Getting vaccinated against coronavirus disease 2019 (COVID-19) will not become a mandated requirement for health care workers anytime soon, says infection prevention expert Sharon Ward-Fore, MS, MT(ASCP), CIC. “It took us 10 years to be able to mandate flu vaccine in health care,” says Ward-Fore, a member of 

’s Editorial Advisory Board. “And there are still some exceptions. I think it will be a long time coming before we’re able to mandate it.” In the meantime, Ward-Fore says infection preventionists will need to educate those inside and outside of the health care community about the value of getting the COVID-19 vaccine. Ward-Fore says that she considers IPs to be “a force to provide education on the necessity of the vaccine, and to help other health care providers understand the importance of getting vaccinated. There’s a lot of fear around the vaccine. And it’s actually quite a bit among health care providers, those frontline first responders.” Also, while this tug of war goes on, IPs need to remind everybody of the importance of social distancing, and wearing a mask. Also: “Don’t forget your hand hygiene. That’s our number one way to protect ourselves.”

So please help us make sense of everything that’s going on with the vaccination rollout and with the variance.

Let’s talk about the variant. I think one thing we need to keep in mind right now, as we get further into this, we will probably learn more about this variant. But right now, I think people need to understand that the importance of masking and social distancing really, really, really is important right now, because of the contagiousness of this new variant. People should not let their guards down even with vaccination happening. People still need to remain vigilant.

 It’s been kind of grim news lately. Do you see anything that might be hopeful? I guess the vaccines is a big hopeful story, right?

Right, the vaccine is hope. It’s on the horizon. But again, we’re nowhere near where we should be with percentage of people vaccinated in the United States. We really, really need to ramp up vaccinations so that now people can sort of, I won’t say relax, but be a little more comfortable with the fact that eventually we will not have to mask and socially distant. And that now is the time with vaccinations we can begin to start loosening restrictions, and maybe opening up restaurants for dining and trying to get some semblance of normality. But again, we’re a long way from being there just yet, so people need to be patient.

Where do infection preventionists fit in all of this? I know in some hospitals they oversee flu vaccination efforts. Do you see them overseeing COVID-19 vaccination efforts at hospitals?

I don’t really see that at this point, because the vaccine is not mandated. But I see them as a force to provide education on the necessity of the vaccine, and to help other health care providers understand the importance of getting vaccinated. There’s a lot of fear around the vaccine. And it’s actually quite a bit among health care providers, those frontline first responders. 

And those are really the folks you want to protect first and foremost, because we don’t want them to get COVID. There is a lot of information on the efficacy of the vaccine. And although there are some side effects, they are very, very rare and very few and far between. I think health care workers should look to the IPs to answer questions about it. And IPs need to be armed with current information about what’s happening in other parts of the world that have been giving the vaccine for quite a bit longer than we have in the United States and provide that information to health care providers to help ease some of their concerns.

What parts of the world are we talking about? I imagine you might be talking about the United Kingdom?

Right, the UK. And the UK has been vaccinating for a while. They’ve seen very few reactions, just a couple severe reactions. But when you think about the number of people they vaccinated, you’re going to see vaccine reactions with any vaccine. I think knowing that it’s been successful in the UK, that the United States needs to look to those folks to provide information to us and IPs need to take that information to the frontlines and say, “Hey, they vaccinated X number of thousands of people here.” And actually, in the United States, there’s quite a bit of people that have received the first vaccine. You can look to those first vaccine folks and say, “You know, I got it. I didn’t have any side effects.” And now we see the second wave of people getting their second vaccine with very little side effects. I think as more and more people are vaccinated, I hope health care will look at that information and step up and get vaccinated themselves.

I have to ask you this. Did you get the vaccine yet? Do you intend to get the vaccine when you’re able to get the vaccine?

I do intend to get it I don’t qualify right now, believe it or not. I’m not old enough. And I don’t have any comorbidities that I’m aware of. But I will say that my husband, he works in health care, also. He did receive both sets of vaccine with no side effects whatsoever. You know, injection site pain. That’s really about it. He’s had both doses. He’s had the Pfizer, I believe, and he said, no problems with it whatsoever. If I could get it right now, I absolutely would. No questions about it.

Do you see COVID-19 vaccinations becoming a yearly or every other year thing in hospitals?

From what I’ve read, it seems as if we’re going to be dealing with COVID-19, like we do with some strains of the flu. And I think the dream is to eventually include it in our flu vaccine. It’s kind of like, you know, a twofer. When you get vaccinated, you’ll be vaccinated against flu and COVID-19. So, according to what I’ve read, we will be dealing with COVID-19 for some time as a seasonal strain. You know, sometimes we see SARS and we’ll see MERS kind of circulate through. It’ll be that kind of thing. But I don’t believe it will be on the same scope of what we see now. And I hope not because eventually, once we have everyone vaccinated, or at least a good percentage, we’ll have that herd immunity necessary to keep it from becoming another pandemic.

Rates of infection seem to be going down in most states. Are you worried that that might lead to complacency?

Absolutely. I’m in Chicago. And right now, our positivity rate is about 8%. So now, our mayor is looking to open indoor dining. Although I understand the need for it, I think we can do it and do it safely. As long as people continue to mask up, continue to socially distance and try and avoid indoor dining as much as possible. I mean, any time you’re in a place and you have to remove your mask, it really puts you at risk and anyone else in the room that’s unmasked. Even people who are masked, because we know that masks are only 65% effective. So, I think I’m a little worried. But I’m hopeful that people will continue to do the right thing. And it will give them just enough leeway to feel more comfortable and continue to follow these restrictions because they’ll feel a little less restrictive.

What I’ve heard from people who are angry about the lockdowns is they’ll say something like, “Well, you’ll notice that everybody who’s pushing for lockdowns, they all have guaranteed paychecks.” There is real economic harm being done because of the lockdowns. Has that line been thrown at you and how do you respond?

I agree there’s a huge range of disparity regarding health care and accessibility. And you’re right, those of us who have been able to work from home, this has been not such a bad thing. But when you’re out in the frontlines…. Say you’re working in the grocery store. And I’m hoping that you’ve been given the best information to help keep yourself safe. But I will say, I was at the grocery store not too long ago. And it was the grocery store workers who are not complying with wearing masks, putting them at risk. And maybe it’s because they’re there eight hours a day, and they’re wearing that mask all day long. I think even with education, there's just fatigue. Think about it. Only those of us in health care are used to wearing masks for extended periods of time. I understand why, you know, the layperson struggles to wear it. But there’s been education about the necessity of it. I think just some people don’t get it or they think it won’t be me.

Advisory Committee on Immunization Practices

 announced that they’re going to meet January 27 to talk about everything vaccine related, like what’s going on with the rollout, what’s going on with efficacy, what’s going on with the willingness of people in general and health care workers to get the vaccine? Would you like to be a fly on the wall at that meeting?

I would love to be a fly on the wall. One of the things I’ve been doing during the pandemic is I’ve been volunteering with the City of Chicago to do contact tracing. And some of the discussions we have had and the frustration that’s been felt with the anti-mask movement is very palpable. I think those same kinds of things will be discussed during this meeting. I don’t think a lot of people understand that public health isn’t just about me. It’s about you and everyone else. And for some reason, we’ve lost that. I think there’ll be frustration that the reason we’re where we are today is because we didn’t get it right in the beginning. I think they’ll talk about lessons learned. I think the mask mandate may be something that’s coming. I know it’s coming for federal employees, which is a good start. Maybe if we can get that done, and they discuss something like that, that will help rein in this more contagious strain, because it is a more contagious strain, which can continue to put a strain on our health care system. I think they’re going to need to address those kinds of things. Vaccine rollout is really, really important. For those vaccines that are sitting on the shelf in the hospital that health care workers don’t wish to take, I think it’s time to put them in the arms of those who do wish to take. And we’ve got to move mountains to get vaccine into arms to be able to get everybody safe and our economy opened up. I think there’ll be a lot of discussion about what’s going to be the fastest way to get this done.

When the infection preventionist wakes up in the morning, what should she do in terms of where they’re getting information from? Should they go to the 

Johns Hopkins Coronavirus Resource Center

? There’s a very good tracking project at 

. Is there a certain source that you look for as soon as you wake up?

I start locally, because you know, every place is different, every demographic is different. I’ll start with the City of Chicago, the Department of Public Health 

 for my local information, to see what’s happening in my neighborhood. And then, they receive their guidance. It all comes from the top-down. The CDC and WHO and then it all flows down. But I think it’s in your best interest wherever you’re located to see what your local departments of public health and officials are recommending. And we’re actually held accountable for the strictest regulations. So, if those are the strictest regulations, and they’re giving you guidance, that’s who you follow. I’ve looked at them for information. That’s why I know today, Chicago, is it 8% positivity, and we were at 10% last week. Things are headed in the right direction in Chicago. Follow your local guidance.

I’m going to put you on the spot here, but mandated COVID-19 vaccination for health care workers: Are you for or against?

I’m actually for it, but I understand the reticence. It’s a new technology. It took us 10 years to be able to mandate flu vaccine in health care. And there are still some exceptions. I think it will be a long time coming before we’re able to mandate it. But I think just like measles, mumps, rubella, all of those vaccines, I think it’s something that we should think about mandating in the future. And it’ll be based on really more long-term data on it, and the efficacy and the safety of it. And once we have that I think more health care workers will decide they want to get it. And then hospitals will be able to mandate it because they’ll have a lot of data behind it. The safety of it, which is the main concern.

Is there something that I didn’t ask you that you think is important for your fellow infection preventionists to know about either about the variants or the vaccination effort?

No, I think you covered it all. But one thing I want to remind IPs is have them remind everyone they interact with to continue to be vigilant. To wear your mask appropriately up on the bridge of your nose so that it’s a nice tight seal on your face and pull it under your chin. Make sure you’re wearing some kind of eye protection. If you’re face to face with people and you’re within that six-foot radius and continue to socially distance, I always say six feet is the minimum and I stand quite a bit farther away. And hand hygiene. Don’t forget your hand hygiene. That’s our number one way to protect ourselves. Infection preventionists need to remind people to be vigilant both in health care and outside of health care. Because we’re not done with this yet. We have a long way to go before we’re fully protected.

This interview has been edited for clarity and length.

Videos

Sharon Ward-Fore, MS, MT(ASCP), CIC:  “Infection preventionists need to remind people to be vigilant both in health care and outside of health care. Because we’re not done with this yet. We have a long way to go before we’re fully protected.”

Infection Preventionists Must Teach Value of COVID Vaccines

The vaccines for coronavirus disease 2019 (COVID-19) are truly miracles of modern medicine. They were created in just 9 months, where often the time it takes to make and distribute a vaccine is measured in years. So—as 

 pointed out recently—hats off to the pharmaceutical companies who pulled off a nearly 

. Now, it’s the federal government’s turn to pull off a nearly impossible feat and President Biden plans to do just that.

 since the first person in the United States was given a COVID-19 vaccine. Since then, about 

 have received at least 1 dose of a COVID-19 vaccine. That’s not much in a country of 

The Biden administration wants to buy 200 million doses of Pfizer and Moderna vaccines and hopes to have 300 million Americans vaccinated by the end of the summer. The administration also plans to increase the number of vaccines being shipped to states weekly from 8.5 million to 10 million.

President Biden also wants to press companies into manufacturing the vaccines faster and is asking Congress for $20 billion to set up mass vaccination centers that, President Biden hopes, will be able to serve more people more efficiently.

 today talks about one of the possible byproducts of vaccination—a humane byproduct. The author is Ben Moor, an anesthesiologist and pain specialist. There are a lot of horrible things about the COVID-19 pandemic. But possibly one of the more heart-breaking aspects is that people have to die alone. Loved ones and friends cannot gather around somebody’s deathbed because of the contagious nature of COVID-19. Moor says that the vaccines offer an opportunity for volunteers to be with those patients in these agonizing moments that often turn out to be their last moments. Moor says that such a movement needs to happen organically, and should probably start with those who have been first in line to be vaccinated—frontline workers at hospitals. It needs to come from doctors, nurses, infection preventionists, technicians, environmental service workers—anyone at a hospital whose been vaccinated—to dedicate a few minutes at the beginning or end of their shifts to be with a COVID patient. To serve as a link between that dying patient and their loved ones.

One hurdle to this project remains the fact that most hospitals have not made taking the vaccine mandatory, even though some federal agencies such as the Centers for Disease Control and Prevention (CDC) and the Equal Employment Opportunity Commission (EEOC) are inching toward doing so because COVID-19 can be considered an 

 feel that there’s still too much we don’t know about the vaccine.

This is one of the many aspects of living with COVID that need to be worked out against a backdrop that sees the recent surge subsiding and states starting to reopen. Yesterday, there were 146,640 newly confirmed cases of COVID-19, according to 

. While the curve seems to be flattening nationwide, case counts continue to rise in a handful of states. They are California (21,823), Texas (21,197), New York (11,040), Florida (9594), and Virginia 8392. And, death counts are rising as well. Yesterday, 4087 people died from COVID-19, according to Johns Hopkins. Only 3 other days in the pandemic have seen more than 4000 deaths.

Overall, in the US, there have been over 25.5 million confirmed cases of COVID-19. About 425,000 have died from the disease. In the world, there have been over 1 million confirmed cases of COVID-19. And, in the world, over 2.1 million people have died from COVID-19.

Articles

Whether to make getting the COVID vaccine mandatory for health care workers is something that needs to be worked out against a backdrop that sees the recent surge subsiding and states starting to reopen.

Push on to Vaccinate Majority of Americans by End of Summer

British Prime Minister Boris Johnson announced today that the variant of coronavirus disease 2019 (COVID-19) that emerged in the United Kingdom, and which experts said could be 50% to 70% more contagious than traditional COVID is also 30% deadlier, according to news outlets such as the 

At a just concluded news conference, Johnson said that “we’ve been informed that in addition to spreading more quickly... there is some evidence that the new variant... may be more associated with a higher degree of mortality.”

The UK's chief scientific adviser, Patrick Vallance, broke it down this way, according to 

. “If you took... a man in their 60s, the average risk is that for 1,000 people who got infected, roughly 10 would be expected to unfortunately die with the virus. With the new variant, for 1,000 people infected, roughly 13 or 14 people might be expected to die.”

's Editorial Advisory Board said that "initial reports that the UK Variant is not more lethal than our current strain and that its increase in transmissibility was possibly due to an increase in viral production by the patient did not make sense. Since, increased viral load should produce a more severe disease in the patient. I was thus hoping for another mechanism, but it now looks like this strain may be more lethal after all and to make matters worse, it may have an increased propensity to infect children and young adults."

The Centers for Disease Control and Prevention 

 that if drastic infection prevention measures aren’t taken against B.1.1.7, it could become the main variant in the United States by March.

CDC investigators examine multiple models of how B.1.1.7 might spread. One of the models assumes that 1 million COVID-19 vaccines are distributed a day, beginning January 1, 2021. That model also says that 95% herd immunity was achieved 14 days after people were given the second dose of the vaccine. Obviously, this hasn’t happened (whether we can ever achieve herd immunity against COVID-19 is a matter of 

), but the investigators wanted to see how much a threat B.1.1.7 would present if near universal immunity against infection is assumed.

“In this model, B.1.1.7 prevalence is initially low, yet because it is more transmissible than are current variants, it exhibits rapid growth in early 2021, becoming the predominant variant in March,” the study state. “Whether transmission of current variants is increasing (initial Rt = 1.1) or slowly decreasing (initial Rt = 0.9) in January, B.1.1.7 drives a substantial change in the transmission trajectory and a new phase of exponential growth. With vaccination that protects against infection, the early epidemic trajectories do not change and B.1.1.7 spread still occurs.

Even with the advent of vaccines, monoclonal antibodies, and testing many COVID-19 discussions circle back to the low-tech tools of infection prevention—hand hygiene, social distancing, wearing a mask—and the CDC’s warning about B.1.1.7 is no exception. A study published in the CDC’s 

 said that “the increased transmissibility of this variant requires an even more rigorous combined implementation of vaccination and mitigation measures (e.g., distancing, masking, and hand hygiene) to control the spread of SARS-CoV-2. These measures will be more effective if they are instituted sooner rather than later to slow the initial spread of the B.1.1.7 variant.”

Unfortunately, the vaccine rollout hasn’t gone as planned, to say the least. A 

 released today by the Kaiser Family Foundation (KFF) finds that Americans are growing impatient with stalled distribution efforts and the fact that vaccine supply cannot keep up with demand. The KFF poll “finds two-thirds of U.S. adults (65%) say the federal government is doing a ‘fair’ or ‘poor’ job of distributing vaccines to the states. About three in ten adults give the federal government a positive rating of ‘excellent’ or ‘good’. Likewise, six in ten think their state government is doing a ‘fair’ or ‘poor’ job of distributing the vaccine to people in their state.”

Kavanagh argues that now is the time for the CDC to be proactive in its outreach to other countries. "The new emerging coronavirus strains underscore the necessity of not only having increased vigilance on our shores and the need to expand our genomic surveillance in the United States, but also to reactivate and expand the CDC's foreign support services and personnel. Similar to Ebola we need to stop these new biological threats in the countries they emerge in, rather than let them spread around the globe and into the United States." 

British Prime Minister Boris Johnson said that the B.1.1.7 variant of COVID-19 which was said to be 50% to 70% more contagious, has now been discovered to also be 30% deadlier. The CDC warns it could become the dominant strain in the US by March.

B.1.1.7 Now Said to Be More Deadly and Contagious

The approval of the Pfizer and Moderna coronavirus disease 2019 (COVID-19) vaccines for emergency use authorization in the United States has brought much attention and focus to the vaccination process. Because of the high demand for and low initial supply of the vaccines, the government has sought to prioritize them for individuals at highest risk for complications from COVID-19, and those who hold essential service roles that are vital to a functioning economy and health care system.

By all accounts, the rollout is still a work in progress. On January 12, Alex Azar, former head of the Department of Health and Human Services, said that focusing on health care workers and long-term care facilities has led to a vaccine distribution bottleneck. Azar issued a directive saying that people aged 65 years and older and those 16 years and older with a comorbidity should be considered priorities for vaccination. That, in effect, pushed about 163 million more people––about half the population––to the front of the vaccine line.

But back to health care systems. What many people outside the health care realm do not realize is that vaccination logistics and planning is in the yearly wheelhouse of hospital systems. Vaccinations to combat a variety of diseases are given every day, from the first-dose hepatitis B vaccine given to a newborn, to the tetanus, diphtheria, and acellular pertussis (Tdap) booster given after one scrapes against a rusty nail, to the yearly influenza vaccination.

The role of an infection preventionist (IP) in vaccination efforts is important, both to patients and providers, regardless of whether the setting is a large hospital system or a small provider’s office. IPs can help to provide best practice recommendations on immunization, from explaining sterilization techniques, to educating health care staff on the importance of vaccination, to working with occupational health in tracking rates of vaccination.

Not all IPs can administer the vaccine directly as some lack a health care degree, but they can be subject matter experts in the logistics of large-scale vaccinations. As such, it is important they participate in multidisciplinary projects involving vaccination efforts.

Proper infection control practices in vaccine administration are critical to ensuring safety and efficacy. Vaccine vials must be disinfected with sterile alcohol prep pads prior to each withdrawal and a new, sterile needle and syringe used for each injection.

Vaccines should be drawn up in clean medication preparation areas that are not next to any dirty items, and doses should be administered as soon as they have been drawn up to avoid any potential for spoilage. For vaccines that have been prepared for administration, the date and time should be marked on the syringe to alert the administrator to when the vaccine can no longer be given.

A common misconception about vaccine administration is that gloves must be worn. Per Occupational Safety and Health Administration regulations, gloves are not required when administering vaccines unless the individual administering the vaccine has open lesions on their hands or is likely to come in contact with a patient’s 

. If gloves are worn during vaccine administration, they must be removed between each patient and hand hygiene must be performed before donning a new pair of gloves. If gloves are not worn, hand hygiene should be performed between each new patient administration.

Vaccine hesitancy is another area in which IPs can aid departments in helping alleviate fears and answering questions. Whether it be the influenza or the COVID-19 vaccine, the misconceptions surrounding them or fear of what may occur post vaccination are just 2 reasons that individuals may choose to not receive the vaccine.

IPs can help to engage health care employees and answer questions while also directing them to primary resources for further information. These include the Centers for Disease Control and Prevention (CDC) and the World Health Organization. IPs can also coordinate with physicians and other subject matter experts on common areas of vaccine hesitancy among staff, and work with key stakeholders to address them.

As vaccine rollouts begin, IPs can also partner with occupational health teams to track and trend compliance with vaccination. Regarding annual influenza vaccination of health care staff, hospitals must report compliance rates to the 

. Often, IPs may be the only individuals who have access to this website, so it is vital they work with occupational health to obtain accurate counts of adherent and nonadherent staff. Trending health care vaccination rates by department or role type can also be valuable indicators for how to focus education efforts during the following years to increase compliance.

Although we do not yet know if the COVID-19 vaccine will be recommended yearly or whether it will offer longer immunity against severe acute respiratory syndrome coronavirus 2, health care facilities will continue to provide the influenza vaccine yearly to employees. They will also be prepared to modify their processes to help increase adherence rates, and IPs can collaborate in these efforts as well.

ANJALI BISHT, MPH, CIC, is the lead infection preventionist at an academic medical center that comprises a number of hospitals and an extensive primary care network in the Los Angeles region in California.

Infection preventionists can coordinate with physicians and other subject matter experts on common areas of vaccine hesitancy among staff, and work with key stakeholders to address them. As vaccine rollouts begin, IPs can also partner with occupational health teams to track and trend compliance with vaccination.

Infection Preventionists Play Crucial Role in Vaccine Efforts

A clinician walks out of a patient’s room. Seconds tick by. The clinician takes a bit too long to clean his hands. “Please sanitize,” a calm voice says. It’s coming from his belt, apparently.

Actually, it’s coming from the badge attached to the belt. The badge reel contains Bluetooth technology, which communicates with sensors affixed to soap and sanitizer dispensers parked in various places around the patient care area.

If hospital administrators could have 1 wish, it might be to have 100% compliance with hand hygiene protocols. So, they are doing everything they can to encourage compliance, which is particularly critical now when people (including 3142 health care workers as of January 7, 2021) are still dying of coronavirus disease 

Electronic monitoring, sensors, and voice prompts aren’t new, and the technology keeps evolving. The Clean Hands–Safe Hands system, for instance, allows users to customize the audio file reminder with their preferred voice and content, such as the infection preventionist’s (IP) or a child’s voice.

Personalized touches like that are born of experience. Hospital experts know that monitoring alone doesn’t change behavior. In fact, technology alone isn’t always the answer either. Some of the most effective systems are a hybrid of the latest technology and “oldfangled” methods such as rewards and recognition.

Take the solutions they came up with at Sentara Healthcare, a not-for-profit integrated health care system based in Norfolk, Virginia. With 12 hospitals, 4 medical groups, and more than 30,000 employees, it’s Virginia’s largest health care system. Nearly 10 years ago, after a large group of health care professionals there did some brainstorming about best hand hygiene practices, Sentara hired QualPro, a quality control consultancy, to test and analyze 21 interventions. Eventually, Sentara decided on interventions that included computer screen savers encouraging hand hygiene and awarding Hero of the Month titles to employees with high compliance rates. Other low-tech interventions included red stop signs to remind staff to wash their hands and random quizzes.

They didn’t stop there. Sentara’s compliance rates “are generally in the 90s, but ‘secret shopper’ audits show lower compliance that varies,” says Linda Estep, manager of infection prevention and control. “This is driving the push for electronic auditing that captures all opportunities we set up, and measures compliance more widely and accurately. Our manual audits are time-consuming and may not cover all shifts consistently. Currently, we’re reviewing electronic hand hygiene monitoring to expand our ability to capture a wider picture of compliance across all shifts.”

In fact, methods such as secret shoppers have underscored the need for more advanced methods of monitoring compliance. Study findings have shown that direct observation captures only a small percentage of all events. What’s more, it can massively overstate actual compliance.

Sentara’s ongoing hand hygiene campaigns are very successful, Estep says. “We update our approach regularly and we pay careful attention to our rates, as well as what we see when rounding on patient care units.” Keeping the message fresh is important, she notes.

Sentara not only has a top-down approach led by divisional leaders, but also peer-coaching efforts that address and overcome the “authority” gradient. “Sentara has a solid, long-standing culture that infection prevention is everyone’s job,” Estep says.

That means getting everyone on board. One of Sentara’s most successful campaigns is All Hands On Deck (AHOD). AHOD is Sentara’s code word to remind staff they forgot to clean their hands when required. “It’s a fun way to deliver the reminder,” Estep remarks. Leaders also model the correct response: Thank the person for the reminder and immediately sanitize hands. “Negative responses prevent our more shy staff from stepping up to coach,” Estep says. “We’re all responsible for creating a culture that promotes coaching.”

The Johns Hopkins Hospital in Baltimore, Maryland, has also found that the personal touch helps keep a compliance program from running out of steam. The hospital doubled rates of compliance with hand hygiene protocols between 2007 and 2008, and increased compliance again by 27% between 

. How? With a hospital-wide communication and education campaign called WIPES:

recautions use (eg, gowns, gloves, and masks)

Hanan J. Aboumatar, MD, MPH, a family practitioner focusing on behavior change and an assistant professor at Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, and Polly Trexler, MS, CIC, director of operations for the Department of Hospital Epidemiology and Infection Control at The Johns Hopkins Hospital, started the program “because there was a lot of work to do.” They spent about a year planning, looking at behavior, and researching how to change it. They used focus groups with hospital staff and leaders to understand the issues and which behavior models to support.

The WIPES project included the usual steps of putting up posters and hosting sessions about the importance of using sanitizers. “The program helped increase compliance 

,” says Trexler. “Then we stalled for a while. People were lagging behind. So, about 5 years into the project we added [the component of] direct feedback. We hired someone in addition to secret shoppers to address those employees who were a little more resistant to change.”

A successful program includes accountability, she believes, referring to “a new buzzword: Just Culture.” That is, applying discipline in a fair way to be sure staff understand expectations. But it’s also important to make it possible for them to comply easily, for example, by having dispensers everywhere. “We set expectations to clean hands on entry and exit, changing the behavior of only cleaning on entry and then thinking ‘I didn’t touch anything’ so not cleaning on exit,” Trexler says. “We did it on purpose to create habits, and to make it simple to keep the new habits.”

The accountability model also includes escalating consequences for noncompliance, beginning with a note to the employee, a note to the supervisor, then a talk with the supervisor, and up the chain of command. Noncompliance after 6 observations in the year means termination. But “we never go over 3 observations,” Trexler says.

The traditional methods—positive reinforcement, educational posters, reminders, rewards, recognition, secret shoppers—help keep the day-to-day level of compliance up, but technological innovations can make it easier for administrators to spot and calibrate for weak areas. An online reporting tool allows managers to collect data entered into a phone or iPad. “It’s real-time data that can be pulled up by hospital, service, unit, health care worker type, and timeframe,” Trexler says.

At Johns Hopkins, compliance is rewarded with the old-fashioned kind of positive reinforcement—compliments and congratulations—but also with data-based reinforcement. Taylor McIlquham, MPH, an infection control epidemiologist at The Johns Hopkins Hospital, says, “We present data to the IC [infection control] committee every month about which units are doing well, and which aren’t, and which ones have reached more than 92% compliance in the previous 3 months.” High performers are treated to individually wrapped cookies (pre–COVID-19, they had pizza parties). Leadership comes to the meeting to thank them (the personal touch again).

COVID-19 has intensified just about everything to do with infection control, including the need to find the right tools for the right situations. According to McIlquham, Johns Hopkins has spent the past 2 years looking into electronic monitoring systems, made by everyone from GE to smaller startups. Time constraints make it hard to rely on secret shoppers, she says. “We have over 50 clinical units to observe each month. Also, it can create bias [in the data] if staff begin to recognize the secret shopper.” Badges and digital monitors take out the human element, she adds. “We’re interested in technology primarily to reduce bias and understand what the numbers actually are, to be as accurate as possible. And to use data to target which interventions improve outcomes.”

It’s a big undertaking. “Even just doing studies, it’s a huge, huge infrastructure,” says McIlquham. “Think about thousands and thousands of people on our campus who would need the badges and monitoring tools. But we’ll continue exploring. We were doing short-term trials. Right before COVID-19 we were just about to do another but put it on the back burner for now.”

Hand hygiene is always important, but during this pandemic it’s crucial to preventing transmission. Now technology is making it possible for hospitals not only to monitor compliance, but also potential viral exposure.

SwipeSense, which initially was intended to track whether staff were washing their hands correctly, has a new application: contact tracing. Via sensors added to staff badges, managers can create a virtual “historical” map of staff whereabouts. If someone has received a COVID-19 diagnosis, administrators can better identify where the person was and who might have been in contact with them.

SwipeSense CEO Mert Iseri is fully aware of the implications of the monitoring, but in a recent interview with CNBC insists the company is “taking steps to alleviate the ‘creep’ factor.” For example, the system doesn’t track people throughout their day. Acknowledging the potential for misuse, he said, “We have to be really thoughtful about the technology we’re building.”3

Used wisely, the technology is a benefit in fighting COVID-19 spread. At Edward-Elmhurst Health in Illinois, where more than 3000 workers agreed to wear the SwipeSense badge, the data populated a dashboard that, by the end of March 2020, could help administrators monitor exposures. In 1 case, they determined that 75 employees had been in the room of a patient who tested positive, so they tested those workers and isolated them for 72 hours. One tested positive and was further isolated, and the virus was 

Hazard Appalachian Regional Healthcare (ARH) in Kentucky is also using the SwipeSense technology for contact tracing. “We are 1 of only 3 hospitals in the nation who are currently utilizing this technology for contact tracing,” James J. Hensley, MLS (ASCP), CIC, system director of infection prevention for ARH, wrote in a blog on the hospital’s website.4 In addition to contact tracing for staff, ARH attaches radio-frequency identification asset tags to mobile equipment such as ventilators. Through the SwipeSense Asset Tracking app, the hospital can virtually map and track equipment throughout the facility.

“This helps us identify equipment that may need [to be] assessed, cleaned, and even quarantined,” Hensley said. “The facility has location hubs connected all over, including in common areas, which ‘talk’ to staff badges and asset tags to log data for asset tracking and also for 

Sentara’s Estep says, “The pandemic has reaffirmed our focus on correct, consistent use of [personal protective equipment] and hand hygiene to prevent exposures. We’re compliant with the Virginia Emergency Temporary Standard for the prevention of SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2], which has a high focus on staff training, including correct hand hygiene technique. We created a training video, 

, that covers all aspects of COVID-19 prevention, and we plan for it to become an annual educational requirement.”

Sentara also continues to explore compliance-enhancing technology. “This will not only emphasize our commitment to 100% hand hygiene compliance,” Estep says, “but also our willingness to identify gaps and opportunities and commit to the technology cost of such a project. We’re also using the more stringent Leapfrog requirements to justify electronic monitoring, since receiving additional points involves a much higher volume of audits than we can achieve manually.” (The Leapfrog Group is a national watchdog organization focused on health care safety.)

The original WIPES program at Johns Hopkins increased compliance in hand hygiene to more than 80%; the enhancements have boosted it to the 90% range, and COVID-19 has made it critical. “Compliance is higher this year than ever before,” Trexler says. “People are more conscientious. We’re hoping this habit will bleed over after the pandemic.” She sees reason for optimism. “COVID-19 will have one benefit: changing behavior.”

Hospitals might get their wish for 100% compliance granted after all.

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

In 1999, Kevin Ashton, of Procter & Gamble, coined the term “Internet of Things” to describe that universe of computers communicating with each other almost independently of humans.

, he said, “In the 20th century, computers were brains without senses—they only knew what we told them. That was a huge limitation: There is many billion times more information in the world than people could possibly type in through a keyboard or scan with a barcode. In the 21st century, because of the Internet of Things, computers can sense things for themselves.”1

Consequently, we now have GPS; smart phones, TVs, and refrigerators; and devices that know when we’re home and when we aren’t.

We also have systems that can tell when health care personnel are washing their hands and when they aren’t—and reminds them when they don’t. The data those systems provide also help hospital managers understand transmission risk. In this coronavirus disease 2019 (COVID-19) pandemic, knowing where hotspots might be lurking is critical.

Here’s a brief look at some of the technological tools available:

 (CHSH) technology helps hospitals identify the most efficient path to improving hand hygiene. Its patented process, which includes gamification, “nurtures a culture of proactive HAI [health care–associated infection] prevention.” According to CHSH, hospitals that have used its technology and followed its process for at least 6 months have seen a decrease in HAIs of between 45% and 81%.

https://cleanhands-safehands.com/technology/

 has been named a “Best Infection Prevention Product” by 

, in association with the Leapfrog Group. Its 55-second disinfection “UV Box,” used throughout more than 700 hospitals and hospital groups, provides up to 99.999% disinfection. According to AUVS, the surface disinfection technology in its products is similar to the technology used in the air systems at the US Pentagon to protect against bioterrorism.

, with a configurable dashboard, provides on-demand intelligence and actionable insights about compliance and clinical workflows. The insights are color coded and available in easy-to-read graphs, making it simple to track compliance history. The company says study results have found its use reduces HAIs and staff absenteeism due to illness.

DebMed Electronic Hand Hygiene Compliance System

 is, according to the company, the only research-based, badge-free system that tracks compliance based on the World Health Organization’s 5 Moments, the Canadian 4 Moments, and the Centers for Disease Control and Prevention’s (CDC) hand hygiene standards. The system can capture 100% of hand hygiene events and opportunities, beyond just room entry and exit. Having an accurate number of hand hygiene opportunities and comparing them to 100% of all hand hygiene events collected, the system provides true compliance rates, providing actionable feedback for the group “without singling out individuals.”

https://www.debmed.com/electronic-monitoring-system/

 is a cloud-based sensor network that runs multiple applications simultaneously and monitors core metrics in one place. It does this “without the burden of logging in to multiple systems,” and with “little involvement from IT teams,” the company says. The system is compatible with existing or new wall dispensers. At-a-glance insights include time series comparisons, day vs night shifts, and soap vs sanitizer use. According to the company, because SwipeSense relies on proven behavior change methodologies rather than short-term gimmicks such as alerts or reminders, it leads to hospital-wide adoption.

’s Best in HealthCare 2020 as one of the best monitoring products for infection prevention. The band measures proximity to other SmartBands in the office. If they’re “too close for too long,” the users are notified by Vitalacy that they may have been exposed. The product does not track user location and keeps all user data anonymous from other team members and their employer. The company says the band is also the only compliance-monitoring wearable that records and improves hand wash duration.

https://www.vitalacy.com/hand-hygiene-monitoring-technology

Hospital experts know that monitoring alone doesn’t change behavior. In fact, technology alone isn’t always the answer either. Some of the most effective systems are a hybrid of the latest technology and “oldfangled” methods such as rewards and recognition.

Hand Hygiene’s Future: Technology, Tradition Get a Grip

, Linda Spaulding, RN, BC, CIC, CHEC, CHOP, argued that infection preventionists need to get more involved in the endoscope cleaning process. Spaulding, a member of 

’s Editorial Advisory Board, says that she’s “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…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.” Michael Cousin, the founder of a company called Sympliant, couldn’t agree more with Spaulding. There’s something amiss with the tracking of the use and cleaning of endoscopes. Cousin believes that the problem lies with something that has been dogging the provider side of health care for decades: Too much is still recorded with pen and paper. Meanwhile, before the coronavirus disease 2019 (COVID-19) pandemic, endoscopic procedures had been rising anywhere from 2.5% to 3% a year, he says. “You’ve got a certain amount of space, a certain number of staff, a certain amount of equipment,” Cousin tells 

. “But every year, the number of surgeries go up and up and up. You end up with a situation where there’s increased pressure on the health care professionals who are who asked to deliver this care.” Cousin believes that the answer to the problem is to use a “web enabled platform” to monitor all phases of endoscope use. This would help take the pressure off health care professionals and lead to much better outcomes, Cousin believes.

Too often the tracking of the use and disinfection is done with pen and paper. That's what leads to problems, says Michael Cousin. 

Q&A: Endoscope Tracking Needs to be Modernized

Doctor Anthony Harris didn’t hesitate in the least when 

 of coronavirus disease 2019 (COVID-19) concerned him. “No,” said Harris, MD, MBA, MPH. Harris is the chief innovation officer and associate medical director at WorkCare, a company that helps businesses with their infection prevention and control problems. WorkCare does a lot on the occupational health safety front. Harris also thinks that the COVID-19 vaccines are safe and that federal agencies have more or less given businesses the OK to make employment contingent on employees getting those vaccines. That’s because the agencies agree that COVID-19 “meets the litmus test that’s been used in the past of an imminent threat. That COVID is an imminent threat in the workplace.” As for COVID-19’s ability to mutate into variants? “So far, it’s not alarming because it hasn’t caused any more severeness of illness,” Harris tells 

. “And to the contrary, it actually may cause less severe illness, even though it’s more transmissible, if you would. We’ll see how this plays out in terms of a safety standpoint.”

How do companies handle the whole vaccination process? Or how should private industry handle the whole vaccination process?

First and foremost, determining the approach to vaccine requirements for your workforce, right? And that’s probably one of the most prominent considerations at this point in time with the vaccine now being in that 1a, 1b phase of distribution. And so, when we talk about what’s required and what’s not, it’s going to be industry specific. Obviously, health care, where you’re having high interactions between the employee workforce and the general public—patients, in this case—it’s required. But considerations should be looked at in terms of those industries that have a lot of employee and customer or patron interactions. And those are the considerations that the company should maybe perhaps require vaccines for their workforce. And if we look at the opportunity from a legal standpoint, we know that ADA [Americans with Disabilities Act], EEOC [Equal Employment Opportunity Commission], CDC [Centers for Disease Control and Prevention] have all kind of greenlighted that process for companies to make those requirements, because it meets the litmus test that’s been used in the past of an imminent threat. That COVID is an imminent threat in the workplace. And we’ll see how it plays out with companies in regard to these requirements outside of the health care industry.

That’s interesting. You’re saying that those agencies that you just mentioned greenlighted employers to say, “You can’t work for us unless you get the COVID vaccines.” Is that an accurate paraphrase?

It is. Now EEOC has not come out and made a statement saying we are clearly supporting mandated requirements for vaccination. They haven’t done that yet. It may be coming. But what CDC has said is that we know that employers have a requirement under the general duty clause of OSHA [Occupational Safety and Health Administration] to keep the workforce safe. And this current pandemic, as some have been in the past, passes the litmus test for the definition of what’s called an imminent threat. And because of that, companies then are permitted to require vaccination. And interestingly, on the flip side of it, there may be litigation from the workforce if companies don’t require vaccinations to keep everyone in the workplace safe because of that threat. And the litigation would follow because the companies would be called to the mat on not keeping the workforce safe under that general duty clause. So again, there’s been legal arguments on both sides of the opportunity to protect the workforce with required versus voluntary vaccination.

What do strong unions have to say about this? Might they get caught in the middle?

Just from my own anecdotal experience with unions: My profession is occupational medicine specialist, right? We’re seeing perhaps teacher unions come down on the conservative side. They’re saying, “Look, we want to do everything within reason to keep our members safe.” We’ve seen it play out in cities amongst the teacher workforce, to say, “Look, we want to continue to be remote. We want to be remotely teaching our students because of the risks of being there in person. Likewise, it would follow that we see the vaccine as an opportunity to keep our workforce safe, our members safe. We want to have that as an offering for those teachers.” It may not be required. But certainly, it would be something that they would push for in terms of access, and early access as a means to protect their members.

I have to ask you this question. I often ask experts this. Did you get the vaccine?

You bet. I received my vaccine several weeks ago. I get my second dose next Monday. I received the Pfizer vaccine. You bet I’m going to be the front of the line because I want to set the tone and the example for the physicians we work with across the country and in our organization that work here, as well as the workforce that we work with. We take care of several million lives in terms of the touch that we have with the companies we support. And we want to continue to undergird the safety of the vaccines—the Moderna, the Pfizer—and the efficacy. Because at the end of the day, the magic number here in the US to reach that herd immunity is approximately 196 million individuals. Either from natural immunity having recovered from COVID or vaccinated. And we’re not going to get there anytime soon if we don’t have people lining up to receive the vaccine. And if you look at the polls, it’s as few as 40% to 60% who say they’ll actually get the vaccine in the general public. And you know, we need higher numbers than that. Because, again, it’s not going to be everyone who develops immunity from these vaccines themselves.

When you get the first dose, are you limited to what you can do and what interactions you have with people until you can actually get the second dose? How does that work?

The numbers play out in terms of risk, and what the efficacy of each vaccine is, which determines your, I call it, safety level, if you would, or the number of precautions you need to take from a personal health standpoint. If you get that first dose of Pfizer/Madonna, you’re about 80% likely to have developed immunity if you look at the phase three clinical trials. After that second dose, you’re about 95%. That means that 5% of people after the second dose may not have immunity. With that vaccine, if we look at AstraZeneca, that number is much lower in terms of the number of people who respond to the vaccine, only 70% efficaciousness. For the AstraZeneca, 30% of people may not be immune after their second dose of AstraZeneca. In terms of the practicality of a day-to-day precaution for an individual who’s received the vaccine, myself included: Still have to wear masks. Still have to practice safe social distancing, because until such time that we’re on the other side of having most people vaccinated, and we start to measure the immune response, i.e. what’s called a titer. If you’re familiar with how vaccines have worked in the past, that titer will say, “Yes, I’ve taken your blood, I see the immune cells and the antibodies in your blood against COVID.” And you should be protected. It won’t be until we have a use case like that more prominent in the general public, that we’ll probably start dialing back on precautions. And so far, we are not just this year away from it, but well into next year before we see those type of changes.

Now these vaccines were granted under emergency use authorization by the FDA. Does that kind of possibly temper what employers can expect from employees as far as getting the vaccine? You know better than I do that the anti-vax movement has been growing over the last couple of decades.

In terms of that FDA EUA, emergency use authorization, and the kind of inference from that. Does that denote any lower level of safety than the full application and approval of a medication, in this case, the COVID vaccine? And the answer is not as far as we know. These manufacturers—Pfizer, Moderna, AstraZeneca—will still need to apply and receive their full approval from the FDA, not just EUA. But if we look at the robustness of the clinical data, the phase three clinical trials, I mean, we’re talking a powerful study that we would normally see in the full process done much more quickly. From a safety profile standpoint, the mRNA vaccines Moderna and Pfizer, have a far lower side effect profile than a lot of the common mainstream vaccines that we’ve been getting for decades. It’s that body of data that allows us in the clinical community to say, “Look, these vaccines are safe.” But you’re right. To your point earlier. We don’t know the long-term effects from these vaccines. The mRNA vaccine is new. First time it’s been approved for use in the US. We’ll see how clinically things play out over time. But there is no evidence to suggest that mRNA vaccines would cause any long-term side effects, because of the very nature of how the vaccine functions in the human body.

Do you think that the COVID-19 vaccine will have to be given every year or every other year?

It’s likely. If we look at the seasonality potential of COVID, it’s there. And it will track with the flu season as well. And many have speculated that even back in the spring in the summertime, and what even Doctor Anthony Fauci has said is we’ll be likely dealing with COVID for five years at a minimum, with the cyclic nature of mutations that occur called genetic drift and genetic shifts that we’re seeing now in COVID. This new strain out of the UK, the strain out of South Africa. We’ve been seeing these strains from day one out of Wuhan, China, when there were only two strains identified at that point in time, the S and the L strain. But now we have multiple … what are called clades—families of mutations that have propagated around the world. And because of that, it may happen that each season, we have to re-up on our vaccines with a different formulation, just like we do with the flu. But we’ll see how it plays out with this round of vaccines protecting from the different mutations that are coming out that we’re identifying. They should still be efficacious. But long-term over the course of another year, the mutations may be substantial enough on that spike protein, which allows the virus to enter cells that our antibodies don’t recognize it. We’ll find that out over time for sure.

A two-part question. How many people have to be vaccinated? I’ve heard anything from 80% to 90%. The second part of the question is, were you surprised by how fast we got the vaccines out? It’s kind of fashionable to paint the pharmaceutical companies as bad guys. Full disclosure, 

 has a story on our website saying that the scientists and researchers at the pharma companies came through and are heroes. I don’t want to put you on the spot, but were you surprised by how fast it happened?

No, not at all, actually. We know that yes, traditionally, it can take up to 10 years for an FDA approval for a pharmaceutical. And that process is not necessarily predicated on time intervals that are hard and fast. We know that there are some there in the US and abroad, Australia, the UK, that have definitive timetables that you must adhere to. However, a lot of it is resource dependent. What we’ve seen in terms of this concerted effort is a lot more resources that will go in and be included in the Operation Warp Speed program poured into the effort to develop these vaccines. And so instead of having a slow, gradual ramp up, from a resource standpoint, it accelerated because of the increased attention and increased dumping of resources into these programs. The key though is: Were these studies robust enough? Did they have a high enough number of participants to really understand what are the potential untoward effects of these vaccines? And the answer to that is “yes.” To the extent that we have done so, and comparatively with a longer process, we can still say that the side effects are few and that vaccines are safe. To the other point of the question … well go ahead and reiterate the second part of the question.

That number is dependent on what’s called the reproductive rate of the virus—the R-naught. The reproductive rate just means how many people are infected on average by one person with COVID. The reproductive rate right now nationwide is between 1.2 to 1.5, meaning 1.2 to 1.5 people are infected by one person with COVID. If we look at some states, in some cities, that R-naught number is as high as 5, in some studies. Meaning five people are infected by one person on average. And that means a greater number of people need to be vaccinated or have immunity to reach that herd immunity. If the number is 1.2, herd immunity happens around 40%. If the number is more realistically around 2.5, then the number jumps up to 60% need to be vaccinated. Again—and the data are showing—we are woefully underestimating the true burden of COVID in the US, because we just don’t have enough testing going on. And what that means is that we’re probably sitting closer to an R-naught of 4 to 5 meaning that 80% of people need to be vaccinated. We’ll see where we land at the end of the day after these new strains and new levels of infectiousness are fully understood. But I would anticipate—as most experts are—60%, 65% is the minimum we need to reach. But it may be as high as 80%.

Do these new strains concern you? Are you worried about them?

No. From a clinical standpoint, in terms of severity of illness, the UK strain, as you mentioned, B.1.1.7, has not been shown to have people develop more severe illness. It may be more infectious in terms of how quickly it can be communicated. As we’ve seen before with the L strain of the virus back in Wuhan, China. In terms of overall concern that we’re going to see a shift in regard to how we have been experiencing COVID-19: No, I’m not very concerned. Because we’ve seen this before. We have a myriad of … I believe there’s over 11 different clades or families of mutations that have occurred thus far. Some literature says 18 times the spike protein has already mutated. It’s not alarming that it’s happening. So far, it’s not alarming because it hasn’t caused any more severeness of illness. And to the contrary, it actually may cause less severe illness, even though it’s more transmissible, if you would. We’ll see how this plays out in terms of a safety standpoint. The same precautions to protect us from this strain and other strains with the social distancing the wearing the masks, that’s key,

What role so you think infection preventionists will play in the vaccine rollout?

They’ll be on the frontlines administering the vaccines. They’ll continue to be on the frontlines, obviously caring for patients that are being on the intake side of things into the clinical care. But also, I think, as we see programs developed around keeping the general public safe, the workforce safe, they’re going to be frontlines again, drawing blood and looking at antibodies toward the end of this year, beginning of next year, confirming that our vaccination efforts are working. And we’re trying to understand how long people are indeed immune to COVID once they received the vaccine, once they recovered from an infection of COVID. There are a number of ways that [infection preventionists] are going to continue to be on the frontlines helping us fully understand the impact of COVID-19 and get to the other side of it.

Anthony Harris, MD, MBA, MPH: “There are a number of ways that [infection preventionists] are going to continue to be on the frontlines helping us fully understand the impact of COVID-19 and get to the other side of it.”

Q&A: COVID Variants Don’t Pose That Much of a Threat

One of the most disturbing reports, which has largely gone unnoticed by the news media, was released on December 18, 2020 by the Health Service Journal (HSJ, Wilmington Healthcare). HSJ analyzed England’s National Health Service Data regarding hospital-acquired SARS-CoV-2 infections. SARS-CoV-2 is the virus that causes COVID-19 and unfortunately HSJ found that hospital-acquired infections (HAIs) are not uncommon, estimated to cause almost 1 in 4 hospital 

. The NHS metric considers any COVID-19 case diagnosed 8 days or more after admission an HAI. The United Kingdom also has a more infectious strain of the virus (B.1.1.7) than is commonly found in the United States.

Information has not been widely available in the United States regarding COVID-19 HAIs. The metric used in the USA is even more restrictive than the one used in the United Kingdom. The U.S. metric defines a COVID-19 HAIs as the: “Total current inpatients with onset of suspected or laboratory-confirmed COVID-19 fourteen or more days after admission for a condition other than 

If one considers that the average incubation period for SARS-CoV-2 is 

 and the average hospital stay in the United States is 

, this metric is next to useless. It will at best detect only a very small minority of cases. A more accurate metric would define cases which occur after 5 days as an HAI, which would better create a balance between false positive and negative cases. And the metric should count cases which occur for a period of 5 days after the patient leaves the facility. Again, creating a balance between false positive and negative cases.

With the CDC projecting that the UK variant will become the dominant strain in the US by March, it is imperative that we bolster our strategies to safeguard both 

Some have postulated the increase in infectivity of the UK strain to an increased ability to attach to cells or to more viruses being reproduced by the infected cells. However, I would expect that if its increased spread was based upon these mechanisms, that we would see an increase in COVID-19’s case fatality rate. Many sources have stated the UK variant is not more lethal than our current variant infecting the United States, D614G.

I feel the most plausible reason for the UK variant’s increased spread is either greater survivability in the environment or an increased ability to aerosolize. Thus, we need an increased commitment and enhanced strategies to prevent spread. This includes all health care workers becoming vaccinated, you owe it to yourselves, your family, and your patients to receive the vaccine. The increase in infectivity also raises concern regarding the importance of spread by fomites. Hence, environmental cleaning needs to have strict and comprehensive protocols. All segments of our society, including front-line health care workers, need better PPE and N95 masks (without exhalation valves). Facilities of all types (including schools and retail establishments) need to increase complete air exchanges and air sanitization. Testing needs to be increased for staff and patients. We also need to eliminate, whenever possible, outpatient waiting rooms. And implement strict social distancing (not having chairs next to doors and areas of traffic flow). Finally, we need “data for action.” We need to have mandatory reporting of worker and patient acquisition of SARS-CoV-2 and the development of COVID-19 with metrics to provide us the most accurate estimate of cases so we can effectively plan and allocate resources.

We need to have mandatory reporting of worker and patient acquisition of SARS-CoV-2 and the development of COVID-19 with metrics to provide us the most accurate estimate of cases so we can effectively plan and allocate resources.

Problem: COVID-19 Hospital-Acquired Infections 

In the past few months, we’ve identified four new 

 of the SARS-CoV-2 virus that causes coronavirus disease 2019 (COVID-19). Identified in the United Kingdom (B.1.1.7), South Africa (1.351), Brazil (P.1), and Denmark (

), these variants have been an added concern to an already stressed health care and public health systems.

Genomic surveillance is not exactly a strong suit in the United States and as we work to rapidly upscale these efforts, in many ways we’re flying blind when it comes to understanding the true prevalence of novel or emerging strains.

Ultimately, what we are seeing is that some variants, B.1.1.7 for example, has increased transmission capabilities, meaning that the variant is more adapt and more efficient at spreading between people. The good news is that these new variants do not appear to be causing more disease or impact the routes of transmission. As the Centers for Disease Control and Prevention (CDC) 

, “Rigorous and increased compliance with public health mitigation strategies, such as vaccination, physical distancing, use of masks, hand hygiene, and isolation and quarantine, will be essential to limiting the spread of SARS-CoV-2 and protecting public health.”

For most of us working in infection prevention, none of this is particularly new—we’ve been reading up on it and trying to address the infection prevention aspects of it for weeks. Emphasizing that something is more transmissible but that the route of transmission is the same is particularly challenging, especially as we’re continuously getting new information in.

Truly, what these new variants drive home is that many are likely in circulation well before we realize it, so continued infection preventions are critical. More than just continued efforts, but really, vigilant. After 13 months of a pandemic, we are all fatigued. Health care workers especially are exhausted and continuing personal protective equipment (PPE) and all the other critical pieces to preventing COVID can be tough both at work and outside the health care setting. So how do we address novel variants in a moment of shear fatigue and frustration?

First, the attention and concern around these variants is hard to miss. This means that it’s important to get ahead of the misinformation or fear. Touching base with your microbiology lab to ensure there’s no concern for impact to testing efficacy is important as this is often a question. Second, how can we disseminate adequate information widely? Starting with our COVID-19 response teams and working it into rounding communication strategies can be effective.

For many of us, an internal webpage on COVID-19 information has been helpful too, so developing a one-page information sheet (with links to the CDC page) is also helpful to refer people to. Perhaps one of the most important pieces though, is building trust and this means acknowledging that we’re still learning more. There are pieces of novel variants that we’re still learning about, like the impact to therapies and how these variants might impact what we know about COVID-19, like reinfection. Being transparent about these unknowns is important but that doesn’t diminish what we do know – existing prevention strategies are effective. Ultimately, if we continue with vigilant infection prevention efforts this can combat when novel strains are circulating and before we understand the full picture. Preemptive and continued prevention efforts help us respond to emergent strains before we even realize what we’re dealing with. Fundamentally, it’s the continued efforts we need to focus on – practice makes permanence.

There are pieces of novel variants that we’re still learning about, like the impact to therapies and how these variants might affect what we know about COVID-19, like reinfection.

How Infection Preventionists Should Approach COVID Variants

Devin Jopp, EdD, MS, has been the chief executive officer of the Association for Professionals in Infection Control and Epidemiology (APIC) for all of about six weeks now. He knew what he was getting into, how much the health care industry leans on infection preventionists (IPs) as never before as coronavirus disease 2019 (COVID-19) cuts a deadly path through society. When asked if he has any second thoughts, Jopp laughs. “I have to admit, I’m very mission driven and focused,” he tells 

. Jopp talks about the challenges of guiding a profession that in the perhaps near future may not be confined to just the 

. Aside from the immediate conundrums that COVID-19 presents to IPs (for instance, convincing the public and even fellow health care professionals to get the vaccine), there’s the demographic challenge that about 40% of IPs will retire within the next 10 years. There are also the problems that not every state requires infection preventionists be certified, that far too few health care institutions offer infection prevention as a career path, or that even fewer universities teach it. Infection prevention is still too often something that somebody might drift into. “We have a big issue with replacement,” says Jopp. “And we have a bigger issue with expansion of the field to fill the need. But I think again, it’s going to be really working with trying to become a lot more open in terms of making sure that we explain how to become an IP, making it available with residency opportunities and that combination of degree and certificate programs.”

What’s the main message and want to put it out there to infection preventionists?

I think the role of the importance of the infection preventionist in really helping us to defeat and to beat back COVID-19. And I think we’ve really relied on infectious preventionists as being our eyes and our ears and our experts on the ground. And so, I think really helping to bolster all of you and your efforts to combat COVID-19 in your facilities and outside of the facilities is going to be crucial. And really trying to also work together with you all to advocate for what we need to help support this. And we know there are all kinds of issues out there, from the lack of PPE to vaccines and the challenges of getting those in the right hands and dealing with some of the resistance that’s out there among our patients, our health care workers. There are lots and lots of challenges but know that we’re here with you and be working with you together.

You’ve only been on the job about six weeks and you jumped in during this world altering pandemic. Did you have any thoughts?

I have to admit, I’m very mission driven and focused. And actually, I was working at American College Health Association, which represented all the college health centers and mental health centers on college campuses. I was very involved in developing the roadmap, documents around college campuses reopening. If you remember the discussion about whether to reopen campuses or not. I wasn’t afraid of COVID-19 in terms of jumping in with both feet. And when I saw APIC, I thought it was a great opportunity to come and to serve an organization that is serving so many others and making a difference. I’m really pleased to be here and to join in arms together in the fight here.

Devin Jopp, EdD, MS:  “I think from sports teams to hospitality to construction sites, to many, many more, the infection prevention field will absolutely be bulging.”