The second point that Linda Spaulding wants to make is that you—you, being infection preventionists and other health care professionals, 

 the public—is to read the fine print. That is, read all the literature that a health care provider will hand to you when you get either the Pfizer/BioNTech or the Moderna vaccines for coronavirus disease 2019 (COVID-19). The first point—the main point—that Spaulding, RN, BC, CIC, CHEC, CHOP, and a member of 

’s Editorial Advisory Board, wants to make is this: Get the COVID-19 vaccine. She can’t stress that enough. “I think it’s important for everyone to get the vaccine that can get the vaccine,” Spaulding said today in a wide-ranging discussion about the benefit of COVID-19 vaccination.

That discussion (which you can see in the video above) was so wide-ranging, however, that it ranged beyond what the Centers for Disease Control and Prevention (CDC) and many other healthcare experts have been telling the public. Spaulding had just recovered from the side effects of taking the second dose of the Pfizer vaccine. Like many people who get sick, whether from side effects or anything else, Spaulding did a deep dive into the literature. She found that the COVID-19 vaccines cannot:

Prevent you from getting COVID-19 again. “The research so far doesn’t know whether you can get reinfected with COVID, although they’re pretty sure you won’t die from COVID even if you get reinfected.” (The lack of research seems to be a 

Prevent you from becoming an asymptomatic carrier. Even after you get to 95% immunity, thanks to the second dose, you can still become an asymptomatic carrier of COVID-19.

Provide definitive data about what they can and cannot do. Though they’ve been granted emergency use authorization (EUA), the vaccines are still, in a sense, in the experimental stage. 

Spaulding says that the makers of the vaccines count on those who get it to help them collect more data. “If you experience any reaction to the vaccine, you scan that barcode on the paper that you’re given when you get the vaccine. It’ll take you to the Pfizer site, and then you have to input the side effects you had from the vaccine. Until this morning, I didn’t know that. And I only know that now because I’m having side effects.”

Spaulding continues: “I just heard it for the first time last night on the news. And it referenced back to the Pfizer and Madonna research studies. But how many people out there get a copy of the research study and read through it? They only take the information that’s coming out in the news media or in person-to-person conversations. And I think what I’m going to do today is I’m going to find those research studies, and I’m going to sit down and I’m going to go through them and find out what else don’t we know.”

Spaulding’s side effects included an upset stomach, headache, and other symptoms “mild enough to make you feel uncomfortable, but not anything that makes you feel super bad. And I have been hearing from some of my co-workers that they’re kind of experiencing similar symptoms anywhere from 1 day to 5 days.” These side effects don’t come as a surprise, really, and they manifested themselves in 

Spaulding doesn’t fear that her voicing caveats about the vaccines’ side effects or effectiveness will discourage the public and even her fellow health care workers from getting vaccinated. She wants to stress that you cannot get COVID-19 from the vaccine. Also, a vaccine that protects someone from dying of a disease shouldn’t be that difficult of a sell. And the more people know about the side effects, the better.

“In a way, it’s a good thing if you have some kind of side effects, because you know your body recognized it and it’s starting to protect you,” says Spaulding. “Now one of the things that I heard last night, and I have to look it up and verify it, but it was from a physician. She was saying that in the Pfizer and Madonna studies that they put out on their testing of the vaccine is that the vaccine did not always protect people from getting COVID. That’s why they keep saying even if you get vaccines still wear your mask, because you could still get COVID but you’re not going to have any symptoms. You’re not going to know you have it. And they don’t know if you can still transmit it to other people.”

However, Spaulding said that there is the risk that what appear to be side effects is actually the disease itself. The most notable tell is the loss of taste and smell. When that happens to health care workers, they are tested for COVID-19.

All of Spaulding’s experience reinforces what Anthony Fauci, MD, the director of the National Institute of Allergy and Infectious Diseases, 

: That people should continue with masking, hand hygiene, and social distancing even after the arrival of the vaccines.

However, the CDC has not been as forthcoming as it should have been, Spaulding believes. “Get the vaccine but know the limitations of the vaccine,” says Spaulding. “The CDC hasn’t been on top of getting all the information out there about the vaccines that it needs to get out there. Read everything that’s given to you—the literature—when you do get the vaccine. And the vaccine is not a miracle drug. There’s not enough literature out there yet to say that once you get the vaccine, you won’t get COVID again, and the literature that is out there says that once you get the vaccine, even if you don’t get COVID, again, you can still be an asymptomatic carrier.”

The CDC also hasn’t done a good enough job of letting the vaccinated know that they should report any side effects to the drug manufacturers. “This information hasn’t been pushed out there, either,” says Spaulding. “It wasn’t pushed to us when we got the vaccine—and we’re in a health care facility—that you need to read the papers that they gave you. And we encourage you to report your side effects. Because that’s only going to make things better. They may be able to change the vaccine, if it’s a vaccine that we have to get every year, to decrease some of those side effects. But if the general public doesn’t help out and let [the drug companies know] when they have the side effects, then companies can only go by the information that they have.”

Of course, getting buy-in from the public to forward information may take some doing.

“The majority of them get the papers, throw them on the other car seat and probably never, ever looked at them because they got the vaccine,” says Spaulding. “That’s all they were there for. But by putting this information out through [

], then people will be more aware. But it’s still not getting on the news where people watch it.”

The level of immunity that the vaccines offer will vary, says Spaulding. “They say 95%, but that is if you have a super-duper immune system. If you have other issues, you might get to 75% or 85%. So not 100% of the people are going to get a 95% coverage. And in the elderly, it might give 55% coverage. That’s just how vaccines are. It depends on how your body responds to it, how quickly it builds antibodies. And we’re all very different.”

Within 2 or 3 months, researchers may have enough data to be able to address some of the concerns that Spaulding raises. “As more of us get the vaccine, and we report side effects and that kind of stuff, then they will be able to take the research to a different level, to try to determine will it prevent some people from getting COVID at all,” she says. “Or will it just prevent people from dying from COVID. And remember, people from the age of20 to 95, have died from this virus.”

And surviving COVID-19 doesn’t always mean that you’ve dodged it. “A lot of the young people they think, ‘Oh, I can go get infected and get over it.’ But a lot of those people are ending up with lung damage for the rest of their life, heart damage for the rest of their life. If you have the COVID vaccine on board hopefully that will prevent you [from suffering from] the lifelong consequences of it.”

With that Spaulding leaves her second point—read the fine print—and returns to her first and main point. Get the vaccine, especially if you’re a health care professional.

“I wouldn’t play Russian Roulette with this vaccine. Because you want to get it, you want to protect yourself, and especially for nurses, you’re taking care of sick patients. You don’t want to be the person who comes to work and infect your patients and cause an adverse reaction.”

Videos

Linda Spaulding RN, BC, CIC, CHEC, CHOP:  “There’s not enough literature out there yet to say that once you get the vaccine, you won’t get COVID again, and the literature that is out there says that once you get the vaccine, even if you don’t get COVID again, you can still be an asymptomatic carrier.”

Pssst! Vaccines Can’t Guarantee COVID Immunity 

As the coronavirus disease 2019 (COVID-19) pandemic continues to rage 

, the need for infection preventionists and other healthcare professionals to man the frontlines against the novel coronavirus (with daunting 

 of complexity still being discovered) grows every day. They’re exhausted from holding off a disease for more than a year that now reaches unprecedented levels every 24 hours; caught in a cycle in which each day is worse than the day before.

When a health care professional is infected by SARS-CoV-2, if the symptoms are manageable, they’re quarantined for 7 or 10 or 14 days, as the US Centers for Disease Control and Prevention adjusts 

. Then many of those professionals—they’ve been called “heroes” with good reason—get right back into the battle. Because they’ve already gotten the disease, they’re now immune. But for how long?

About five months for about 17% of those workers, says a study by Public Health England (PHE) of about 20,000 health care workers in Great Britain. “The study found that antibody protection after infection lasts for at least 5 months, on average, and scientists are currently studying whether protection may last for longer,” PHE said in a 

. “This means that many people who contracted the disease in the first wave may now be vulnerable to catching it again.”

The PHE’s SIREN (SARS-CoV-2 Immunity and Reinfection EvaluatioN) study examines data of health care workers collected from June 18 to November 24, 2020, and found 44 reinfections—2 classified as “probable” and 42 as “possible—among 6614 workers who’d tested positive for antibodies. That’s an 83% protection rate from being reinfected by COVID-19.

However, asymptomatic carriers continue to be a 

 of COVID-19 spread. And the fact that 83% of health care workers appear to be immune from reinfection after 5 months, those who work, live, or gather with them may not be so lucky. These findings represent only the first stage of the SIREN study.

The PHE press release says that “although those with antibodies have some protection from becoming ill with COVID-19 themselves, early evidence from the next stage of the study suggests that some of these individuals carry high levels of virus and could continue to transmit the virus to others.”

Just how much protection and for how long the COVID-19 vaccines provide were not part of the investigation. As is the case with nearly all expert advice about avoiding COVID-19 infection, the SIREN investigators emphasize that the so-called 

 of infection prevention still need to be followed: hand hygiene, social distancing, masking.

“We now know that most of those who have had the virus, and developed antibodies, are protected from reinfection, but this is not total and we do not yet know how long protection lasts. Crucially, we believe people may still be able to pass the virus on,” PHE says in its press release. “This means even if you believe you already had the disease and are protected, you can be reassured it is highly unlikely you will develop severe infections but there is still a risk that you could acquire an infection and transmit to others. Now more than ever it is vital we all stay at home to protect our health service and save lives.”

Articles

It’s possible that infection preventionists and other health care workers who caught COVID-19 in the first wave can be reinfected.

Health Care Workers Can Get COVID Twice (at Least)

Environmental service (EVS) teams play a crucial (

) role in preventing infection at hospitals and long-term care facilities (LTCFs), but they’re not trained as well as they should be and see themselves as having a low social status. These are two of the findings in a preprint 

. Investigators with Clemson University conducted a systematic literature review of English language studies about EVS conducted between 2000 and 2009.

While environmental service workers (ESWs) felt that they provided little value to the organizations that they worked for, most of them nonetheless felt that the work itself was important in keeping patients safe from infections. The problem is that ESWs are not trained in any systematic and ongoing manner, the study states.

“To sustain improvements in disinfection practices, education/training sessions need to be continuous,” the study states. “The long-term commitment of an organization is also essential for continuous improvement in disinfection outcomes. While knowledge transfer is critical for behavior change, education/training also needs to focus on the skills and perceptions of ESWs.”

In 31 studies that the investigators looked at they note that ESWs know how to do their jobs but that knowledge “does not address many of the barriers identified by ESWs, such as high work demands, ‘me/us versus them,’ interruptions, low status or value for ESWs, and lack of communication,” the study states.

Training of ESWs should not only focus on organizational and work environment elements, but also intrapersonal and interpersonal skills. “Even in a skills-focused field like environmental service, leadership, self-management, conflict resolution, communication, emotional intelligence, and other ‘soft-skills’ are necessary to perform the job effectively,” the study states.

But how to measure how well ESWs perform? In the best of all worlds, that would be done by microbial assessments before and after cleaning. However, there are substantial barriers to doing so, including time constraints, financial costs, and the need to have the microbial samples examined in a laboratory.

At any rate, training about pathogens and microbials should be handled with care. “Many ESWs may not be able to understand advanced microbiology,so information in some areas (e.g., pathogens) should be simple. For example, rather than giving detailed descriptions of what pathogens are, the focus should be on how these pathogens can spread in hospital environments and what procedures ESWs can implement to prevent the spread of pathogens.”

Investigators also noted a dearth of data about EVS at LTCFs, which have been one of the main nexuses of the coronavirus disease 2019 (COVID-19) pandemic. Only one study looked at LTCFs.

“Long-term care facilities have been reported to pay considerably less attention in disinfection than hospitals, perhaps because of limited staff, insufficient infection prevention education, and staff perception of isolation and contact precautions,” the study states.

The training of ESWs noted in the studies involved presentations, instruction booklets, photographs, checklists, and online education modules. Training interventions covered importance of environmental disinfection, importance of disinfecting frequently touched objects, and transmission of health care associated pathogens and infections. “Opportunities for providing feedback during the intervention was reported as a motivational strategy in many studies to improve performance,” the study states.

study is that hospitals and LTCFs must make more of an effort to train ESWs and make them feel welcome.

“Even with the ongoing COVID-19 pandemic highlighting disease transmission in health care facilities, environmental services is still an occupation that receives little attention in society, and carries low occupational prestige in the United States,” the study states. “In the United States, many ESWs are immigrants, people of color, and receive low wages. The reviewed studies identified many ESWs who feel limited respect, appreciation, or positive feedback at work, yet ESWs consistently identified the need to do the job well. They are concerned about patient safety, which forces them to do a good job even if it takes too much time and they are possibly underappreciated.”

Many members of environmental service teams feel underappreciated and these health care professionals are not trained in any systematic and continuous way, a study states.

Environmental Service Workers Not Feeling the Love

 has been paid to two mutant strains of coronavirus disease 2019 (COVID-19) that have cropped up recently. There’s the B.1.1.7. strain that first appeared in the United Kingdom. It may be 70% more infectious than the strain the world’s been fighting for the last year. But indications are that the COVID-19 vaccines will 

Then there’s 501.V2. That’s a strain that first appeared in South Africa. That may prove to be more of a problem. Within that strain scientists have found what they’re calling an “escape mutation” 

. It’s feared that this escape mutation will do just what the name implies, allow the South African COVID strain to escape some of the antibodies that a vaccine will throw at it. So far, scientists say that it won’t render the vaccines useless, but it might weaken their effectiveness.

Meanwhile, the rollout of the COVID-19 vaccines that has not been going 

, might get even more problematic. The idea was that health care workers on the frontlines and all residents and workers in long-term care facilities should be first in line for the vaccines. Yesterday, that changed. Alex Azar, the head of the US Department of Health and Human Services, 

 that that approach has led to a vaccine distribution bottleneck. Only about 9.3 million people have received their first dose of the vaccine, according to the 

US Centers for Disease Control and Prevention

 even though 38 million doses of the vaccine have been made available to the states so far.

Azar yesterday pushed about 163 million more people to the front of the vaccine line. That’s about half of the adult population of the US. He did that with a directive saying that everybody 65 and older and anybody 16 or older with a comorbidity, such as diabetes or even someone who smokes, should now be considered priority targets for getting the vaccines.

In making the announcement, Azar used an analogy of boarding an airplane, saying that “you might have a sequential order in which you board people. But you don’t wait until literally every person from a group is boarded before moving on to the next.”

But does that analogy work in this case? Will the changed guidelines for who gets to be first in line make the COVID vaccine bottleneck even worse?

The CDC’s Advisory Committee on Immunization Practices (ACIP) created the COVID vaccine rollout guidelines that put health care workers and nursing homes at the front of the line. Beth Bell, a professor at the University of Washington, who chaired the ACIP working group, expressed dismay at Azar’s decision. She tells 

 that while everybody wants the most efficient vaccine rollout possible, she’s quite concerned that Azar’s changes aren’t the way to get there. Some experts, like Bell, fear that it will lead to longer lines and more confusion as to who should get vaccinated. For instance, as 

 points out, a 24-year old smoker will have the same vaccine priority as somebody who’s 85 and frail.

This goes on as COVID-19 continues to surge to unprecedented levels. Yesterday, 4320 people in the United States died from coronavirus disease 2019 (COVID-19), according to 

, a record and only the second time that more than 4000 people have died from the disease in a single day. Over the past week, an average of 3300 people 

 from COVID-19 each day. That represents a 217% increase from the average number of deaths per day in mid-November.

Since the pandemic began in the United States, there have been almost 23 million confirmed cases of COVID-19. About 381,000 people have died from the disease. In the world, there have been over 91 million confirmed cases of COVID-19. And, in the world, nearly 2 million people have died from COVID-19. Johns Hopkins University brings you these stats as well.

Within the South African COVID strain scientists have found what they’re calling an “escape mutation” named E484K. It’s feared that this escape mutation will do just what the name implies—allow 501.V2 to escape vaccine antibodies.

E484K Mutation Might Make COVID Strain Vaccine-Resistant

When it comes to infection control and prevention, especially in light of what we’ve learned during the coronavirus disease 2019 (COVID-19) pandemic, it’s best to get everybody involved, not just infection preventionists. Cedric Steiner, a licensed nursing home administrator, takes that even further: The entire building needs to be involved. He’s not talking about everybody who works in a hospital or long-term care facility, but the buildings themselves. “We have these aged facilities, right?” he tells 

. “But we know we need a better facility, a facility that’s capable of responding with the most basic of infection control, which is negative air pressure.” Computer technology will allow health care facilities to switch entire wings into negative pressure areas with just the flip of a switch. And, for long-term care facilities, the money’s there to make that conversion, Steiner argues. They pocketed a lot of taxpayer money under the Paycheck Protection Program and, in addition, residents at these facilities are mostly covered by Medicare, which also pays well. As Steiner puts it “that’s a significant amount of money.”

 did you find anything that surprised you? Or did it just reinforce what you already knew?

I was surprised at the success of those organizations, particularly Children's Hospital Philadelphia, when they had prepared for a pandemic with using the facility. The premise was looking at it from an infection control point of view—the actual facility. What can we use? What can the facility do for us? And organizations that had invested in building management systems, I think were highly successful. In our discussion with [CHOP’s Senior Director of Building Systems, Operations and Refrigeration] Rachel McCarthy at Children's Hospital of Philadelphia they told me that they had planned, and they had seen it coming. And I believe she mentioned at the time that they were more concerned about, well, there were several of them that came in … you remember SARS, but hemorrhagic fever or Ebola, I think was a big one that really kicked them off. And so, they saw that they needed more negative pressure rooms, and they looked to just broaden it to the whole facility. So a building management system is a system where it’s centrally controlled, and you can…. It’s not individual rooms. It’s the whole units, and she had described several floors with a flip of a switch that can be turned over. Of course, it needs to be monitored those first couple days, but it was turned over rather quickly in that whole area then became AIIR [Airborne Infection Isolation Room]. An area where you could protect your employees and your healthcare workers and the residents. My side would be the nursing home side. It’s a reflection of the hospital. The nursing homes were designed after hospital models. So, they were they were overflow. In the 1950s, there was an act—[

Hill-Burton Free and Reduced-Cost Health Care

 Act]. It gave loans and money to facilities to try to…. It was originally for hospitals, and then it went into nursing homes. So, they have similar models. Talking from a nursing home side of things, thinking retrospectively of what happened in hospitals, I think they’re going to have to do it—and I actually I think nursing homes are going to have to do it. Because we look at the pandemic. I mean, back in Washington State, you look at where it all started. At that nursing home there in Washington County, Washington. And if you look at that facility, it just tore through that facility tremendously. In my article, I led with a hospital up in New England that saw it coming and that was their response. I mean, the first thing that they decided to do was put in a negative pressure floor. So, I can’t imagine that they’re not going to see that as one of the first things that they want to do with their infrastructure. And I mentioned that bill in the 1950s because that was the last time a lot of money went into hospitals. If you think back to 1950 and the money that hospitals used to build, they weren’t thinking about these kinds of things. A lot of the infrastructure is outdated. And you can see that with that hospital, for example, that I mentioned in the article that converted [a floor] into a negative pressure floor. They had to do it on the fly. And they were very out front about doing it. And they were kind of advertising that they had done it. I can’t imagine that that wouldn’t be a focus going forward.

Who’s going to make negative pressure rooms work?

It’s going to be your building management, environmental services directors. And that’s the situation in some hospitals, I think, is that they’re actively involved, but they’re going to take a more active approach. And on top of that, you’re going to have to bring in as, as one of the gentlemen I interviewed Nick Clements says, you’re going to have to bring in IT services. Because really, where the system is heading is a building management system; it is a computerized building. So outside of the mechanicals, you’re going have your infection preventionist, and then you’re going to have the facilities manager, the people that can manage HVAC systems. They’re professional engineers. And then you’re going to have programmers. You’re going to bring in…. It’s the computer age. You’re going to bring in an IT specialist who makes sure these programs are written. Either that or they’re going to have to be out on the cloud, and as a hospital, you’re going to be contracting with somebody off-site to make sure that this is all functioning. I see that there’s going to be three parts here. You’re going to have the infection preventionists, the medical prevention team, the facilities prevention team, and then they’re going to have an IT component to that either on-site or off-site.

Nursing homes were designed as hospital models to take off of the hospital those residents so that they wouldn’t be so high cost in the hospital. They’re kind of like little mini-hospitals almost, in a way. Your question is really good, because you asked me about the hospital, and I’m starting with the nursing homes. But you’re dead on, it’s got to start in the hospitals. But the nursing homes are going to have to do the same thing. In fact, there might be more of a vulnerability in the nursing homes then there is in the hospital. Particularly with COVID-19. We’re looking at age, population. The hospital is pretty transient. But the nursing home…. One could make an argument that it’s more important there in some ways, because have you those residents in smaller spaces. You have a lot of visitors coming in and out. You have health care workers, and one of the problems is sharing of health care workers. A lot more sharing of health care workers happens in nursing homes then it does in hospitals. Where does it fall first? You’re probably right. It’ll go to the hospitals first, and then they’ll act as models. And then the nursing homes will have to pick up on that. And like I wrote, I think that’s already happening. And that facility [in Lancaster County, Pennsylvania], they’ve treated 100. Last time I checked recently, there were 100 residents that they had moved through that negative pressure space. It was only 13 beds, but it gave them the ability to treat and keep the virus confined to that area of the nursing home. And health care workers didn’t…. When we 

 they didn’t have any cases of health care workers getting the virus in that facility. So, 100 residents. And that was in what would be a rehab facility. And so, when you talk about how the financials work with nursing homes, those 100 patients where it would be paid by Medicare. They were well paying residents for the facility. It worked out very well for them in that they could bill infection isolation and get Medicare reimbursement. I think that there’s a need here in the nursing home. What I’m working on right now is working with building management systems to try to deliver a product to nursing homes so that they could have these zones that they could turn on with a switch, much like the hospitals. I think that’s where we’re going to have to go. Either that or the whole model of nursing care and nursing home care is going to change.

The model that we’re currently using: The only way you can get reimbursed or use Medicaid money really is if you go to a nursing home. Most state laws and most federal laws don’t allow Medicaid money to be used at home. If you want to stay at home, you couldn’t use that. I think there are some waivers, but usually you have to go to nursing homes. Well, you go to the nursing home, but that creates an infection control issue. Everybody’s supposed to be isolated, right? We were all supposed to stay at our homes, but instead you had to go to the nursing home or you you’re putting these individuals in nursing homes. And so, we have this problem. And then there’s the funding issue. The nursing homes were able to get PPP [

] money. I want you to think about it. They were able to get two and a half months of expenditures. Just a straight check, basically, to keep the lights on. That’s just you filed your expenditures, and the government wrote you a check for that money. It’s millions of dollars. A 100-bed facility probably is going to get like somewhere of upwards of $1.2 million to $2 million. And what do you do with that money? And the government said, “Well, it’s forgivable as long as you use it for PPE, utilities, and things like that.” One of the questions in the latest AARP magazine was where’s that money? What did they do with that money? Did they just spend it on testing? Did they spend it on employees? Staffing was a big issue. That was a legitimate issue: increasing staffing and pay. But how to account for that. If the long-term care industry decides that they’re going to pocket some of that money? I think that’s going hurt. It hurts them in the long run. I think the numbers are somewhere over 20% or 30% nonprofit and the other 70% or 80% is for profit. If you have some sort of public backlash with the taxpayer giving this large check to nursing homes, and they’re going to put it in their pocket and not go after infection control—what we’re talking about here—that, to me, is going to be…. Somebody is going to uncover that. I think the AARP is already going after it in their articles. So that’s a big issue. And I think that the hospitals will just defer it to the nursing homes, but I don’t see how they can. If the nursing homes do negative pressure or invest in their buildings, the hospitals surely do too. Which is going to come first, the hospitals or the nursing homes? That’s a great question you asked. I predicted nursing homes, you think,

You think so? That would be exciting, wouldn’t it?

Because as you said, they have a bucket full of money. They were the hotspots really of the COVID-19 infection. And there are definitely infection prevention problems at nursing homes. Most nursing homes do not have infection preventionists on staff for one thing. Some of that money can be paid to hire a full-time infection preventionist. And also, to convert some of those wings into negative pressure areas. That’s my take.

That’s my take as well and I’m out there talking to building management, systems providers. The technology’s there. As you go into Lowe’s or Home Depot, you have people hooking up their houses with their doorbells, video cameras and other things. And it’s when we’re talking about a building management system, we’re talking about card swiping. You can track medications. And running the HVAC system, and the air around the facility. It’s a whole bunch of pieces that all come together under that one network to really make your building a living component to your infection control. No more of this static building space. It needs to get involved with how you’re going to respond. And to those people who are infection preventionists out there—your audience—this is something that they need to look at. They need to really look at, “Hey, who else can help me out in my infection prevention.” In a nursing home, and I’m sure many of your readers know this, when influenza comes in, they start shutting the doors. First thing they do. So, of course, it’s in the back of their mind, but it needs to come to the forefront. I think it would be highly successful in it. You know, for the organization that I was at, I did some calculations on the number of residents that they had in the COVID wing and what those would be paying and that’s a significant amount of money. I mean, it replaced their rehab, when the rehab wasn’t available. As you know, many hospitals were no longer doing knee surgeries and that type of elective stuff. We have these aged facilities, right? But we know we need a better facility, a facility that’s capable of responding with the most basic of infection control, which is negative air pressure. And we know we need to get there like that hospital did and many hospitals around the world responded similarly.

This interview has been edited for clarity and length

Cedric Steiner: “But the nursing home…. One could make an argument that [infection control is] more important there in some ways, because you have those residents in smaller spaces."

Pressure’s on to Build Negative Pressure Facilities

Just when you think the numbers can’t get any worse, they do. December 2020 was the cruelest month when it came to coronavirus disease 2019 (COVID-19), that is until January 2021 came along. The United States topped 200,000 new COVID-19 infections yesterday for the seventh day in a row. In addition, the US has averaged more than 3000 COVID-19 deaths a day over the past week, according to 

 warned that the public should have greatly curtailed participation in social gatherings over the 

 and that might have happened to some extent, but not to the extent needed to avoid what could become one of the most brutal winters in US history from a public health standpoint.

 for a long time that asymptomatic carriers of the disease make it particularly difficult to control. Linda Spaulding RN, BC, CIC, CHEC, warned her fellow infection preventionists back in 

, that they might become unknowing carriers of SARS-CoV-2 who “could possibly give it to our co-workers and everybody we’re around and we’re never going to know we’re an asymptomatic carrier.”

The role of asymptomatic carriers continues to be explored in two recent studies in the 

 pre-print study, investigators with the University of Louisville found that 37% of patients presenting at a hospital are asymptomatic carriers of SARS-CoV-2. “The proportion of asymptomatic patients admitted with SARS-CoV-2 was significant,” the study concludes. “Identifying and isolating asymptomatic patients likely prevented exposure and development of hospital-acquired COVID-19 cases among healthcare workers and other patients, supporting the universal surveillance of all admitted patients.”

, investigators with Universidad Autónoma de Zacatecas in Zacatecas, Mexico found that “thirty-four (42%) contacts in the study were positive for SARS-CoV-2. Twenty-three (67.6%) manifested less than 2 respiratory symptoms, and 5 (14.7%) remained asymptomatic,” the study states. “The average of positive contacts by index COVID-19 case (R0) was 4.3 and the mean of time of positive COVID-19 test at sampling time was 18.9 days. Positive antibody test against SARS-CoV-2 was observed in 16% of the participants.”

In the study by the University of Louisville investigators, data were collected from patients who tested positive for COVID-19 and who were admitted from April 9 to July 1, 2020 to UofL Health, an acute care hospital in Louisville.

“All patients admitted to the hospital with positive SARS-CoV-2 RT-PCR tests were identified,” the study states. “The patients who had COVID-19 symptoms on admission were analyzed separately from those who were asymptomatic.”

Of the 103 patients who tested positive for the coronavirus, 65 were symptomatic, while 38 were asymptomatic. “The proportion of SARS-CoV-2 patients who were asymptomatic varied over the duration of the study but trended up from 20% at the onset of the study period to 60% at the end,” the study states.

Assume that everybody in a hospital setting might be an asymptomatic carrier of COVID-19, which will better protect not only patients, but infection preventionists and other healthcare workers as well.

“An important strategy to protect healthcare workers and other patients is to perform a surveillance test on all patients admitted to the hospital,” the study by the University of Louisville investigators states. “In addition to surveillance testing for SARS-CoV-2, other strategies utilized were standard and transmission-based precautions, as well as universal masking of all staff.”

Investigators with the Universidad Autónoma de Zacatecas found that respiratory symptoms alone might not be enough of an indicator to identify those infected with COVID-19. “The proportion of close contacts of COVID-19 patients infected with SARS-CoV-2 (42%) and with less than 2 or with no respiratory symptoms (82.4%) was high in the study population,” the study concludes. “A low proportion of COVID-19 patients had a positive test for antibodies against SARS-CoV-2. The screening for SARS-CoV-2 in close contacts of COVID-19 positive patients should be encouraged to avoid spreading the infection and the expansion of the disease.”

Investigators examined data collected from 100 patients from June to July 2020. They found that 34 of the subjects tested positive for COVID-19, and of that 34, 23 exhibited fewer than 2 respiratory symptoms, while 5 were asymptomatic.

“The proportion of close contacts of COVID-19 patients infected with SARS-CoV-2 (42%) and with less than 2 or with no respiratory symptoms (82.4%) was high in the study population,” the study concludes. “A low proportion of COVID-19 patients had a positive test for antibodies against SARS-CoV-2. The screening for SARS-CoV-2 in close contacts of COVID-19 positive patients should be encouraged to avoid spreading the infection and the expansion of the disease.”

Assume that everybody in a hospital setting is an asymptomatic carrier of COVID-19, two recent studies suggest.

Asymptomatic Carriers May Play a Huge Part in COVID-19 Surge

When the US Centers for Disease Control and Prevention (CDC) released 

 on shortened quarantine options, there was a mixture of relief and concern. What does it mean for infection prevention though?

As the coronavirus disease 2019 (COVID-19) pandemic reaches new records across all metrics—cases, hospitalizations, and deaths, we are struggling. Vaccine bottlenecks and distribution hurdles are stressing public health and healthcare resources even more and ultimately impact the public’s attitude towards the vaccine.

This pandemic has also pulled back the curtain on so many disparities across the United States, many of which we already knew about, but others that have been amplified by the stresses of the pandemic. A year into this, many of us have continued to hear accounts of people unable to quarantine after exposures. For so many, their places of work outside of healthcare have made it hard to be safe while paying bills, like having to take time off to quarantine if you have been exposed. Tough decisions like this make safety a challenging goal and if you have bills to pay and can’t take 14 days unpaid, it leaves little room but to work during quarantine.

Situations like these have challenged public health interventions to get people to quarantine for 14 days following an exposure. Late last year, the CDC released 

 on options to reduce quarantine. The goal was simple—if we can get people to quarantine for at least a minimum amount and get tested, we might have a better chance at getting them to stay home. Two options were presented—10 days of quarantine without a test, or 7 days with a negative test (test must occur on day 5 or after).

In both cases, people were still expected to monitor their symptoms until 14 days had passed since the exposure, Moreover, people still needed to mask, distance, wash their hands, avoid crowds, and other COVID-19 prevention efforts. The CDC noted that people need to follow their local public health department for quarantine requirements, but these recommendations had been made available. “CDC continues to endorse quarantine for 14 days and recognizes that any quarantine shorter than 14 days balances reduced burden against a small possibility of spreading the virus. CDC will continue to evaluate new information and update recommendations as needed.”

I think we can all agree that having some quarantine is better than none, but ultimately this really speaks to bigger issues with employers and how we financially support companies and their employees during a pandemic to encourage safety. When this guidance was released, there was a mixture of gratitude for its message, but also concern for how it would be utilized. With an average incubation period of 4-6 days, testing on day 5 or 6 for a 7-day quarantine period has the potential to miss infections.

(MMWR) evaluated a shortened quarantine period in Tennessee and Wisconsin from April to September 2020. The authors noted that “Among persons exposed to COVID-19 in the household who were asymptomatic and had negative laboratory test results through 7 days after symptom onset in the index patient, 19% experienced symptoms or received positive test results in the following week.”

The coming months will be telling in terms of how we approach quarantine and the implications of shortened quarantine periods. While it might be easier for people to adhere to, there is still concern for disease transmission and it is critical that those pieces be communicated to the public. For infection preventionists, there is likely pressure to utilize these measures, but it is important that we stick to local public health guidance and work to communicate the limitations of a shortened quarantine while promoting the need for continued infection prevention efforts.

The coming months will be telling in terms of how we approach quarantine and the implications of shortened quarantine periods. While it might be easier for people to adhere to, there is still concern for disease transmission.

Reasons for Shorter Quarantines Need to be Explained

The United States continues to struggle with vaccine distribution for coronavirus disease 2019 (COVID-19). Despite a federal goal of 20 million first doses by the end of December 2020, 

 people have been vaccinated so far. In fact, only 151,000 have been fully vaccinated. Over 22 million doses have been delivered to states, but as we know, delivery does not translate to distribution. A population-scale vaccinate rollout is no easy feat and with each state doing things a little differently, it’s not surprising that things are slow. Moreover, as hospitals and public health departments are primarily responsible for coordinating and managing the actual rollout can we blame these already stressed systems for falling behind? The goal of vaccinating as many as possible in a quick fashion is hard though and despite some reports, the issue isn’t really about people jumping ahead in line, but rather a larger, institutional failure to adequately resource large-scale vaccine rollouts. Vaccines sitting in freezers do us no good, so as we struggle with healthcare worker vaccine hesitancy and work to combat the bottlenecking, it’s important to look at the larger roadblocks that set the stage for these issues. Considering that only 30% of the distributed doses have been given, there is a lot of work we need to do and that isn’t just education and combatting hesitancy, but also making the process more accessible and easier to understand. Transparency about the hurdles and challenges helps people understand that this isn’t reflective of the importance or efficacy of the vaccine, but that such efforts require a lot of logistics and resources.

The news of two new SARS-CoV-2 variants over the past few weeks wasn’t particularly surprising, but something that added more stress. The two variations—B.1.1.7 first identified in the United Kingdom and 501.V2 first identified in South Africa, raised the red flag for the continuing challenge that is COVID-19. Perhaps the hardest piece to this is navigating what we know and what we don’t know, while there is continued and often sensational press coverage. This can make it hard to answer questions we’re getting in infection prevention—whether it be about the impact to testing or vaccination or even isolation precautions. The term “mutation” often triggers images of scary gain of function in the virus that concurs images of super strains. It’s important that we communicate to healthcare workers (and the public) that genomic changes in a virus are exceedingly normal. Moreover, we should be supporting more genomic surveillance to identify these more swiftly. What we do know is that the new strain B.1.1.7 is likely more transmissible, but does not appear to be causing more severe disease. The good news is that it 

. As we learn more information about 501.V2, more information will be released, which is why communication to frontline staff is so important. This doesn’t change the routes of transmission, but with a new strain that is more adept at spreading between people, it’s critical we are vigilant in infection prevention measures in the healthcare setting, but also outside of it. If nothing else, these new variants should serve as reminders of just how important these infection prevention measures are and our need to truly follow them.

For vaccines: Delivery doesn’t mean distribution. For variants: Their appearance underscores the importance of infection prevention methods.

Hot COVID-19 Topics: Vaccine Rollouts, Variants

In the life-or-death battle that infection preventionists and other healthcare professionals have been engaged in with coronavirus disease 2019 (COVID-19) this last year, some rudimentary infection control practices may have been sidelined if for no other reason than elective procedures have been sidelined. That concerns infection control expert Linda Spaulding, RN, BC, CIC, CHEC, CHOP. Spaulding, a member of 

’s Editorial Advisory Board, worries that in the post-COVID healthcare setting, the proper cleaning of endoscopes might not happen—at least not right away. “Those scopes have been sitting there for how many months now?” Spaulding tells 

. “We have to get back together and put together better programs and make sure we’re safe from there on.” Spaulding believes that infection control needs to function as a buddy system. “Whether it’s cleaning scopes, decontaminating and sterilizing surgical instruments, or putting on PPE. Somehow, in my opinion, we have to start having buddies in the hospitals, in clinics, in long-term care. We keep an eye on each other and remind each other about infection prevention practices.” Spaulding believes healthcare needs to be looked at in a “totally different light” post-COVID because “we can fix a lot of things before our next pandemic.”

So what are your thoughts about the cleaning of endoscopes?

Linda Spaulding RN, BC, CIC, CHEC, CHOP: 

OK. Well, you know, for the past few podcasts, we talked a lot about COVID. I think now it’s time to try to get back to other things, post-COVID, or in conjunction with COVID. And prior to COVID happening, we had been working a lot to prevent infections being transmitted from endoscopes. And what I mean by that is the endoscopes are used on the internal parts. Inserted internally on multiple patients with the same endoscope. Processing these scopes in between each patient is extremely important so you don’t take bacteria from one patient and accidentally insert it into the next patient and cause an infection. 

Over the years, we’ve had many outbreaks of infections related to endoscopes not being processed correctly. In January 2017, the CDC’s (US Centers for Disease Control and Prevention) HICPAC (Healthcare Infection Control Practices Advisory Committee) group; we had worked on new endoscope guidelines for probably a couple years before they were published. And they were published January 25, 2017. And what we found is that we got a little bit of traction, but not as much traction as we would hope to see. When people are hired into the endoscopy department, sometimes they do the endoscopy and assist the physician as well as clean the scopes. If you’re having a really busy day, the scope might not get cleaned as good as it should. And if it was cleaned properly, we wouldn’t have had clusters of infections related to them. So, one of the things that I think is essential for us to get out to people post-COVID—to start thinking about these things, again, trying to get back into some normalcy—is people in these departments and managers of these departments need to go on the HICPAC 

. And they need to download this document that I have right here with some of my notes on. It’s called “

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

.” This is an incredible tool that I wish I would have had earlier in my infection control career. 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. It gives you a policy format. It gives you audit tools. It gives you a competency verification tool, so you can make sure your people are competent. It gives you an inventory repair and maintenance log so you can log every single time a scope breaks and when it goes out. You can identify if you have a problem scope because it keeps going out for repair. And it also gives you a gap analysis tool and an RCA template. Now, some people may not know what a gap analysis tool is. But this is the actual tool that’s on the website. And it goes through everything you need to look at to make sure you have a good strong program in place. As you go through this, if you can answer “yes” to all of this, then you can be comfortable, you probably have a pretty good program in place. If not, it gives you the chance to say “OK, we don’t have this in place” or “We’re weak in this area.” And then that’s what you focus in on improving. I’ve gone in to do accreditation for hospitals where they didn’t even track their scopes. They didn’t know what scope was used on what patient or they didn’t know 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. What we did with the HICPAC committee is we put every single document together that you need to be able to have a strong, effective safe program. And CDC has their HICPAC meetings on campus in Atlanta. And we have general public people that are allowed to make comments at the end of the meeting. And I was a liaison on the HICPAC committee for five years. At the end when the general public would get up and ask questions, we would have family members that would come to the mic and tell us how we need to concentrate on endoscopes because their husband, their father, their daughter, had died because of an infection that was contracted from an endoscope. We want to think that all hospitals do everything correct. They all have best practice at heart. Nobody wants to do something wrong. But some just don’t have the tools to know what they’re supposed to be doing. They were hired, they were shown how to clean the scope. And then they’re out of orientation. If they were taught wrong, they’re cleaning the scopes wrong. There has to be verification and validation of everything.

Who actually does the physical cleaning of the scopes? Is this something that infection preventionists oversee? Or do they clean the scopes themselves?

No, usually infection preventionists don’t have anything to do with it. If there’s an outbreak, then infection preventionists will be all over it. But essentially, you could be hired by a hospital tomorrow. You can be told you’re going to be the endoscopy scope cleaner, or tech. They’ll bring you in, they will work with you, show you. Put you through training on how to clean the scope. Show you where everything is. And then you’re the endoscopy cleaning person. In some hospitals, it might be a nurse, because the nurse is helping the physician do the scope, then the nurse is cleaning the scope afterwards, getting it ready to use on the next patient and the next doctor who is coming in. You could see how shortcuts could be taken. And so, anybody can be trained to clean the scope. It’s just how well are they trained? And is the person training them really doing it correctly? And usually when we have outbreaks in these areas, we find that somebody was trained wrong. Or somebody says, “Yes, I follow all the steps that’s on this poster.” And then when you observe them, you find out they missed one or two steps. Those one or two steps are critical. We were talking about central line infections in another talk. I think I brought it up. It’s the same thing. If somebody’s not visually verifying and validating that the person is still doing it right, even if that person has been there 25 years, then things can go wrong, and you can end up with infections. You have some people that have been there 25 years. All they’ve done is scope cleaning. “Of course, I’m really good at it. I’ve been doing it for 25 years.” Yet we still find shortcuts. Because somewhere in their career, they decided to take a shortcut because they had to turn the scope over really fast. And then it’s like, “Oh, well, it worked that time. I’ll just keep doing it this way, because it’s quicker.” And nobody’s going to know that there’s an outbreak from endoscopes until enough physicians identify for themselves that, “Oh, I have a patient that got infected.” Then they hear from another doc. “You know, I have a patient that got infected after an endoscope.” And then they hear the third doc. And then the docs kind of put it together. “Wait a minute, there are three patients that had endoscopes here.” But if each physician is only seeing one at a time, nobody’s putting it all together that there’s a problem because the likelihood of one physician—unless he’s the only one that does the endoscopes—being able to identify an infection and [know how many people got infected is unlikely.] And if the docs aren’t talking and sharing that information, then nobody really knows until you have a whole lot of people infected. We’ve had CRE (carbapenem-resistant 

) transmitted by endoscopes. There has been 

 transmitted to multiple patients through endoscopes. Our goal would be: “Wouldn’t it be great if we had disposable endoscopes?” And we were 

 prior to COVID. And then all that stopped. So, we have to get back to basics, post-COVID, and start looking at our programs again. Because most likely, during COVID, people got out of the routine of cleaning endoscopes because we weren’t doing them because they were elective. And those scopes have been sitting there for how many months now? We have to get back together and put together better programs and make sure we’re safe from there on.

And finally, where do infection preventionists fit in this? Should they insist on trying to have more oversight on the endoscope cleaning process? Or will people be wary of that?

No. Infection preventionists need to learn how to clean an endoscope, or at least observe the cleaning. Every company that puts endoscopes out have really good posters on how to clean each part of the endoscope. Infection preventionists need to make rounds, they need to talk to the person processing. They need to watch the person processing and making sure there are no steps missed. Maybe I’m doing it and I missed step number three, and I didn’t even notice it. So, I go on to step four or five or six. If I have a buddy standing next to me, they can say, “Oh, wait a minute. You missed this one.” Infection control has got to become a buddy system. Whether it’s cleaning scopes, decontaminating and sterilizing surgical instruments, or putting on PPE. Somehow, in my opinion, we have to start having buddies in the hospitals, in clinics, in long-term care. We keep an eye on each other and remind each other about infection prevention practices. Even hand washing. See a physician or nurse or an aide or housekeeper come out of the room and they forgot to wash their hands. Everybody needs to say, “Oh, you missed a handwashing opportunity.” I tell my clients, during orientation you tell them that if a person walks out of the room and hasn’t washed their hands, that they will be possibly seen and another co-worker will say, “Hey, you missed an opportunity to wash your hands.” And the only thing you can respond is “Oh, thanks for letting me know” It takes away the meanness that can come out. “Don’t tell me what to do.” Or “I’m always being picked on.” Hospitals should let people know at the time of orientation that this is the culture we have at this hospital. If you don’t have your PPE on right, somebody may come to you and say, “Hey, let me help you put that on because it’s not on correctly.” We’ll save healthcare workers lives and will prevent infections in our patients. I think we just need to look at healthcare in a totally different light post-COVID than we did pre-COVID. Because we can fix a lot of things before our next pandemic.

Linda Spaulding RN, BC, CIC, CHEC, CHOP: “Infection preventionists need to learn how to clean an endoscope, or at least observe the cleaning…. Infection preventionists need to make rounds, they need to talk to the person processing.”

Endoscope Cleaning: What Infection Preventionists Should Know

That doesn’t mean that the United States and the rest of the world cannot return to something closely resembling what our lives were like before the coronavirus disease 2019 (COVID-19) pandemic, says Kevin Kavangh, MD, a member of 

’s Editorial Advisory Board. But just the fact that animals can catch COVID-19 is just one of the reasons that makes the disease endemic, says Kavanagh. “We really do need to learn to live with the virus,” Kavanagh tells 

. “Things will get much better, but I don’t think we’re going to be able to eliminate this virus off the face of the earth, similar to what we did with smallpox.” On the other hand, Kavanagh believes that the new COVID-19 vaccines will be effective against the variants of the disease that have recently cropped up. “Because as you know, a vaccine causes a myriad of antibodies to be formed to that spike protein. And a virus would have to evade every single one of them to be successful. And that’s a tall order.”

The appearance of that new strain of COVID-19 got many people thinking about what we might have to fear from 

Well, I think it was because it was timed with the vaccine, that people started to pay attention to these mutations. But actually, these mutations have been going on since March. And I wish at that time people would have said, “Hey, we need to slow down the spread of this virus,” and really observe social distancing, wearing masks and obeying public health advice. You need to remember that the first mutation of significance was probably the D614G mutation, which came to the United States from Europe. And that’s the prevalent strain, and it is also thought to be more infectious. This mutation just ratchets up the infectivity of this virus, which is of course a major concern. The more people that get infected, the more people that will potentially die, or become disabled from this disease. However, currently, there’s no indication that the disease that it produces is more severe. The jury’s still out on whether or not it can avoid vaccines. But from looking at the science, that is a tall order for the virus to do and it probably will not do that at this point.

I thought it was interesting that you just used the phrase who might die or become disabled from COVID-19. Can you explain a little bit more about what disabilities might result from COVID-19?

Well, one of the things that’s really frustrated me with this epidemic and pandemic is that people are totally focused on dying. In other words, who is going to have a fatality or a fatal result. But in actuality, the disabilities are much, much more concerning because that is even affecting the young people. And it can be chronically disabling to people. Not saying that death isn’t a terrible factor or a terrible outcome. But the disability can be long-term. You’ve heard the term long-haulers. And people that are hospitalized, oftentimes are discharged with chronic lung, chronic kidney, and chronic heart disease. As you know, I’ve written 

 that advocated that in many ways, COVID-19 is a heart and lung virus. Because it can have asymptomatic mild carditis, which can present decades later as a cardiac myopathy. This is to me very concerning. And as with any disease, as we learn more and more about it, unless people die, those individuals that escaped death are often severely sick and have chronic long-lasting effects of this disease. We really do need to also focus on that. In other words, what is the true toll on our society?

How many mutations could we possibly see with SARS-CoV-2?

There’s literally been thousands of mutations with this virus. If you go to 

, you can see them plotted over time, and over distance and location. But only the mutations which affect either infectivity or affect the spike protein which causes attachment of 

this virus to the ACE2 enzyme, those are the ones which are important, and the ones which are discussed in the media and tend to be tracked. This is an RNA virus. It mutates quite a bit. We shouldn’t be surprised at that. But the important mutations are ones of concern and they need to be followed. Now, I should add that infectivity is a lot easier for the virus to mutate than to mutate away from a vaccine. Because as you know, a vaccine causes a myriad of antibodies to be formed to that spike protein. And a virus would have to evade every single one of them to be successful. And that’s a tall order, because in that evasion, the virus also still needs to maintain the ability of that spike protein to attach to the ACE2 inhibitor. Otherwise, it trades survival from the vaccine for loss of being able to infect and reproduce itself with the cell. This is kind of the situation we see with the measles virus, where it does a lot of mutations. But it can’t mutate out of the vaccine’s coverage because if it does, it can’t become infectious. Now, as far as for monoclonal antibodies, or monoclonal cocktails, where you just have a small number of different types of antibodies, that the virus could evade, and there are some strains now, one, which I believe was detected in Scotland and in Romania, which has been able to mutate and evade, for example, a single monoclonal antibody. But that’s different than evading the whole vaccine. Of course, it’s still possible. And if it does happen, that will be a grave concern. Luckily, with the new types of vaccines we have, they’re kind of printed out in the lab. They’re not cultured. They’re not grown. You type in the sequence of that new spike protein, and out comes an mRNA, which can be inserted into the vaccine. It really is revolutionary, and it adds to safety. That would take four to six weeks to do. But nevertheless, the big problem is how do you re-vaccinate the entire world? We need to slow down the spread of the virus so we can slow down its mutations. That is of utmost importance. I think that they have to be able to articulate this message to the public, to give this as another reason why they shouldn’t be out and about and gathering. You have to remember, it’s not the vaccines which prevent disease. It’s vaccinations, and we don’t have enough vaccinations that have been performed. And so, they need to do that. And they also need to remember that if they do see something strange, or they do see a spike in cases, or they see people that are developing reinfection, they need to culture that virus and get it genetically sequenced. Contact the local health department. I’m sure they’ll be able to have instructions on how to do that. And certainly, the state and the CDC would be interested, because you want to make sure that a spike in reinfections is not being caused by a viral mutant. And so that’s going to be of utmost importance. And that’s something they need to be looking out for. [The vaccines] will still be effective. That’s what the good money is on. Can’t guarantee it. But certainly, that is the likelihood and what is expected to happen. But that doesn’t mean we should keep spreading around the virus because eventually the virus may find a combination that can both maintain its attachment to the ACE2 receptor, plus evade the vaccine. It’s just not good to do. This is another reason why this whole philosophy of herd immunity is just rubbish and magical thinking. We’re going to have to learn to live with the virus. We’ve talked about this before. We’re not going to have everybody taking the vaccine, and the virus has already showed up in the animal population of multiple species. It is unlikely that we’re going to totally eliminate the virus. I think getting a vaccine may become a yearly or every other year type of ritual that we’re going to have to start to undertake.

Why do you think herd immunity is magical thinking?

Well, herd immunity is where there are enough infected individuals that will stop the spread of the virus, and the percentage will depend upon the infectivity of the virus. The more infectious the virus is, the more people that need to be immune. The problem is if you have animal hosts, if your immunity drops, and it will over a couple of years, they’ll just reinfect you. You won’t be able to truly wipe out the virus. It’s not a good strategy of getting over this, we really do need to learn to live with the virus. Things will get much better, but I don’t think we’re going to be able to eliminate this virus off the face of the earth, similar to what we did with smallpox. And the reason for that is it has an animal host. The idea of going out getting infected and the virus will go away, that’s not going to happen. It’ll get better, infections will drop dramatically. We can return to a more normal life. But I think right now, it’s going to be pretty much endemic either in animals or in ourselves. And that will see it reoccurring in spots or in areas. And if we all let down our guard and let down our ability to fight off the virus by not getting vaccinations, we may go through this again a decade from now. We do need to follow public health advice. And we really need to get vaccinated at this point, especially if you’re a frontline worker. And it’s not if, but when you’ll come down with COVID-19.

What is happening here? It seems that you’re describing something like the measles and also, in a way, something like the flu that comes back every year.

Well, it’s going to be kind of like the flu in that it can mutate and come back, although maybe not mutate quite as fast as the flu. It’s unlike the flu, in that it affects every organ of the body. And I think it’s the people that are asymptomatic, that have the primary heart and vascular involvement. Although it’s asymptomatic, it still can be affecting those organs. And as you know, they account for up to 50% of the transmissions. And so, in that way, it’s very different. We’ve really never seen anything quite like this. And I believe it’s definitely deadlier than the flu that was back in 1918. There are two reasons for this. One, the 1918 flu had a tremendous amount of bacterial co-infections, up to 90% in the lungs of individuals. And at that time, medicine couldn’t treat that. So that resulted in a large excess mortality. And the other thing is, is that when you look at the infectivity of the virus, the 1918 virus was probably more infective. But it wasn’t because of the characteristics of the virus. It was because of the characteristics and behavior of the human population. At that time, we were in World War I. There was an initial outbreak, I believe it was in Kansas at one of the barracks. And from there, it just spread. And you talk about packing people into trains, into ships, into training camps, on the frontlines and trenches. It just spread the virus like wildfire, and so that you had a huge amount of spiking in cases along with fatalities which occurred. And this occurred worldwide because it was a world war. And so yes, you may see more actual fatalities in total from the 1918 flu. But that doesn’t mean that virus was more deadly because we were involved at that time in a world war, which was optimizing the transmission of that virus throughout our population. And remember that fatalities from a pandemic is equal to both the case fatality rate, but also the transmission of the virus. And that is a function of both the infectivity of the virus and the behavior of the population it has infected. So, I know that’s kind of a long answer. But this virus is entirely new, although it does have some similarities to some other viruses, and other infections, which allow us to predict what’s going to happen.

What’s your reaction when you see stories of famous people who are caught violating the social distancing rules that they’re telling the rest of us to follow?

Massive amounts of frustration, because that creates doubt in the public as to the validity of their advice. And this has been happening as you know, fairly commonly. You have a number of leaders who are not preaching the message that they are following. But there are also many leaders who are on both sides of the aisle. You can look at 

, all of whom are preaching the correct public health messaging of wearing masks, social distancing. Senator Bill Frist from Tennessee recently called upon both his governor and all governors to enact mask mandates during this terrible crisis that we’re currently undergoing for these few weeks. I do think that the messaging is a problem. We need to keep people on track. And I’ll be honest with you, the thing that bothers me more than anything, is that it seems like some of our leaders who have voiced so much that this virus is not much to worry about—“don’t wear masks”—seem to be at the front of the line to get the vaccine. And so that also is something which really gets me. I am kind of of the opinion, and I hate to say this on record, but if you haven’t been following public health advice, you should get a vaccine, of course, but maybe you should let others to be in front of you because you’re responsible for creating the predicament which we’re in. So that is another area that I think is very frustrating.

Isn’t that the crux of the situation? Human nature? Isn’t that what we’re up against here?

Oh, yeah. It’s all human nature, but it drives the public crazy. But this virus doesn’t care. The best example that I know of is what happened at the Louisville Zoo with the snow leopards. I think I mentioned this in my 

. The snow leopards, they’re very good at enforcing physical distancing. Not so good at wearing masks, and they caught COVID. You have to do both. The virus doesn’t care. If you congregate, you give it a chance, it’s going to spread. Your best defense right now is following public health advice. And when the vaccines are available, please get the vaccine.

Any final words of advice for infection preventionists?

Well, just that they should reassure people at this point to get the vaccine. The vaccine will in all likelihood be effective because, again, it’s very difficult for the virus to evade the myriad of antibodies that your body will produce to the spike protein, and at the same time, maintain its infectivity and ability to attach to the receptor on the cell. So please message your patients not to panic, but to please be diligent and follow public health advice, because even a more infectious virus can cause more deaths and is more dangerous. But the good news is, the vaccine still should work, as should social distancing and wearing masks making you safer. Although this is not good news, it’s not anything I feel to panic over. But it is something that should increase our diligence to follow public health advice.

Kevin Kavanagh, MD:  “One of the things that’s really frustrated me with this epidemic and pandemic is that people are totally focused on dying…. But in actuality, the disabilities are much, much more concerning because that is even affecting the young people.”