal testing in nursing homes, which we did an abysmal job at the beginning. And so, our elderly are more protected. And unfortunately, many of the vulnerable have already been sick. The third reason is that I think that we have better treatments. So, if you do get into the hospital, there are better treatments. We’re more prepared in the hospitals. Fourth is that I think that this universal masking has a lot to do with it. I really do think that a mask reduces the particles that you get into your nose and mouth. And if you get in less particles, you get less sick. And that’s the data we’ve been working on about masking and severity of illness. And then the final reason—I said there are six reasons—I do think that there is beginning to be more immunity in the population. Unfortunately, there has been a lot of exposure, the recent WHO report is that probably 10% of people in the world have been exposed. That means that we have some short-term immunity, which even if we get exposed again, we’re not going to get sick.

There’s a difference between herd immunity. Herd immunity means that you are at the point where the virus is going around, and they can’t even find anyone to infect because so few people are susceptible. The way that we’re going to get to herd immunity is more through vaccination, because we don’t want the virus to be completely unleashed. We don’t want to mingle and get people sick. There’ll be too much mortality. But even less than herd immunity, even having some of the population either not be susceptible or have antibodies that fight off an infection or T cells that fight off a new infection. Even if they get it again, they get reinfected. It’s asymptomatic. So, it’s not exactly herd immunity. It’s just slowly developing immunity.

Which country in the world handled COVID the best?

I think it is important to give New Zealand credit. They are an island, but they did a great job in terms of making everyone stay home. And then they got the prevalence so low that when they went out, they didn’t have very many cases. However, the Asian countries—and I mean, Singapore, Hong Kong, Thailand, Vietnam, South Korea, and Japan—these are countries that never had an issue with masking. Not even one. No one is out on the street protesting facial masking to get through this pandemic. And they have actually been more open. Their economies have not been devastated. Because there’s absolute compliance with public population wide facial masking. And that’s because of [SARS-CoV-1]. Right. They went through this in 2003. They knew how to act. They made it part of their culture. They hand out masks. Taiwan handed out masks starting on March 6. So early in the pandemic, they started making masks and handing them out. I have to give them a lot of credit for how they managed it. You never hear about them, because they’re doing quite well.

Do you think this will change the way infection prevention is handled in the United States from here on out? And how?

Yes. I think that if we can—we and other groups are looking at this idea that the amount of virus you’re exposed to is related to how sick you get—then it will keep us away from people. I mean, it’s sad because with a respiratory virus, it means we have to truly socially distance, not have big crowds and facially mask. But I don’t think we’ll ever have this kind of controversy again, where keeping away from each other and doing these social distancing guidelines and hand hygiene and all that is going to be as much of a big problem anymore because people are going to understand it. Same thing with a new bacterial illness, the more you get, probably the sicker you get. I think our hand hygiene, things are going to change forever. I think that how we think about hygiene and approaching each other is going to change for a long time. I think it’s hard. It’s a very hard time in the world. And it feels like it’s going to go on forever, but it’s not. We will get to the end of this. We will get to a combination of vaccine and natural infection, enough people getting herd immunity that this will stop. This will stop and we will get back to normal. I want to give people that ending comment that it’s not going to be forever and just get help us get through this time with you with these kind of public health guidelines.

I read a little bit of your biography and know that you specialize in HIV. Do you see any similarities between how these two things progressed in the population?

Yes. I mean, there’s been a lot of similarities to me for HIV and infectious disease. We could say with HIV that it was a sexually transmitted disease, mainly also spread by blood products. And this is a respiratory disease. So, they’re different in that way. They’re different in that the risk factors are different, and who got it, and who could get it was different. On the other hand, what’s similar to me is that I’ve been very unhappy with the kind of stigmatizing aspect of COVID-19 just like HIV was stigmatized. There’s been more of a blaming of the individual. “Oh, how did you get COVID? Are you not doing enough of the public health guidelines? Did you leave your house? Did you hang out with friends?” This kind of stigmatizing language is not appropriate in public health. I think that we need to message to people that of course, you can close down for several months and this has been really hard. Of course, people want to see each other. We have to think about better, gentler, more loving, harm reduction ways of messaging. Yes, see your friends. Use a mask but see your friends. The stigma is reminding me. I have a lot of my patients who are living with HIV, and they say, “This feels like living through HIV all over again.” And then there is this kind of anti-science sentiment that’s going on in this country that also went on with HIV. This kind of resisting of the facts that led the government in the 1980s…. The president didn’t even speak of HIV until 1987. There has been a little bit of that distancing from what’s going on, that reminds me of it. But the thing that makes me positive, is that I’ve never seen progress move this fast as it’s moving with COVID-19. The therapeutics, that vaccines are in phase three, we could get data so soon. Things are moving fast. And that’s why we’ll get through this.

Probably many infection preventionists are fearing the fall and winter. Do you have any advice for them?

I am not fearful of the fall and winter because of the public health measures that we’re doing that I think will reduce the severity of cold and flu. Any respiratory virus really is going to be prevented by hand hygiene, social distancing, and facial masking. It’s just that we don’t ask the population to facial mask every winter. But if we did, I think we’d have a lot less influenza. I think we’re not going to see it as bad as we think. I mean, the other thing I’d want to say about infection control is that the surface issue, that it exists on surfaces, has really been receding, has really been going away. There’s been great data over the last couple of weeks, that that risk is greatly exaggerated, because it really is through the respiratory route that we get infected. I think a little bit less emphasis and fear about touching things and the disinfection, and more on the respiratory aspect of infection control.

Will we ever get back to the way we were before COVID hit us?

We will. I really mean it. I think we will. I think we’ll be going to movies. That people will be going to the theater. People will be going to sports events will hug each other, will hang out. We’re going to get back to normal, but it’s going to take a year and a half. January 2022. It’s so hard to say. But I do think it’s going to take until January 2022. We need to get the community transmission down. We need to get a vaccine. We will vaccinate the whole populace and then it will stop because it can’t go anywhere because we have immunity and we will get there.

Do you think nursing homes should be staffed with infection preventionists?

You’re absolutely right that this pandemic revealed the fault lines in our nursing homes here. Absolutely. We need infectious disease epidemiologists who fast test. We need better protection of our nursing homes. It revealed that we didn’t have a unified regulatory system on nursing homes, where people were kept safe. And I think that’s going to be one of the biggest lessons of this pandemic.

This interview has been edited for clarity and length.

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Monica Gandhi MD, MPH:  “We will get to the end of this [COVID-19]. We will get to a combination of vaccine and natural infection, enough people getting herd immunity that this will stop. This will stop and we will get back to normal.”

Q&A: The Old Normal Will Return (in January 2022)

The use of red boxes in hospitals should be re-evaluated because their presence in a patient’s room might lead to less compliance among healthcare providers to protocols for hand hygiene and personal protective equipment (PPE). This was the finding of one of a study unveiled at 

. Investigators with Northshore University Hospital in Manhasset, New York who conducted the study (“Assessment of Personal Protective Equipment Adherence in Red Box Using Remote Video Auditing”) describe the red box as an area at the entryway of a patient’s room. It’s where healthcare providers can conduct consultations with patients without having to wash their hands or don personal protective equipment (PPE).

What happens when those healthcare workers step out of the red box and into the patient’s room? To find out, investigators used remote video auditing in 4 hospital rooms with red boxes and 2 without. The prospective observational study—conducted between February 26, 2019 and February 27, 2020—captured 6959 patient encounters in the 6 rooms. The red boxes were a 3-foot area at the entrance to the patient’s room that were marked off by red tape and were more than 6 feet from the head of the patient’s bed. To do the study, investigators placed cameras at the entryways of the 6 rooms.

Using binomial regression models with a log link, trained individual observers reviewed adherence to using PPE such as gowns, gloves and masks and to hand hygiene.

When healthcare workers used the red box, 69.9% did not practice hand hygiene, 91.6% did not use gloves, and 95.2% did not use gowns. When healthcare workers using the red box stepped into the patients’ rooms, there was “significantly increased non-compliance” with PPE and hand hygiene protocols compared to those healthcare workers who went into rooms without red boxes.

Healthcare-acquired infection (HAI) rates were not significantly different between the red box rooms and those rooms without a red box. Nonetheless, investigators suggest that the red boxes may have created a false sense of security. They conclude that hospitals should consider educating healthcare providers about the optimal use of red boxes or discontinuing the red box use altogether.

Infection preventionists (IPs) should always keep their guard up against infection no matter where they happen to be in a hospital, said Saskia v. Popescu, PhD, MPH, MA, CIC, a member of 

’s Editorial Advisory Board. The headline of an 

 last month states the problem succinctly: “For Infection Preventionists Battling COVID: Beware of the Breakroom.”

Popescu wrote that “too commonly we focus on the risk of patient-facing interactions and not those outside of those care environments. For example, we often think the highest risk interaction is in the patient’s room but not in the breakroom, where people are eating and talking without masks on.”

 published in the Center for Disease Control and Prevention (CDC)’s 

) that looked at just how healthcare workers can become infected by COVID-19.

She concluded that the study’s findings point to “the need to address exposures that might have occurred outside the healthcare setting…. As these healthcare worker serology studies are designed and performed, we need more insight beyond just PPE use and symptoms, but also internal and external exposures, awareness and knowledge of infection prevention, and if they felt supported in their efforts to wear PPE.”

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When healthcare workers using the red box stepped into the patients’ rooms, there was “significantly increased non-compliance” with PPE and hand hygiene protocols compared to those healthcare workers who went into rooms without red boxes.

Not Thinking Outside the ‘Red Box’ Endangers Patients

Despite a clear requirement of water vapor during the human breathing process, the presence of water in the gaseous state, or humidity, in buildings has acquired a bad reputation. Even hospitals prefer to turn humidification systems off in patient-occupied spaces. The reasons for a dislike of humidification are complex, but the lack of understanding about health problems associated with low humidity has resulted in harmfully dry indoor environments. In fact, we now know that low humidity strengthens infectious microbes and weakens the human immune system.

This is especially problematic in regions with cold winter months when outdoor air is heated to comfortable indoor temperatures and the indoor relative humidity plummets to values of less than 30%. Are our prejudices about indoor humidity correct? Turning to scientific data is essential when trying to differentiate between subjective opinions and best-practice actions based on objective data.

Where can we gather relevant data on water vapor and occupant health? One great place for such research is the hospital. The reason for this is that we collect reams of data from the most relevant occupant—the patient. From vital sign measurements, blood cell and chemistry analysis, microbiology culturing of every imaginable fluid to imaging and other diagnostic procedures, we gather tremendous amounts of data from the patient. This wealth of data on humans can be correlated with indoor air metrics to understand whether our views on best indoor air quality is truly beneficial to people.

Currently, clinicians caring for in-patients focus on medical and surgical interventions that will hopefully heal the patient. Meanwhile, hospital facility managers follow building standards that are not necessarily based on medical data. Caught in the middle are infection preventionists (IPs), the team that strives to protect the patient from encountering infectious microbes during their inpatient treatment that could result in a healthcare-associated infection (HAI). By having an understanding of how the built environment influences clinical outcomes, the infection control team can utilize a whole new set of tools for reducing HAIs. We are now learning just how impactful these measures are.

A 2014 landmark study in a tertiary care hospital analyzed patient room metrics in conjunction with HAIs in the patients occupying those rooms. Data on clinician and visitor activity, indoor air metrics, and new infections in the patients inhabiting those rooms was logged for 1 year. Rigorous statistical testing using multivariable regression analysis was applied to the data to look for independent correlations between the indoor environment and patient HAIs. To the surprise of the author, the most significant correlation with which infection rates was room relative humidity (RH) less than 40%.1 When the patient room RH was above 40%, the infection rate was close to 0.

Another study following this protocol was done in a nursing home in 2015. Once again, when the indoor RH fell below 40% the infection rate was high.2 The ideal zone of indoor humidity for best patient outcomes was found to be RH 40%-60%. Although these 2 studies reveal powerful correlations between dry indoor air and poor patient health, they do not prove causation because of the lack of data from a simultaneous control group.

In 2016, researchers at the Mayo Clinic published a study that showed a causal relationship between low indoor humidity and increased infectivity of the influenza virus in preschool children.3 This study compared indoor RH of 20% or 45% with the number and infectivity of influenza virus in classrooms and with the number of school days missed by the children in each area. The humidified rooms had fewer and less infectious viral particles as well as significantly fewer children absent from influenza illness.

The infectivity of airborne viruses and bacteria depends on the transmission and infectivity of pathogens and on the vulnerability of the secondary human host.

When a person with a respiratory infection breathes, talks, or coughs, their airways expel thousands of droplets containing saliva, mucus, and embedded microbes into the ambient air. Moisture levels in the expelled droplets quickly equilibrate with ambient air water vapor through condensation and evaporation. Thus, vapor equilibrium, or RH, of room air determines the resulting droplet size, concentration of salts and the viability of the infectious microbe.

When expelled droplets encounter dry room air with RH less than 40%, they instantly shrink by roughly 90%. The resulting tiny droplet nuclei with diameters less than 0.5 microns can remain airborne for extended periods of time and be carried over great distances.

Prior to the use of genetic analysis tools, microbiologists determined the infectivity of these tiny droplet nuclei through the ability to grow the organisms on incubated petri dishes, known as tissue culture. This technique vastly undercounted the number of potentially infectious particles. We now supplement tissue culture with techniques that identify the genetic material of particles. This has revolutionized our thinking about microbes, human health and the indoor environment. For example, we have learned that infectious microbes in dry airborne aerosols are often temporarily in a dormant state, yet highly infectious when rehydrated.

When desiccated droplet nuclei suspended in low RH ambient air are inhaled by a secondary host, the droplet rehydrates in moist airways and many pathogens are able to begin a new infectious cycle (Figure 1).

Conversely, when ambient RH is above 40%, the respiratorydroplets maintain larger diameters of approximately 50 microns. Becausethe droplet diameter dictates the settling distance and rate,these larger droplets land on surfaces within 4 to 6 feet oftheir source where they can be efficiently removed with surface cleaning. Clearly, as transmission through room air or mechanical systems is decreased, the possibility of a secondary host being exposed is proportionately decreased (Figure 2).

Air sampling that mistakenly excludes the dormant pathogens in droplet nuclei underestimates the infectious load of indoor air particles. In fact, microbiologists now conclude that most infectious microbes that can transmit disease through contact also move through the air at some point between the initial host and a secondary host. Because of this airborne component of disease transmission, even the strictest adherence to hand, surface and short-range droplet hygiene will not reduce the incidence of infectious diseases as much as when the airborne route is also managed.

Not only does low indoor RH increase pathogen infectivity and transmission, it also diminishes the integrity of the human immune system. When RH is maintained between 40%–60%, the natural human skin and respiratory tract defenses and immune cell functioning are optimized.

In summary, the hospital’s physical environment has a significant impact on the health and healing of patients. Unfortunately, avoidable HAIs harm too many patients and cause significant waste of healthcare dollars.

By maintaining RH in patient care spaces between 40% to 60%, the transmission and infectivity of airborne pathogens will be reduced, surface cleaning will be more effective and patient immunity will be optimized.

Current indoor air guidelines for hospitals do not specifya lower limit RH in patient care areas and are evenpromoting lowering the minimum acceptable RH level inoperating rooms from the current 35% down to 20%.This is a mistake! Management of healthcare facilities mustfocus on the number one priority— patient healing.

Managing the indoor physical environment of hospitals and out-patient centers to optimize patient care is neglected. This may be because awareness of the powerful impact of indoor air quality, and specifically the value of proper humidification, on human health is lost between the silos of clinical medicine and facility management. The infection control team, once again, must come to the rescue of patients.

Stephanie Taylor, MD, M. Arch, is an infection prevention consultant at Harvard Medical School. She is also the CEO of Taylor Healthcare Consulting, a member of ASHRAE Epidemic Task Force, Environmental Health Committee and a Distinguished Lecturer.

Where can we find data on whether or not water vapor is necessary for humans residing in buildings? One great place for such research is the hospital. There is a tremendous amount of data that is collected from one type of hospital building occupant—the patient.

Why Water Vapor in Hospitals Matters

An updated version of just what constitutes close contact with a person with coronavirus disease 2019 (COVID-19) will greatly increase the number of people who could consider themselves at risk for contracting COVID-19. The guidelines that the US Centers for Disease Control and Prevention had been working under said that close contact more or less means being 6 feet or less from an infected person for 15 minutes or more. The updated guidelines, partly precipitated by a new 

), says that the contact doesn’t need to be for 15 or more consecutive minutes. The contact could constitute multiple encounters with an infected person of 6 feet or less that adds up to 15 or more minutes.

Investigators say that a corrections officer in a Vermont prison had had “multiple brief encounters” with whom the study defines as 6 incarcerated or detained persons (IDPs) who had COVID-19 but did not know it yet. The 6 people had been tested for COVID-19 but had not yet gotten their results back.

“During his 8-hour shift on July 28, the correctional officer was within 6 feet of an infectious IDP an estimated 22 times while the cell door was open, for an estimated 17 total minutes of cumulative exposure,” the study states. “IDPs wore microfiber cloth masks during most interactions with the correctional officer that occurred outside a cell; however, during several encounters in a cell doorway or in the recreation room, IDPs did not wear masks.”

The corrections office did wear a microfiber cloth mask, gown, and goggles during all the interactions, and he wore gloves most of the time. “The correctional officer’s cumulative exposure time is an informed estimate; additional interactions might have occurred that were missed during this investigation,” the study states.

CDC investigators say that there is no precise definition of what close contact means, but it’s generally agreed among healthcare providers that it’s about 15 minutes of contact with an infected person who is 6 feet or less away.

“Additional factors to consider when defining close contact include proximity, the duration of exposure, whether the infected person has symptoms, whether the infected person was likely to generate respiratory aerosols, and environmental factors such as adequacy of ventilation and crowding,” the study states. “A primary purpose of contact tracing is to identify persons with higher risk exposures and therefore higher probabilities of developing infection, which can guide decisions on quarantining and work restrictions. Although the initial assessment did not suggest that the officer had close contact exposures, detailed review of video footage identified that the cumulative duration of exposures exceeded 15 minutes. In correctional settings, frequent encounters of ≤6 feet between IDPs and facility staff members are necessary; public health officials should consider transmission-risk implications of cumulative exposure time within such settings.”

An unidentified source within the CDC told the 

 that scientists at the agency had been discussing updating the social distancing for weeks, and the 

 study seems to have pushed them into making that decision.

As the Washington Post indicates, the new guidelines are likely to be most felt in workplaces, schools and group settings where people are more likely to have the disjointed encounters with those infected by SARS-CoV-2. Infection preventionists and other healthcare professionals use the guidelines to, among other things, determine who should be the subject of contact tracing.

The changed guidance comes as many states deal with an uptick in COVID-19 cases, hospitalizations, and morality rates.

In the United States, there have been about 8.3 million confirmed cases of COVID-19, and about 222,000 people have died from COVID-19, according to Johns Hopkins University. In the world, there have been about 41.3 million confirmed cases of COVID-19 and about 1.13 million people have died from COVID-19.

Investigators say that a corrections officer in a Vermont prison had had “multiple brief encounters” with whom the study defines as 6 incarcerated or detained persons (IDPs) who had COVID-19 but did not know it yet.

CDC Updates Social Distancing Guidelines

Investigators wanted to see just how likely those 65 and older are to contracting influenza and what that costs the healthcare system. They looked at data in the claims database in IQVIA ParMetrics Plus in flu seasons from October 1, 2012 to March 1, 2019. The investigators work of IQVIA, which is a company specializing in health information technology and clinical research. Their study (“Health Resource Burden of Influenza Among the Elderly with Underlying Conditions in the United States”), which was unveiled at 

, concludes: “Hospitalizations, ED visits, and total healthcare costs are elevated in the elderly after evidence of medically-attended influenza, but to varying degrees depending on baseline comorbidities. Continued efforts to reduce influenza burden in high-risk populations are needed.”

The investigators used the earliest date of influenza diagnosis as the index date and patients had to have evidence of renal, pulmonary, or cardiovascular disease before the index date. Patients had to have been continuously enrolled for a year or more in the database and the data collected were from 30 days or more after the follow-up index. The investigators identified medically attended flu cases by primary influenza diagnostic codes or if the patient had been tested for flu within 14 days.

“Influenza [patients] were 1:1 propensity score matched to [patients] without influenza using baseline demographic and clinical characteristics and baseline healthcare costs,” the study states. “All-cause hospital and emergency department (ED) visits and total healthcare costs during follow-up (30-day and in the index influenza season) were compared in the matched cohorts.”

Investigators found that the mean healthcare cost for treating elderly influenza patients per patient per flu season ranged from $3,299 to $12,398 higher than the costs for treating patients with congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, and stage 5 renal disease. In addition, patients with influenza had 3 to 7 times higher 30-day hospitalization rates compared to patients without influence. The breakdown: congestive heart failure (41% vs. 8%), chronic obstructive pulmonary disease (35% vs. 6%), coronary artery disease (23% vs. 4%), and stage 5/end stage renal disease (ESRD)/dialysis (44% vs. 13%; all p< .05.

“Hospital and ED visit rates in the influenza season were 2 to 3 times higher in [patients] with vs. without influenza; ED visit rates were 49% vs. 23%, 44% vs. 18%, 37% vs. 14%, and 60% vs. 28%” for patients with congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, and stage 5 renal disease respectively, the investigators note.

Data from the Southern Hemisphere seem to indicate that the flu season may be a mild one this year, partly because the things people do to protect themselves from COVID-19—social distancing, hand hygiene, masking—seem to work particularly well against the flu.

However, Bilal Naseer, MD, the infectious disease specialist, at the not-for-profit healthcare system CommonSpirit Health, recently told 

 that it is still way too early to let our guard about the flu. The flu season “still has a long way to go,” Naseer said. “Sacramento, where I am located, we get the majority of our flu peaks around Christmas time or New Years, sometimes going into January and February of next year. I think we still have a way to go, but I think the importance of vaccine against influenza cannot be overemphasized because we know respiratory viruses attack weaker hosts. If a lot of patients actually get influenza and never really truly get ill, but if they get vaccinated, they will stay healthy and their immunity will be the best bet against an infection for which you don’t have the vaccine, such as SARS-CoV-2.”

Naseer also noted that mortality figures for COVID-19 have gone down dramatically because healthcare providers have a better handle on how to handle it, even though there’s no cure yet. “Because COVID-19 numbers and mortality are trending down, and there is awareness in the public about the importance of prevention, I expect us to see milder COVID-19 and possibly a smaller influenza season this year,” Naseer said.

Investigators found that the mean healthcare cost for treating elderly influenza patients per patient per flu season ranged from $3,299 to $12,398 higher than the costs for treating patients with congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, and stage 5 renal disease.

Just What the Flu Costs the Healthcare System

As portable medical devices wind their way from hospital unit to hospital unit, they might be dragging the pathogens that cause healthcare-acquired infections (HAIs) along with them. Unfortunately, there are no national protocols for disinfecting these portable medical devices (aside from manufacturer recommendations); the protocols for disinfecting them differ from institution to institution. Investigators with the Central Texas Veterans Health Care System wanted to see how well a disinfection tracking system (DTS) device would work in alerting healthcare professionals when computers-on-wheels or vitals machines needed to be disinfected. They unveiled their findings in a study (“HAI Prevention: SSIs, Disinfection, and Hand Hygiene100—Effect of Disinfection Tracking System on Cleaning Events of Portable Medical Equipment”) at 

They found that a prompt on the DTS device led to an increase rate of disinfection for computers-on-wheels. In addition, disinfections of both the computers-on-wheels and vitals machines were done more times than mandated by the healthcare system. “Additionally, it captured disinfection events successfully on the database demonstrating [that the DTS device can be an effective] tool for demonstration of compliance,” the study states.

Some of the data were gathered over 25 days in an acute care unit that had been recently equipped with a DTS device. In this part of the experiment, the DTS display screen had been turned off. Then came 42 days with the display screen on, which told the operators the number of hours since the last recorded disinfection event.

The DTS devices were placed on 10 computer-on-wheels and 5 vitals machines. “An interrupted time series analysis, using a Bayesian model compared the number of events in the display screen-off to the screen-on period,” the study states.

When the DTS screen was on during the 42-day trial period, there were 845 disinfections; with 104 events on the vitals machine and 741 on the computers-on-wheels.

“The mean events per device per day in the screen-on period for [computers-on-wheels] were 1.32 (1.10 – 1.57) times greater than those in the screen-off period,” the study states. “The mean events per device per day in the screen-on period for [vitals machines] was 1.37 (0.89 – 2.01) times greater than those in the screen-off period.”

The tracking of HAIs has become much more problematic since the arrival of the coronavirus disease 2019 (COVID-19) pandemic.In an 

, Rebecca Leach, RN, BSN, MPH, CIC, wrote that “not only were [infection prevention] programs stretched during the pandemic as part of the public health response, but also the HAI reporting was still being done. [Infection preventionists] had to figure out how to manage all the workload of the pandemic response and continue to keep surveillance and data reporting current and active.”

’s Editorial Advisory Board, added that “the work of HAI prevention was also impacted similarly, with less time for IPs to do rounding and focus on the elements that contribute to HAIs. As the national data is analyzed and released in coming months, it will be interesting to see if HAIs were impacted by COVID-19 and to understand exactly how a pandemic influences HAI prevention efforts. Anecdotally, patients with COVID-19 were seen to be high risk for HAIs, particularly CLABSI and CAUTI, due to long lengths of stay, duration of ICU admissions, proning treatments to help with respiratory function and other unique aspects of care.”

Investigators found that a prompt on a disinfection tracking system led to an increase rate of the disinfection of computers on wheels at a veterans’ hospital in Texas.

Disinfection System Targets Portable Medical Devices

It’s a hard thing to deny and a difficult pill to swallow—we’re in a third wave. Over ten months since the U.S. began to have cases of Coronavirus’ disease 2019 (COVID-19), and we’re still learning more about this pandemic and the transmission dynamics. Perhaps what is most daunting though, is not just the growing case counts and hospitalizations, but what we’re seeing in terms of demographics and data on complications.

Two new reports from the Centers for Disease Control and Prevention (CDC) in their 

(MMWR) shed light on some concerning trends we’re seeing with COVID-19. First, 

a research team analyzed over 9,000 hospitalized patients through the national Veterans Health Administration (VHA). Ultimately, they assess in-hospital complication risks for those with COVID-19 and influenza

 and found that those with COVID-19 had a higher risk for not only 17 complications, but also a five-times higher risk of dying in the hospital. The authors noted that “compared with patients with influenza, patients with COVID-19 had two times the risk for pneumonia; 1.7 times the risk for respiratory failure; 19 times the risk for ARDS; 3.5 times the risk for pneumothorax; and statistically significantly increased risks for cardiogenic shock, myocarditis, deep vein thrombosis, pulmonary embolism, disseminated intravascular coagulation, cerebral ischemia or infarction, intracranial hemorrhage, acute kidney failure, dialysis initiation, acute hepatitis or liver failure, sepsis, bacteremia, and pressure ulcers.”

excessive deaths associated with COVID-19

 from January 26 to October 3 of this year. Not only did the study find that there were nearly 300,000 excess deaths during the study period (66% were attributed to COVID-19), but the largest increases were in those aged 25-44 and among Hispanic or Latino patients. The authors shared that “excess deaths reached their highest points to date during the weeks ending April 11 (40.4% excess) and August 8, 2020 (23.5% excess).” In terms of racial and ethnic trends in excess mortality, the research team noted that “among racial and ethnic groups, the smallest average percentage increase in numbers of deaths compared with previous years occurred among White persons (11.9%) and the largest for Hispanic persons (53.6%), with intermediate increases (28.9%–36.6%) among AI/AN, Black, and Asian persons. “

These 2 MMWR reports are not only deeply disturbing about the direction of this pandemic, but should be seen as a blueprint for what we need to do. Focus on excess deaths, targeted prevention and testing resources, and ultimately acknowledging that currently we’re seeing a younger population being particularly impacted. It has been widely known that there 

COVID-19 has underscored disparities among underrepresented racial and ethnic groups

, so the question is: What are we doing about it? From an infection prevention standpoint, incorporating public health into our rounding and education can be helpful. Discussing vulnerable patient populations and how we can better serve them in the community, but also in the hospital. Ultimately, we need to start approaching infection prevention for what it is—the intersection of healthcare and public health.

It’s no longer just a matter of case counts and hospitalizations due to COVID-19, but it’s what we’re seeing in terms of the demographic groups being affected and associative complications.

Frontline Report: COVID-19’s Third Wave Has Arrived

Investigators with St. Barnabas Hospital in the Bronx in New York City want to point out that theirs is a small study—comprising just 18 patients—and so therefore the ubiquitous caveat toward the end of every study that “more studies on this subject should be performed” carries a little more weight than usual.

And though it may be small, it is certainly timely. They wanted to find out if patients suffering from both coronavirus’ disease 2019 (COVID-19) and influenza have worse outcomes than patients suffering from COVID-19 alone.

“There was no difference in the outcome in COVID-19 patients co-infected with influenza compared to non co-infected patients, however, a larger sample of cases will be needed for further assessment of these outcomes,” concludes the study “Association Between Influenza Co-infection and Poor Outcomes in Patients Hospitalized with COVID-19,” which was unveiled at 

The study notes that there have not been that many reported incidents of people co-infected with COVID-19 and the flu. But…. “Both infections have been known to share similar mechanisms of transmission, however currently, there is no evidence regarding the relationship between co-infection between this viruses and worsening outcomes,” the study states. “Once social distancing measures are eased, and daily activities resumed, there is a possibility for a second wave of cases. Given the incidence of influenza is higher during winter, a higher co-infection rate is expected in these months.”

Infection preventionists and other healthcare professionals have been bracing for the double whammy of flu and COVID-19 for several months. Back in August, Linda Spaulding, RN, BC, CIC, CHEC, CHOP, a member of 

 that this is uncharted territory; the healthcare system has never had to deal with SARS-CoV-2 and influenza at the same time. “Infection control people really have to monitor closely all respiratory viruses that are out there and be sure that you’re working actively with management to help put in place whatever needs to be put in place,” Spaulding said.

The St. Barnabas Hospital investigators in their hospital-based case-control study found 19 patients who’d been co-infected with the flu and COVID-19, but 1 of the patients did not meet the inclusion/exclusion criteria. Investigators reviewed the medical data on the remaining 18 patients.

“Controls were selected from the remaining pool of patients with COVID-19 in the same period. Cases were matched for age, sex and underlying comorbidities (hypertension, diabetes mellitus, liver disease, cardiovascular disease, HIV status, immunocompromised state other than HIV),” the study states. “The measured outcomes were: in-hospital mortality, need for mechanical ventilation, need for vasopressors and need for renal replacement therapy. For each outcome, Chi Square test and Odds ratio were obtained.”

Investigators stated concerns that the social distancing, hand hygiene and masking that’s been so crucial in attempts to slow COVID spread might be relaxed giving both COVID and influenza a chance to infect more people.

’s Editorial Advisory Board, said in a 

 back in August that those methods used against COVID seem to be particularly effective against the flu. The rates of flu in the Southern Hemisphere and in even back in March in the United States “just plummeted.”

“It’s a very steep slope,” Kavanagh said in August. “And so one would ask, ‘Why did that happen?’ Well, it happened because of the use of masks, hand hygiene, and social distancing. These same public health initiatives and strategies which are very effective on COVID-19 are even more effective with the flu.”

The St. Barnabas investigators found: “After statistical analysis, no significative difference was found in the following variables: in-hospital mortality [Odds ratio (OR) 0.769; 95% confidence interval (CI): 0.185-3.191; p value= 0.717], need for mechanical ventilation (OR 1.3; 95% CI: 0.313-5.393; p value= 0.717), need for vasopressors (OR 1.923; 95% CI: 0.383-9.646; p value= 0.423), need for renal replacement therapy (OR 1.0; 95% CI: 0.208-4.814; p value= 1.0).”

Nonetheless, flu and COVID co-infection remains a concern as winter approaches.

Study: “There was no difference in the outcome in COVID-19 patients co-infected with influenza compared to non co-infected patients, however, a larger sample of cases will be needed for further assessment of these outcomes.” 

Measuring Effects of Flu, COVID Co-Infections

Patients with coronavirus disease 2019 (COVID-19) are more at risk of contracting central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) than patients not afflicted with the novel coronavirus, according to a study by investigators with Denver Health Medical Center which was unveiled at 

. The retrospective cohort study was conducted at a 555-bed safety net hospital where infection rates from urinary catheters and central venous catheters were measured. Investigators compared infection rates from 6 months before the COVID-19 pandemic (October 2019 to March 2020) with infection rates during the initial pandemic phase. The hospital received its first patient infected with SARS-CoV-2 in late March 2020.

Hospital administrators sectioned off a part of the facility (4 units, 125 beds) to be used for patients who had been confirmed to have COVID-19. The other units in the hospital only accepted patients who tested negative for the coronavirus (except for a labor and delivery and a designated mixed unit).

The study states: “Patients hospitalized for suspected or confirmed COVID-19 often require high levels of support, including supplemental oxygen or ventilation, intravenous fluids and pressors, prone positioning, and strict input/output monitoring. Increased utilization of invasive devices such as indwelling urinary catheters and central venous catheters may be needed in this population.” In addition, healthcare providers minimized contact time with patients in the COVID units.

The use of indwelling urinary catheters increased during the initial pandemic stage by 36%, while use of central venous catheters increase by 25% in the same time period. CAUTI rates were 83% higher and CLABSI rates were 65% higher in the COVID-19 units compared to the non-COVID-19 units. In addition, rates for urine cultures were 69% higher and rates for blood cultures 73% higher in the COVID areas.

“Patient care protocols, device utilization and culture ordering all require further investigation,” the study concludes.

In September, Maya Gossman, RN, a vascular nurse and member of 

 about how important working with infection preventionists can be when it comes to containing CLASBIs and CSUTIs.

“Although both vascular access and infection prevention have their own focus, our commonality is in ensuring patients get the care they need while minimizing their chances of nosocomial infections,” Gossman wrote. “Infection preventionists have a wide scope, as infections can be caused by many factors while in the hospital, from medical devices to the hands of the healthcare workers caring for them. Vascular access specialists focus on the devices placed into the bloodstream of patients in order to deliver needed medications, allow access for dialysis, or accurately monitor blood pressure. It is because we know that these devices can be a conduit for life-threatening infectious agents that infection preventionists are vital to our specialty.”

Gossman relates how she and the IP at Stillwater Medical Center, in Stillwater, Oklahoma, worked together when the first COVID-19 patient arrived. The IP oversaw how Gossman inserted a vascular access line while wearing personal protective equipment. It turned out to be a success, but Gossman knew that there would be other COVID-19 patients.

“Less than 24 hours after placing that PICC line I met with our infection control nurse to discuss how the COVID-19 team was going to interact with the vascular access team,” Gossman wrote. “We collaborated to create a plan for best protecting our team of 2 from exposure while also ensuring that our patients were protected from further infection caused by a vascular access device. In addition, the infection control nurse and I met with the directors of the lab, the medical floor, and the intensive care unit to discuss ways to minimize exposure of their staff to the patients with confirmed COVID-19 infection.”

CAUTI rates were 83% higher and CLABSI rates were 65% higher in the COVID-19 units compared to the non-COVID-19 units. 

Study: CLABSI, CAUTI Rates Higher for COVID Patients

The growth of antibiotic resistant pathogens, the so-called Superbugs, has long been a concern for healthcare professionals. One of the main causes has been the overprescribing for antibiotics.

There are 4 “moments” involved as a healthcare professional at a long-term care facility (LTCF) weighs whether to prescribe an antibiotic to a patient or resident. Those 4 moments, as spelled out by the Agency for Healthcare Research and Quality (AHRQ), an arm of the US Department of Health and Human Resources, are:

Does the resident have symptoms that suggest an infection?

What type of infection is it? Have we collected appropriate cultures before starting antibiotics? What empiric therapy should be initiated?

What duration of antibiotic therapy is needed for the resident’s diagnosis?

Re-evaluate the resident and review results of diagnostic tests. Can we stop antibiotics? Can we narrow therapy? Can we change to oral antibiotics?

Investigators with Johns Hopkins University and other research institutions, with the aid of an AHRQ grant, set out to find whether having these moments help put the brakes on the overprescribing of antibiotics. The answer seems to be “yes.”

“By targeting both antibiotic prescribing culture and knowledge of best practices, the AHRQ safety program led to significant reductions in antibiotic use across a large cohort of LTCFs,” concludes their study (“Outcomes from the AHRQ Safety Program for Improving Antibiotic Use Across 439 Long-term Care Facilities”) unveiled at 

The investigators launched the AHRQ safety program in 439 LTCFs in the United States from December 2018 to November 2019. “Through webinars held 1-2 times per month and other educational content, the safety program emphasized 1) the science of safety to improve teamwork and identify antibiotic-associated harm and 2) clinical best practices in making antibiotic treatment decisions,” the study states.

Physicians, nurses, and nurse assistants were encouraged to participate. The LTCF recorded antibiotic days of therapy, number of urine cultures ordered, lab results identifying 

and the number of new antibiotic prescriptions.

“Generalized linear mixed effects models were used to calculate pre-post intervention changes at bi-monthly intervals for antibiotic DOT, antibiotic starts and UCX, each per 1,000 resident-days (RD), and 

LabID events per 10,000 RD, comparing the beginning (1/2019 and 2/2019) and end (11/2019 and 12/2019) of the safety program,” the study states.

The majority of the 439 LTCFs that completed the safety program the study describes as mid-sized, or 75 to 149 beds (229, 52.2%). Most were not affiliated to a hospital and were owned by a larger healthcare company (246, 56%), and there were even distributions between rural and urban settings. Three hundred and forty-eight (79%) of the LTCFs submitted both beginning and ending results.

“Antibiotic starts decreased from 7.89 to 7.48 starts/1000 RD; P = 0.02),” the study states “Days of therapy for all antibiotics decreased from 64.1 to 61.0 DOT/1,000 RD; P = 0.068) and for fluoroquinolones (an antibiotic targeted in the Safety Program) from 1.49 to 1.28 DOT/1,000RD; P=0.002. UCX decreased from 3.01 to 2.63 orders/1000 RD; P = 0.001). There were no significant differences in 

 about how COVID-19 has complicated the tracking of antibiotic resistant bacteria. Patients afflicted with COVID-19 have an increased susceptibility to antibiotic resistant infections both from prolonged hospitalizations and the use of immunocompromising agents such as dexamethasone,” writes Kavanagh, who is a member of 

’s Editorial Advisory Board. Kavanagh points out that patients with COVID-19 have longer hospital stays than patients with flu-like symptoms who have not been infected by the coronavirus. He also writes that COVID patients are much more likely to be hit by a healthcare-acquired infection, than non-COVID patients.

Kavanagh writes that preliminary data by the US Centers for Disease Control and Prevention “found that during the pandemic, total hospitalizations in the United States decreased by approximately 25%. However, inpatient antibiotic usage did not markedly change. The most common types of antibiotics prescribed were ceftriaxone for presumptive community acquired pneumonia, which increased by 22% in April and then fell during the summer, and azithromycin, possibly used in conjunction with hydroxychloroquine, the rate of which increased by 55% in April and then also fell. It was evident to me that in both cases the usage pattern represents changes in both diagnostic ability and treatment recommendations.”

There are 4 “moments” involved as a healthcare professional at a long-term care facility (LTCF) weighs whether to prescribe an antibiotic to a patient or resident. 