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

Though less likely to suffer from severe COVID-19, children do have the potential to be major spreaders of the disease and incubators for new variants, including one that might be able to rebuff antibodies from prior infection or vaccines, according to a 

. In addition, children may be more infectious than adults who display similar symptoms of the disease.

Investigators with Massachusetts General Hospital write that their findings show “that pediatric patients of all ages, from infancy to young adulthood, can carry a high SARS-CoV-2 viral load in their upper airways, particularly early in the course of infection, and an elevated viral load corresponds with high levels of viable, replicating virus.” In addition, the study states that “pediatric populations have the potential to serve as a community reservoir of actively replicating virus, with implications for both new waves of infection and the evolution of viral variants.”

Data were collected from a prospective cohort of 110 patients 21 or younger (median age of 10) who sought care at the hospital or its satellite urgent care centers between April 20, 2020 and April 20, 2021.

Investigators relied on respiratory swabs that had been collected from the children, and the SARS-CoV-2 viral loads were measured by reverse transcription polymerase chain reaction (RT-PCR) tests.

The 36 (33%) children who had to be hospitalized were mostly older (ages 15 to 21, for the most part), and 18 of those children required supplemental oxygen or respiratory help. Thirty (27.3%) of the cohort were asymptomatic. Data collected from the pediatric population were compared to data from adult patients collected from April to August 2020.

“Symptomatic and asymptomatic children can carry high quantities of live, replicating SARS-CoV-2, creating a potential reservoir for transmission and evolution of genetic variants,” the study concludes. “As guidance around social distancing and masking evolves following vaccine uptake in older populations, a clear understanding of SARS-CoV-2 infection dynamics in children is critical for rational development of public health policies and vaccination strategies to mitigate the impact of COVID-19.”

The study comes at a time when debates about the reopening schools dominate public discourse in many regions of the United States. The study’s authors state that there’s not enough data yet to determine just how infectious children can be. The study states that “the role that children play in viral transmission remains poorly understood. Epidemiologic studies suggest that children exhibit lower transmission rates than adults…, however, these findings are potentially confounded by higher rates of asymptomatic or paucisymptomatic [those with few symptoms] infection in children, increased social isolation by children early in the pandemic, and reduced COVID-19 testing in children. To date, one small study demonstrated that live virus can be cultured from children.”

Investigators argue that their data add to the argument that a vaccine needs to be created for children and that children should get it.

“Our findings have significant implications for both public health policy and the potential role of universal vaccination of pediatric populations in fully curbing the COVID-19 pandemic…. Our results suggest that the low rates of transmission in settings such as schools and daycares cannot be attributed to low viral loads, low rates of viral shedding, or rapid clearance of virus in younger patient populations. As changes in masking and distancing policies are implemented for vaccinated adults, consideration of how and whether policies changes will be applied for children will be critical for ongoing reduction of new COVID-19 cases.”

Articles

Not only can pediatric patients of all ages carry high viral loads of SARS-CoV-2, but they can also serve as a means for the virus to mutate, according to a new study.

Children Could Incubate the Next COVID-19 Variant

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

Even in Shadow of COVID-19, Influenza Poses Pandemic Threat

The ability of any infectious agent to maintain constant transmission enables it to be an ongoing threat to public health. Few pathogens have achieved greater success at ongoing transmission potential than the influenza virus.

Infection preventionists and other health care providers need masks that can easily be fit-tested or are more moldable to ensure a good seal—Saskia v. Popescu, PhD, MPH, MA, CIC.

As COVID-19 infection, hospitalization, and mortality rates head downward, pediatric SARS-CoV-2 rates rise, and nursing homes can again become disaster zones. And remember: Winter is coming.

COVID-19 Vaccine Hesitancy Among Health Care Workers: Why?

Vaccine hesitant health care professionals are most likely to be persuaded by fellow workers. Meanwhile, mandates can backfire.

Twofer Vaccine in the Making Works Against ‘Twindemic’ of Flu, COVID-19

A one-and-done vaccine that prevents both influenza and COVID-19 might help alleviate vaccine hesitancy for both conditions.

Take 5 minutes to catch up on Infection Control Today’s highlights for the week ending October 15.

Weekly Rounds with Infection Control Today: Battling COVID and Flu, Fixing Masking Problems, Vaccine Hesitancy in Health Care Workers

Before the COVID-19 pandemic, hospital administrators were familiar with the purpose and vision of the infection prevention and control (IPC) department. When health care–acquired infections (HAIs) were high or outbreaks present, administrators would turn to their IPC colleagues to better understand what steps were being taken to reduce infection rates and prevent the spread of disease within the hospital. Despite their importance in the prevention and control of infections, some IPC departments have historically felt unsupported by hospital administrators.

Occasionally, these departments have received little to no support for more full-time employees and no additional funding for prevention efforts. They also have had a limited role in making hospital decisions that ultimately affect infection prevention and control.

As COVID-19 spread, hospital administrators looked to IPC experts to determine how to protect employees, patients, and visitors. IPC quickly became one of the most important departments in the hospital. Infection preventionists (IPs) were at the table for every decision and department capacity was increased to sustain prevention and control efforts. The increased attention and support are what we have needed for decades to substantially reduce HAIs in hospitals.

The pandemic has had a detrimental effect on progress in reducing HAIs.

 (See table below.) If we can harness the energy present between the IPC department and hospital administration during the pandemic, together we can become change catalysts, tackling HAIs with such gusto that the road back to zero infections will be paved in yellow bricks. But to accomplish this, we need a road map. We need defined steps that will lead hospital administrators and IPs along the path to improved patient safety with decreased HAIs.

First, to see the changes we hope for in hospital IPC, we need the full support of hospital administration. For too long, preventing and controlling infections has rested solely on the IPC department. If we want sustained improvements in our hospitals, administrators must visibly show support for IPs while investing time, resources, and hospital funding to increase the capacity of the IPC department.

As Tamasin Adams, MPH, CIC, manager of infection prevention for the Lutheran Hospital of Indiana, states, “With the combination of administrative support and IP knowledge, new processes can be supported and implemented to keep patients and staff safe.” Yet many activities, such as increased surveillance for HAIs or electronic hand hygiene monitoring, will require additional staff and funding. Currently, many IPC programs barely have the capacity to keep up with mandatory HAI surveillance and reporting requirements.

Although HAIs tied to mandatory reporting and hospital reimbursement are priorities for the hospital, many other HAIs are being neglected due to limited staffing within IPC departments. With administrative support to increase infection prevention staffing, IPs could move beyond HAIs tied to reimbursement and target those not regulated by mandatory surveillance and reporting requirements.

Visible support from hospital administration increases staff buy-in for IPC efforts. Although IPs have the tools and knowledge to decrease HAIs, hospital administrators must make those efforts visible and rally buy-in from frontline staff. Without frontline support, efforts to improve prevention practices and mitigate the spread of infections will quickly fail.

One of the most overlooked methods for gaining frontline support is having existing relationships and trust with frontline staff members. When hospital administrators and IPs show their respect, trust, and support of frontline staff, those staff members will respond in kind. When we work collaboratively, we work toward positive change. During the pandemic, everyone throughout the hospital turned to the IPC department for answers.

Relationships with frontline staff members were forged through the fires of COVID-19 prevention and response. Now that trust, respect, and collegial relationships have been established, hospital administrators and IPs must continue to collaborate with frontline team members to prevent and control HAIs.

For Sara Townsend, MS-HQS, FAPIC, CIC, manager of infection prevention for Children’s Hospital of Philadelphia, COVID-19 allowed her IPC department to develop partnerships with frontline staff in their fight against HAIs. According to Townsend, “Suddenly [individuals] I never knew existed called me their new best friend. I, like others on my team, saw the never-ending list of questions and [individuals] as an opportunity. Today, as we dive back into scary times, those who labeled us their ‘new best friends’ have become reliable partners.” When hospital administrators and IPs build relationships with staff, those individuals become collaborators in the journey toward decreased infections.

Once we have the full support of hospital administration and the buy-in of frontline staff members, we must get back to the basics of infection prevention to reduce the rate of HAIs. We must reemphasize the focus on basicpractices such as good hand hygiene, proper use of personal protective equipment (PPE), and environmental cleaning and disinfection. These are effective strategies that will work again with support and resources provided to infection prevention teams. But how, with extreme staffing shortages and a burned-out workforce, do hospital administrators and IPs successfully improve infection prevention practices? In short, we must keep it simple. First, we must set up our staff for success in achieving best practices in all areas of basic infection prevention. Hand hygiene supplies, disinfectant products, and PPE must be kept readily available and easily accessible to support best practices. Next, we need hands-on education with return demonstration by all staff to ensure competency. Then, to ensure practices are sustained, we need appropriate auditing, monitoring, encouragement, and feedback to frontline staff. Finally, we must continue education through frequent reminders and signage about best practices for basic infection prevention.

But according to Erica Jones, BSN, RN, CIC, director of infection prevention for Mt. Washington Pediatric Hospital in Baltimore, Maryland, “Education isn’t always the answer.” Sometimes, even with the best hands-on education, we find that our efforts fall short of producing sustainable change. Jones says “it is about engaging frontline staff in processes to understand their day-to-day and how to incorporate basic prevention principles into processes that are already in place.” It comes back to collaboration. Again, for prevention efforts to succeed, we must work as a team with frontline staff, listening to their perspectives and involving them in our efforts to improve the prevention and control of infections.

But listen closely, because this is important: None of this can be accomplished without the full support of hospital administration.

The work ahead for IPs will take more administrative support and funding than ever. The COVID-19 pandemic has brought a significant rise in HAIs. The reasons are abundant but the solution is simple. We need administrative support to increase the capacity of the IPC department, we need increased funding and visible support from hospital administrators for IPC efforts, we need buy-in and involvement from frontline staff, and we need to return to the basics of infection prevention. But together, hospital administrators and IPs can stem the rising tide of HAIs in our hospitals. United, with increased support of the IPC department, we can sustain positive change in the prevention and control of infections. 

HEATHER SAUNDERS, MPH, RN, CIC, is director of infection control at Johns Hopkins Office of Population Health in Baltimore, Maryland. She is also owner of and primary consultant for Broad Street Prevention, where she guides health care and business leaders in the prevention and control of infectious diseases.

Greene MT, Gilmartin HM, Saint S. Psychological safety and infection prevention practices: results from a national survey. 

. 2020;48(1):2-6. doi:10.1016/j.ajic.2019.09.027

Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network. 

. Published online September 3, 2021. doi:10.1017/ice.2021.362

If we want to see sustained improvements in our hospitals, administrators must step in and visibly show their support of IPs while investing their time, resources, and hospital funding to increase the capacity of the IPC department.

How Hospital Administrators Can Help IPs Manage HAIs

Perhaps one of the more perplexing developments during the COVID-19 pandemic has been the display of vaccine hesitancy among some health care workers (HCWs). Because infection preventionists (IPs) often lead vaccination drives at hospitals, they’ve found themselves having to encourage their fellow workers to get the COVID-19 vaccine, and it hasn’t always 

But just whom among HCWs want to avoid getting the vaccine? Investigators with the University of Illinois at Chicago wanted to address that question and presented their findings in a preprint 

“A surprising proportion of vaccine hesitant respondents cited insufficient evidence for vaccine efficacy, a somewhat concerning finding given the survey population,” the study states.

Politics, it seems, cannot be avoided when discussing vaccine hesitancy and investigators found a divide depending on party affiliation. Nearly half of the HCW participants in the study who said they were Republican said that they had not been vaccinated, nor do they intend to be vaccinated.

However, HCWs who did not get the vaccine also tended to be younger, non-physicians, and Black. Also, some HCWs expressed concerns about adverse side effects having to do with getting pregnant or delivering a baby. Overall, Black and Republican HCWs had lower rates of vaccine uptake.

“Although we acknowledge that COVID-19 and its vaccines have been politicized more than any other disease in recent history, it is equally important to acknowledge there is more to human intersectionality, values, and experience than political affiliation,” the study states.

Investigators surveyed HCWs in 3 large academic medical centers in the Chicago area between March and May 2021 and found that about 3 out of every 20 HCWs self-reported vaccine hesitancy. Of the 1974 respondents, about 85% said that they had gotten or planned to get the COVID-19 vaccine. “Multivariable logistic regression found HCWs were less likely to receive COVID-19 vaccination if they were Black (OR 0.34, 95% CI 0.15-0.80), Republican (OR 0.54, 95% CI 0.31-0.91), or allergic to any vaccine component (OR 0.27, 95% CI 0.10-0.70) and more likely to receive if they believed people close to them thought it was important for them to receive the vaccine (OR 5.2, 95% CI 3-8),” the study states.

They found that—and this is where IPs might come in—HCWs tended to trust information that’s relayed to them by a fellow HCW than by any marketing campaign. Rather than rely on such campaigns, hospitals should instead foster trusting relationships among employees across departments and job roles. Doctors and nurses are principally viewed as trustworthy, the study states.

“It will be especially important to create safe spaces where HCWs, including clinicians, food providers, and environmental service workers can express their questions and concerns in an open and transparent forum due to inherent power structures and hierarchies that frequently serve as barriers to the agency of vulnerable persons,” the study states.

Many hospitals and health care systems across the country have mandated that their workers be vaccinated against COVID-19, sometimes leading to workers either 

As authors Mary Jean Ricci, MSN, RNBC, and Frances Amorim, MSN, RN, CCE, recently put it in an 

, mandating vaccinations for health care workers is a balancing act. The title of their article: “Ethical and Practical Considerations Surrounding Mandatory Vaccination.” They wrote: “Infection preventionists and the hospital leadership teams need to communicate with all stakeholders to balance the health of the community and protect the current and future workforce.”

 study also recognize how tricky vaccine mandates for HCWs can be. “Hospitals, health care systems, and state governments are increasingly mandating vaccination against COVID-19 for health care workers across the United States,” they write. “While we support these efforts, vaccine mandates come with attendant harms and the potential to exacerbate issues of mistrust, hesitancy, communication, and inequities in agency. Although it is likely vaccine mandates for health care workers will increase uptake in the vaccine, it is also possible these mandates may lead to backlash, leaving health care workers fearful of losing their jobs or feeling obliged to receive the vaccine against their personal values or concerns.”

 to assess concomitant administration of any vaccine with either an adenoviral vector or mRNA COVID-19 vaccine found the combination with influenza vaccine is safe, produces immunogenicity associated with separate vaccination, and supports the combination as an efficient intervention against the possible “twindemic.”

Validation of a more efficient means to vaccinate against these viral infections is particularly welcome as flu season has commenced in the US and northern hemisphere countries, and a recent 

 from the National Foundation for Infectious Diseases (NFID) shows that 44% of the US population are unsure or do not plan to get vaccinated against influenza.

Rajeka Lazarus, DPhil, Department of Microbiology, University Hospitals Bristol and Weston, NHS Foundation Trust, Bristol, UK, and colleagues of the ComFluCOV Trial Group anticipate that concomitant administration would reduce burden on health care systems, and report, “concomitant vaccination raises no safety concerns and preserves the immune response to both vaccines.”

The investigators recruited 679 participants who had received the first dose of either the adenoviral vector SARS-CoV-2 vaccine ChAd0x1 (AstraZeneca) or the mRNA vaccine BNT162b2 (Pfizer/BioNTech) and randomized 1:1 to receive either placebo or an age-appropriate dosed influenza vaccine (adjuvanted trivalent or cellular or recombinant quadrivalent) with their second COVID-19 vaccine dose. Follow-up monitoring was available for 665 participants.

The study monitored for adverse effects and assessed laboratory indicators of immunogenicity from April 1 through June 26, 2021, outside influenza season. The study was interrupted April 8 when notice was received of thomboembolic events associated with ChAd0x1, and resumed April 9 with exclusion of participants with risk factors for thrombotic events.

The primary outcome was one or more solicited reports of systemic reaction within 7 days after vaccination such as fever, chills, or joint pains. Secondary outcomes involving safety and adverse response included solicited local reactions such as pain or tenderness and unsolicited adverse events, including medically-attended adverse events.

The secondary outcome of immune response was determined from measures including SARS-CoV-2 S-protein immunoglobulin G (anti-S IgG) concentration in serum collected on day of vaccination (D0) and day 21; and hemagglutinin antibody inhibition (HAI) against the 4 strains of influenza contained in the 2020/21 formulations, on D0, day 21 and day 42. Other immunological measures that will be in a subsequent report include neutralizing antibodies against SARS-CoV-2 on D0 and day 21 and mucosal immune responses to COVID-19 vaccines in saliva.

Lazarus and colleagues reported that, overall, 555/665 (83.5%) of participants had at least one solicited local adverse reaction after vaccination on DO; in 85.2% of those receiving concomitant vaccinations and 81.7% with placebo in lieu of influenza. The numbers with local reactions 7 days after injection were similar in both groups, although higher among those receiving the active combination at day 21. Rates of medically assisted adverse events were similar between groups following both D0 and day 21.

The Anti-S IgG geometric mean units (GMU) at day 21 were similar between those who received either SARS-CoV-2 vaccine alone or with concomitant influenza vaccine. Seroconversion rates (SCR) ranged from 89-100% and 79-93% 21 days after either BNT162b2 or CHAd0x1, respectively, whether administered alone or in combination with influenza vaccine. There were no significant differences in the HAI GMR for any influenza strain 21 days after influenza concomitant vaccination with SARS-CoV-2 vaccine compared to previously studied cohorts receiving influenza vaccination alone.

“By performing the trial in relation to the second rather than the first dose of COVID-19 vaccine, we have evaluated safety and immunogenicity in primed individuals,” Lazarus and colleagues point out. “Therefore, the findings are also likely to be more relevant to the question of concomitant administration of booster doses and seasonal influenza vaccines, which over time may become the 'norm' in many parts of the world.”

The United States today mourns the passing of one of the country’s most famous veterans, former Secretary of State Colin Powell. Powell, a four-star general whose long list of accomplishments embellish a storied career, died yesterday of complications from COVID-19. The 84-year-old Powell had been fully vaccinated against SARS-CoV-2, but was also fighting underlying health conditions, including multiple myeloma and Parkinson’s disease. Powell’s death at Walter Reed National Medical Center in Bethesda, Maryland, resulted from a breakthrough infection.

) published last week looks at veterans in an attempt to refine methods of determining level of vulnerability to 

breakthrough infections. Investigators with the Veterans Affairs Ann Arbor Healthcare System (VAAAHS) conducted an observational case series report on 10 veterans admitted to the facility with breakthrough infections between March 15, 2021, and April 15, 2021, because they wanted to add to the limited data on breakthrough infections.

“Given the variability of vaccine breakthrough infections requiring hospitalization, serologic testing may impart clarity on timing of infection and disease prognosis,” the study concludes. “Individuals at risk of diminished response to vaccines and severe COVID-19 may also benefit from selective serologic testing after vaccination to guide risk mitigation strategies in a post-pandemic environment.”

All 10 of the veterans were older than 70 and, like Powell, suffered from multiple comorbidities. The mean time between when the veterans had gotten their second dose of the COVID-19 vaccine and the breakthrough infection was 49 days.

“In the seven individuals with acute infection, none had observed serologic response to mRNA vaccination, five developed severe disease, and one died,” the study states. “Three individuals had anti-N IgG antibodies and a high polymerase chain reaction cycle threshold (Ct) value, suggesting resolving/resolved infection.”

 and other news outlets report, Powell—who’d gotten his second shot of the Pfizer-BioNTech vaccine in February—had been scheduled to receive a booster shot this week, but was too sick to get it.

 study note that the Food and Drug Administration currently says that routine antibody testing to determine immunity after someone’s been vaccinated for COVID-19 isn’t necessary.

 study states, “without a better understanding of vaccine response, many high-risk individuals could be at even greater risk as mitigation measures are relaxed (e.g., mandatory masking) for the fully vaccinated. For high-risk individuals, the selective use of antibody testing for anti-S IgM and IgG may be useful to identify those that would benefit from enhanced precautions to SARS-CoV-2 exposure.”

VAAAHS vaccinated over 25,000 veterans between December 30, 2020, and April 1, 2021.

Our experience with Michigan veteran patients demonstrates that despite higher-than-average vaccination rates within this population, surging case counts within the community will lead to an increase in breakthrough infections and hospitalizations,” the 

 article states. “As the Delta strain and other highly virulent strains become more prevalent, this report reinforces the need to not only rapidly vaccinate entire communities, but also practice other risk mitigation strategies if local COVID-19 case volumes are high.”

More frequent testing and continuation of mitigation measures such as masking would better help to protect the more vulnerable among us such as Colin Powell, a study concludes.

Breakthrough COVID-19 Infection Kills Colin Powell

As the United States and the rest of the world grudgingly accepts that COVID-19 will be with us from 

, another infection that hits us in waves seems not to be getting the attention it deserves: 

Just over half of US adults are planning to get vaccinated for influenza despite urging by health officials concerned with potential influenza resurgence during the COVID-19 pandemic, according to a new 

 by the National Foundation for Infectious Diseases (NFID).

The survey, conducted August 12-16, 2021, found that although 61% agree that flu vaccination is the best preventive measure against flu-related deaths and hospitalizations, 44% of US adults are either unsure or do not plan to get the vaccination. The NFID-sponsored survey was conducted by NORC, a social research institution at the University of Chicago.

 announcing the survey findings, Rochelle Walensky, MD, MPH, director, Centers for Disease Control and Prevention (CDC), emphasized the importance of the influenza vaccination.

“While we do not know what the activity will be like this fall, I urge everyone age 6 months and older to get vaccinated. If you are unsure about getting a flu vaccine, please take the time to get the information you need to make the right choice for your health and to get vaccinated,” Walensky urged. “The COVID-19 pandemic is not over, and the risk of both flu and COVID-19 circulating could put additional strain on hospitals and frontline health care professionals.”

An NFID statement indicated that the survey was conducted to obtain a better understanding of the beliefs about flu and pneumococcal disease, as well as attitudes and practices around vaccination, and how these may be affected by the COVID-19 pandemic. The survey included 1126 complete responses, with 1064 via the web and 62 via telephone, from US adults age 18 years and older representing all US states and the District of Columbia.

Among those not planning to get vaccinated, the most frequent reasons were: do not think vaccine works very well (39%); never get the flu (36%); concern about potential side effects (25%); don't think flu is serious illness (20%); concern about getting flu from vaccine (19%).

The prospect of low vaccination rates poses particular hazard to those at highest risk for flu-related complications, according to the health experts at the news conference. They noted that nearly 1 in 4 (23%) adults who are at high risk had indicated that they were not planning to get vaccinated this season, not only leaving them vulnerable, but increasing likelihood of transmission.

“Amid the ongoing pandemic, we remain extremely concerned about patients with chronic health conditions who are at higher risk for pneumococcal disease and complications from flu and COVID-19,” indicated Cedric Rutland, MD, West Coast Lung, Newport Beach, CA.

Patricia Stinchfield, RN, MS, NFID president-elect highlighted the youngest, vulnerable population."Children age 6 years and younger are at higher risk of serious flu-related illness, and we need to ensure our children are protected before flu starts spreading in schools and communities. Flu vaccines can be life saving for children," she declared.

Laura Riley, MD, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, noted that the current 55% vaccination coverage of pregnant women was similar to the prior season. “Nearly half of pregnant women and their infants remain unprotected against flu,” Riley said. “All pregnant women should get a flu vaccine to protect themselves and their newborn babies from severe complications.”

77% would be willing to take an antiviral medication if prescribed to reduce severe flu symptoms.

Among respondents who had not received at least one dose of a COVID-19 vaccine, 63% won’t, and 28% are not sure whether they will get a COVID-19 vaccine.

51% are not familiar with pneumococcal disease, although about a third (32%) of those at higher risk report having been advised to receive pneumococcal vaccine.

54% report they will wear a mask at least sometimes during the flu season.

Black adults (73%) and Hispanic adults (62%) are more likely than White adults (46%) to report they will wear a mask during flu season.

“Survey findings highlight the importance of raising awareness and addressing misconceptions about flu, pneumococal disease, and COVID-19 vaccines, and the importance of health care professionals strongly recommending vaccines for their patients,” the NFID indicated in the press release.

Although 61% surveyed agree that flu vaccination is the best preventive measure against flu-related deaths and hospitalizations, 44% of US adults are either unsure or do not plan to get the vaccination.

Too Few Americans Willing to Get the Flu Vaccine

Water needs to flow in hospitals and office buildings because stagnant water and/or the pipes it sits in can quickly become reservoirs of pathogens. That’s a message Brian Flannigan, vice president for corporate sales and business development with Phigenics, an Illinois-based water management company, brought last month to the annual conference of the International Association of Healthcare Central Service Materiel Management (IAHCSMM). Too often during the COVID-19 pandemic, water was shut off and stayed off for long periods, which caused many problems, Flannigan tells 

“Water treatment equipment and water systems are not designed to operate sporadically,” says Flannigan, whose presentation was titled “Water Safety & Quality During Medical Device Reprocessing.” He continues: “They operate much better whenever they operate continuously. There have been a number of operational issues that have arisen during the pandemic around sterile processing during operations and during the restart of operations.”

He said the result of this is much greater awareness in and outside of health care about the importance of water management. “We have seen and recognized many of the health care heroes, the ones on the front lines who responded to the pandemic and the heroic efforts that they provided to support patients coming through the door,” said Flannigan. “What we haven’t seen necessarily are the behind-the-scenes folks who have been responsible for [managing] the infrastructure of those hospitals.”

Flannigan said, “We are strong proponents of the multidisciplinary team and the benefit that that brings.” That team should comprise infection preventionists, environmental services (EVS), building management, and, of course, sterile processing professionals. It needs to follow standards mandated by the Centers for Medicare & Medicaid Services (CMS), standards that mirror those created by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), Flannigan says. ASHRAE Standard 188 contains specific benchmarks when it comes to managing waterborne pathogens and water systems.

“CMS said that a health care facility had to have a water management program in place,” says Flannigan. “This risk management process for water systems starts with a multidisciplinary team. As you can imagine, the facility engineers…are on this team. But a key player on that team is always infection prevention. We’ve seen that the water management programs in some hospital systems are driven by infection prevention as opposed to facility management. But in all cases, they partner with others in the hospital.”

EVS workers play a crucial role in ensuring that water doesn’t become contaminated. “As they clean the rooms, they are often tasked with making sure they run the fixtures in the room,” says Flannigan, who adds that in many rooms, patients are often too sick to shower or use the sink. “Very sick patients may not see water usage for weeks at a time,” says Flannigan. “EVS is how most hospital systems and water management teams make sure that water flows through the fixtures and that the disinfectant they have in the water systems has a chance to be effective.”

Although infection preventionists and EVS members staff the water management team at many health care facilities, it is significant that Flannigan is making his presentation at the conference of the largest organization representing sterile processing professionals.

“The reason why water quality and water safety are so important in sterile processing is that there have been direct connections made between the water systems and hospital infections: operating room infections, asset life problems, maintenance problems, staining and discoloration of equipment,” says Flannigan. “There have been all kinds of issues that have been traced back to water systems over time. I would suggest that the awareness of that is increasing. The fact that we have this so-called water management team within the hospital that is responsible for making sure that, for instance, the overall distribution system for the building is safe. That team is now being leveraged because it’s the same group of players that for all intents and purposes would help support the sterile processing areas and the water systems that support them.” p

Newly updated standard 188 includes a comprehensive update to enforceable, code-intended language. American Society of Heating, Refrigerating and Air-Conditioning Engineers. August 2018. Accessed September 29, 2021. https://www.ashrae.org/news/esociety/newly-updated-standard-188

Note: In January 2022, IAHCSMM will change its name to the Healthcare Sterile Processing Association.

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Brian Flannigan: “The reason why water quality and water safety is so important in sterile processing is that there have been direct connections made between the water systems and hospital infections: operating room infections, asset life problems, maintenance problems, staining and discoloration of equipment.”

Troubled Water Makes for Sick Hospitals

Anthony Harris, MD, MBA, MPH, has visited 

) before during the course of the COVID-19 pandemic, where he discussed how private industry might want to hire 

, and the promise of vaccines. Recently he spoke to 

 about vaccine mandates. This is a subject that Harris knows much about because he’s the CEO and medical director for HFit Health, a company that helps businesses with their infection prevention and control problems, including the challenges of imposing vaccine mandates on employees. Harris also spoke about the need for a vaccine for children aged 5 to 12 and how that should be mandated, vaccine hesitancy among health care professionals, and the danger still posed by COVID-19 variants, including the so-called monster variant, an iteration that would be more infectious than the Delta variant, and also immune to antibodies generated either through prior infection or vaccines. His advice for infection preventionists charged with trying to convince their fellow health care professionals to get the vaccine is to “just speak to the benefits” the main ones being that the COVID-19 vaccine prevents hospitalization and death.

Vaccine mandates are being challenged often in the form of lawsuits. How do you see that playing out?

I see [vaccine mandates] prevailing, with the [Biden] administration’s documentation of precedence. We know that mandates such as this don’t exist in isolation. For any school age child that wants to attend public school, guess what? Be vaccinated. Likewise for universities, in many cases. If you’re living in a dormitory scenario. This is not a far cry from precedent that’s already been set. And we know that many clients and large employers that we work with are anticipating that this is going to go through. Even those scenarios, in particular from state to state [where] we see pushback, even from state OSHA [Occupational Safety and Health Administration], perhaps.… I’ve spoken with a number of state OSHA council members. And they said we’re going to maybe not enforce the penalty for companies that are not in compliance. But we’ll see how that shakes out in terms of their mandate to comply with, at a minimum, the federal mandate from an OSHA standpoint. Like you mentioned, a lot of moving parts. But we think that this is going to be something that will be with us in terms of a mandate for businesses that meet the criteria.

Are you concerned at all about the reaction among some health care professionals who have quit or resigned as a result of vaccine mandates? Did that surprise you?

I’m not too surprised. We know that there are very strong feelings on both sides of this issue, in terms of personal choice versus mandates. And we’ve seen this again play out with school aged children. Parents that have chosen to homeschool their children because they did not want their children vaccinated. It is something that is anticipated and a part of our sense of normalcy and the freedoms that we enjoy here in the U.S. It’s not alarming, but at the same time, on the flip side of it, it’s not alarming, too, that the majority of U.S. eligible individuals for the vaccine have been vaccinated. We’ll continue to see that number increase as we move forward because there will be ongoing pressure for individuals to be able to enjoy the normalcy that we used to enjoy—days of old, at this point—but certainly that’s going to look like a more vaccinated populace at a high level.

The two groups that seem to be most hesitant to get the COVID-19 vaccine are Republican men and African Americans. Does that surprise you? That opposition to vaccines is making some strange bedfellows?

We’ve seen this play out at this point in time for the last year and a half in regards to first, mask mandates and social distancing, and then vaccinations. And if we look particularly at the African American community, we know that there is a longstanding distrust of governmental mandates and projects so to speak, harkening back to the Tuskegee experiments. and that distrust carries on into generations today in these communities. And me living here on the Southside of Chicago, I see it firsthand. Where individuals will say, “Look, I’d rather disregard any attempt to get a vaccine until I see someone drop dead in front of me.” That’s the kind of proof in the pudding for them. Obviously, a high bar. But now we are seeing these communities 

disproportionately affected by COVID-19. I think we will see an increase in the vaccinations amongst African Americans because of the impact that COVID-19 has had in these communities. When it comes to Republicans, again, you know, being pro-choice—if we want to use that language around vaccinations, maybe a little controversial—but at the end of the day, it is something that we have seen in politics. Albeit on opposite sides in regards of the particular issue that we’re talking about. But we know the data are the data. There are almost twice, if not almost two thirds, as many Democrats who are vaccinated currently in the U.S. than Republicans. And I hope that it is not for a lack of communication of accurate data. Information that’s going to help save lives, help save communities, help save families from potential devastation, when it’s a potentially preventable outcome. And so that’s what we are germanely concerned about in the political community, and our messaging for sure.

that says that children can be just as infectious as adults and that children could be the incubators of the next variant that pops up. When a vaccine for children arrives, do you think that there will be mandates that children get it?

Yes, hands down, because of the Delta variant and because of the Delta Plus variant that has several unique mutations.… We know that the airborne propensity for transmissions is increased because of Delta Plus, even above and beyond what we saw with Delta, and certainly with the Alpha strains that we experienced last year. Because of the burden of viral particles in a droplet, five microns or smaller, we believe that children will likely be a source of infection and reservoir for infection until they’re vaccinated. And even once they’re vaccinated—again, not to be the doomsayer—but just looking at the data, and the data I like is the data out of Israel looking at 39% efficacy for prevention of infection, certainly higher for hospitalization, 88% and 92% for severe illness. But only 39%. [That means that] 61% of people are still susceptible to transmit COVID-19 from an infection after being fully vaccinated. We need to drill down and understand that kids will likely fall into that same or similar profile in terms of ability to contract and transmit. And that is why we won’t get to the other side of this pandemic by way of herd immunity, but only to make the disease endemic. Albeit a far worse outcome endemic compared to a flu or other illnesses that we deal with on a regular basis.

 Infection preventionists are often in charge of trying to educate their fellow professionals about the benefits of getting the COVID-19 vaccine. Any words of advice?

My best words of advice would be taking the approach that I’ve learned anecdotally through serving as the chief COVID-19 doc for our organization nationwide since March of last year. And that is let’s just speak to the benefits and lay the benefits out clearly. Anybody that says, “Hey, get vaccinated to help prevent infection” is not telling you the opposite side of that. Where you’re not going to see a tremendous benefit to the majority of people to prevent infection. Why do we get vaccinated? We want to prevent hospitalization and severe illness and death. And if we look at U.K. data, of their one dose policy that they had starting at the end of last year into this year for vaccination, we saw a dramatic difference between what they experienced from a mortality standpoint, with this latest rise in cases that we experienced starting back in August here in the U.S. and in the U.K. They had almost three times less of a death rate from the similar spike in cases and at some points in time they were higher than we were in terms of number of cases. But again, they experienced less mortality. That’s why we need to preach vaccination. We need to prevent the excess deaths that we’ve documented over and over in literature between what we’ve seen during the pandemic and what existed and was expected prior to the pandemic. Those are lives that could have been prevented in terms of loss. And that’s why moving forward, we want to be proactive to help prevent that loss.

Some health care experts have said that what keeps them up at night is the monster variant, a COVID-19 variant that’s more infectious than the Delta variant but that’s also immune to the antibodies produced either by prior infection or vaccines. How worried are you about that in light of the fact that most of the world hasn’t been vaccinated?

You’re right, and the monster variant may be amongst us already. Again, I mentioned the Delta Plus variant. We know that there were four mutations that occurred in the spike protein that actually moves the virus away from binding with our antibodies more fully as the Delta variant had done previously. It’s something that we’re seeing active. We have been through genetic drift. If we do see a genetic shift, meaning a more dramatic mutation that allows the coronavirus to escape our antibodies, then we’re going to be in a tremendous position to have a lot of devastation in those communities that haven’t had access to vaccinations. And I’ll mention, though, that there is a potential treatment that I believe may have a dramatic impact for those vulnerable communities. And yes, I’m talking about molnupiravir, the Merck medication [for which the company is] seeking 

. The data on that is pretty darn good. And we saw in their studies that they ended their recruitment early because the results were so prominent in regards to decreasing death; not just death, but hospitalization, severe illness in those vulnerable individuals who have a pre-existing condition. And we know that Merck is gearing up to produce on an order of 2 million doses by the end of 2021. And a majority of those are going to help Third World countries that don’t have access to IV solutions. There is help on the way. There are a number of other nucleoside antivirals that are in the pipeline, and we hope they will be just as efficacious for preventing loss of life and severe illness. But we still have a lot of work to do in terms of getting the right treatment, and then hopefully preventing, through vaccination.

Does the fact that COVID-19 vaccine effectiveness wanes over time make it more difficult to mandate vaccination? People can turn around and say, “Look, it doesn’t even work.”

Right. It does make it harder to demand a vaccination, I believe, from the perspective of transmission prevention. And then we see also, in terms of even severe outcomes, if we were looking at the data, it wanes over time. Even the data that looked at boosters for Johnson and Johnson for the mRNA vaccines as well. We saw that waning over six months [causing] more breakthrough transmissions in those who are fully vaccinated. Anecdotally, large employers that we work with…. I spoke at a national safety conference in Austin recently, and after my talk, a gentleman came up—a safety professional, heads a large organization—and said, “Look, 70% of our cases that we’re seeing today are in fully vaccinated individuals.” That's alarming. And so that is why we’re seeing Israel saying that because of the waning immunity for natural immunity, as well as acquired immunity, you need a third booster in order to be considered fully vaccinated. Three shots gets you fully vaccinated in Israel. We have yet to declare such a leap forward in the U.S., but I do anticipate—looking at the waning immunity in what we’re seeing—that that will likely be our scenario as well, in order to maximally protect the public from more devastation from COVID-19.

Doctor Harris is there something that I neglected to ask you that you think is pertinent and that you want your fellow health care professionals to know about vaccine mandates or anything about COVID-19?

From the infectious disease side, the companies out there that are going to be subjected to the mandate need help [in formulating] the best strategy to execute on their vaccine protocols, to execute on testing. This is a point in time that certainly I’ve never seen in my career—and even those who have been in this business twice as long as I have, for 40 plus years—have not seen the level of demand for our services as professionals in this industry. I want to cajole everyone to offer your best practices to organizations to help maximize their efforts to protect as many people as we can and to help them not just be compliant, but to be protected.

This interview has been edited for clarity and length.

Anthony Harris, MD, MBA, MPH: “We know that mandates such [as the COVID-19 vaccine mandate] don’t exist in isolation. For any school age child that wants to attend public school, guess what? Be vaccinated. Likewise for universities, in many cases. If you’re living in a dormitory scenario. This is not a far cry from precedent that’s already been set.”

Why COVID-19 Vaccine Mandates Are Necessary

The US health care system was caught off guard when COVID-19 was declared a worldwide pandemic in March 2020.

 Infection preventionists and other health care professionals had to innovate in a hurry, the most obvious example being how to deal with the lack of N95 masks.


Among the frontline workers who had to make do with what they had were sterile processing professionals. IAHCSMM held its annual conference virtually last month. One of the presenters was Berg, who was president of IAHCSMM’s board of directors in 2018 and 2019 and is now the organization’s vice president for strategic initiatives. The presentation by Berg and Amanda
Benedict, vice president for standards for the Association for the Advancement of Medical Instrumentation (AAMI), was titled “Sterile Processing Unscripted.” Berg spoke to 

 before his presentation about the innovations that sterile processing professionals had to come up with to function during COVID-19’s first wave.

“Sterile Processing Unscripted.” What’s that all about?

Damien Berg, IAHCSMM Vice President for Strategic Initiatives: 

It’s great. I do want to give a shout-out to my copresenter, Amanda Benedict, the vice president for standards at AAMI. She and I had this conversation a long time ago….during the first COVID-19 wave. There were several things going on, like reprocessing of N95 masks. They asked sterile processing departments to process 3D-printed items that I have never used and there are no standards that cover this stuff. There were a lot of things that happened during the COVID-19 time during the [FDA’s Emergency Use Authorization (EAU) act] that were confronting sterile processing professionals like myself. I manage a department for a large health care system and when I tried to reference standards—I have been part of the [American National Standards Institute and the AAMI] standards committee for 16, 17 years—I couldn’t find anything. And on the AAMI side, Ms Benedict, she was getting calls, emails, and questions from [individuals] like me asking: “What do we do when, basically, the standards don’t match the reality of what the world’s going through right now? How do I do it?” We said it’s sterile processing unscripted because we’re dealing with something that doesn’t have a script. We’re doing something that doesn’t have a [standard attached to it]. How do we do that? How can we create a pathway moving forward, so that whatever hits us next, it’s not this panic scenario on our part?

Can you give an example of how this might work on the ground?

A good example is recently in Louisiana when we had the hurricane and there was immense flooding, power outages, and water outages. What people don’t realize is that in hospitals when the city water goes out, how are you getting your steam? How are you getting your water to wash things? How are you handling that? There is no blueprint or anything to cover that. So, we wanted to say, when the water turns back on, how do you boil the water when you’re drinking water from the boiler? Water that you sterilize or wash your instruments with? We wanted to create blueprints for [individuals] to pick up and go so they don’t have to think on the fly. We want to give the leaders of either AAMI or IAHCSMM a tool to move forward with. That’s our presentation. We’ve got different areas we’re talking about: on the regulatory side, how standards are made and the rigor behind them. Then I’m going to talk about how that impacts the end users and my members and how they use those devices. Then, what are some examples when nothing matches either the education and/or the regulatory side? What do we get?

You mentioned hurricanes and the electricity going out. I imagine that AAMI and IAHCSMM already had protocols about what to do in emergencies. Was COVID-19 just something so unusual that they didn’t apply?

Most facilities have emergency operation plans. But it’s tough to write a standard or metric. You can be educated on certain points. Honestly, with COVID-19 and Emergency Use Authorization, that changed the dynamic. Never in modern history can I remember being allowed to do things that we would never have been allowed to do before. Again, I use that idea of reprocessing the N95s or reprocessing [personal protective equipment]. We were [previously] just told, “No, you can’t do that.” Once that was allowed, then other things happened. We were approached by the end users about all kinds of [methods]. “Well, hey, what about using this now, but you can’t do this.” You open the door for it. Now you can do this. The industry people love it. This is where I think back to the Industrial Revolution and those times when America was creative, creating stuff nobody ever saw or thought of. People in the industry were really being creative with 3D printing and/or coming up with new devices to substitute shortages in the supply market, that we’ve never seen before. There literally were no standards to develop around that or education around it. They basically kept saying, “Why can we do it with the N95 mask and not with this?” We wanted to talk about that and say, “This is the way we need to address this moving forward.” And industry…it is awesome that people are thinking outside the box to solve [problems] in the real world. But we also want to make sure we’re doing it safe for the patients and the providers using these devices that we reprocess. Also, it’s reproducible. I can almost guarantee that I can sterilize and clean anything once. Can I do it multiple times with the same efficacy? That’s the rigor you need to put behind this. It’s like giving your kids permission to do something, and then you say, “Sorry, never mind. You can’t do that now.” And they’re like, “Wait a second. You can’t tell me I can do it, then tell me I can’t. You can’t say it was safe for me, and now it’s not safe. What’s the difference now?”

 It sounds like you’re talking from painful experience here.

Yes, sir. Also, one thing I didn’t tell you, and it’s something about me. I also spent 21 years in the military as a combat medic and [found myself in] multiple adverse conditions where I didn’t have things I needed. Sometimes you just improvise. We make it happen. I’m used to doing that. I came from that same thought process and mindset. The difference is I was—with reaching out to industry experts and standards and my background—able to show that we put some rigor behind doing it. We just didn’t listen to the noise out there. We didn’t listen to everybody saying, “Just do this” and run around like Chicken Littles shouting that the sky is falling. We did testing on N95 masks. We did documentation. I was able to track every mask to every reprocessing cycle to every end user and the number of times….The steps are so if there ever was an adverse event or outcome later, I was able to trace it back. But I also said at a certain point, we need to stop doing this because the supply chain will be back to normal, which it is in certain spots. It’s still wavy. But it has created that pull/push from the end users saying, “Well, I got this pin and I’m going to go and sterilize like we did with the N95s.” We have to say, “Well, that’s just not how we do things. Right now, we’re following policy, because there are no emergencies.”

You mentioned that you were a medic and I want to thank you for your service. You have to be a special kind of person to be a medic.

During the presentation…I’ll be using some of those real-world examples. There were things you just had to do, because you didn’t have an option and you had to go through with it. It was about explaining the “why.” So, the N95 masks—we literally knew our burn rate for them. And if we did not move—and we use UV light reprocessing at my health care facility—if we did not do that, the “why” would be that we would run out of masks in 5 days. That was our approach—thinking outside the box, using research from other institutions that are well renowned and had some stuff done to say, “OK, this is how we’re going to do it.” We got a multidisciplinary team together to come up with a process and the “why” behind it. “Why” wasn’t because we just wanted to do it, but because if we didn’t do it our care providers and our patients and we wouldn’t have N95 masks when we were treating the first wave of COVID-19. We really had to say: “This is the call to action.” On the military side, I’ll give a graphic example. I was in the field for a unit and I did not have surgical gloves or sterile instruments. I had to go inside someone’s inner body cavity with my bare hands and instruments that I sterilized on my own to stop the bleeding. The “why” was if I didn’t do that, that person would die. What would impact a patient greater: Me not having sterile gloves and me getting exposed to their blood, or me just saying I don’t have them so I’m not going to do anything? You must make choices. Those are 2 extreme examples. When I have to do things in this world now, I always use the old method. I check my pulse, and if I have a pulse, then I can calm down and move on. I don’t get too excited about things anymore. I just think through them differently. That’s unscripted, because you’re going to have those unscripted moments where you can’t wait for the regulatory folks to say, “Do this.” You’ve got to use some common sense but also your science and background and then do what we call in the military an action review. You look backward and say, “OK. What did we do? Why did we do it? How do we do it? And do we need to change anything on why we did it?” I think the same thing really applied to this road map. I had some [individuals] do some soul searching and ask: “Do I really want to do this profession anymore?”...The level of stress that they went through, they probably never experienced in their lifetime. There are different levels of stress and [individuals] handle it differently. They’re just kind of soul searching, saying “Is this really what I want to do? Am I close to retirement? Should I just retire? Or do I switch career paths and do something different?” That’s fine for everybody. I look back and think, “Boy, we did some innovative stuff.” I’ll give you some good examples. Where sterile processing really was—and it’s still holding true; it’s a byproduct of COVID-19—we were looked at, because we’re the cleaning disinfection and sterilization experts in the facilities….People didn’t really know that. COVID-19 put a light on sterile processing professionals in a positive way. We became a force multiplier in the hospital by the things we did. And we got known. We got asked more questions about: Is this contact time right? What’s the dwell time? What’s the chemical ratio? They didn’t know what dwell time was prior to COVID-19. Not the masses. They didn’t know what contact time was. They just did their thing. But now they rely on us as subject matter experts. To me, that is a longer-lasting thing to keep me in the profession vs the small lap or the stressful intense time of the first wave…. Now we’re dealing with multiple smaller waves that are hitting, but we’re using those lessons learned. That passion for what we do is to keep moving forward.

Is there something that I neglected to ask that you think is pertinent and you want fellow health care professionals to know?

Great question….Years ago, I joined the military at 17, and wanted to be a combat medic, and I did surgical tech and flight medical. I did sterile processing in the military, but I never thought that was my calling. When I transitioned to the civilian side—I’m still in the National Guard—I found sterile processing to be an honorable profession that does impact patient care, and you are appreciated. You need to know that. To the sterile processing people out there: Know that you do make a difference. Everything you do touches a patient’s life, and thus the families and thus the surgeons and thus the hospital community. We do make a difference. You are appreciated. You’ve got to know that. You’ve got to soul search that, and be proud of it by getting certification, by knowing your standards, and by being engaged in your community. That’s by far what I want to leave you with.

Kavanagh K. Viewpoint: US woefully unprepared for COVID-19 pandemic. Infection Control Today®. March 11, 2020. Accessed September 30, 2021. https://www.infectioncontroltoday.com/view/viewpoint-us-woefully-unprepared-covid-19-pandemic

Diamond F. Survey: many hospitals have only 10-day’s-worth of N95 masks left. Infection Control Today®. March 26, 2020. Accessed September 30, 2021. https://www.infectioncontroltoday.com/view/survey-many-hospitals-have-only-10-days-worth-n95-masks-left

IAHCSMM’s Damien Berg: “COVID-19 put a light on sterile processing professionals in a positive way. We became a force multiplier in the hospital by the things we did. And we got known.”

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