KEVIN KAVANAGH, MD, is the founder of the patient advocacy group Health Watch USA

For many decades I have been amazed that our health care system primarily focuses on treatment and not prevention. I had assumed it was because the United States has a profit-driven system, but the COVID-19 pandemic has revealed additional important factors. Public health’s primary focus has always been on prevention, but when public health is successful, often nothing happens, and the impact public health workers have had on our communities goes unnoticed.

Unfortunately, infection preventionists (IPs) fall firmly into this category. Preventing infections hides an infection’s true threat and firmly places IPs into the category of unsung heroes. The inability of some leaders to focus on preventing infections has placed our nation in peril, resulting in an ineffective COVID-19 response, fueled an exponential growth in monkeypox infections, along with a 

, and has allowed all but conquered diseases, 

Credit: Eric Feigl-Ding, ScD, Twitter, July 23, 2022

When the principles of public health are not vigorously applied (and in some cases all but abandoned) our communities suffer. Individual freedom will not stop a pandemic or contain a disease, only community-wide actions can do this, and the political willingness to act and embrace public health strategies has languished. A recent 

, ScD, portrays this recalcitrance with the prevention of spread. Scientists early on warned of exponential growth, while politicians declared the epidemic gone, then under control. Only when the barn has burned down did elected officials become concerned about the once avoidable epidemic.

Take, for example, monkeypox, a DNA virus which has limited ability to spread compared with SARS-CoV-2. The monkeypox pandemic emerged with a few cases. Despite warnings, too little was implemented too late. We should have been able to contain this outbreak, with effective case tracking, ring vaccination, and public education.

“There are both vaccines and antiviral medications which are effective against orthopoxviruses. In addition, 

epidemiological case tracking and public education

 are expected to bring this (monkeypox) outbreak under control.”

Instead, the United States made similar mistakes to what we witnessed at the beginning of the SARS-CoV-2 pandemic, providing too little too late, which allowed monkeypox to exponentially grow into an epidemic.

Monkeypox currently appears to be primarily spread by male sex with men (MSM). Unfortunately, there are beginning signs that monkeypox is spilling over into the general population. It is estimated that monkeypox has an 

 (1 infected person spreads it to approximately 2 others), which is much less infectious than our current strain of SARS-CoV-2, but more infectious than the seasonal flu which has an average 

. In addition, this strain of monkeypox may be 

 than once thought. 

Last week, the Centers for Disease Control and Prevention reported that 

 in the United States have contracted monkeypox, and there is mounting evidence that monkeypox can, under at least certain circumstances, aerosolize, which may augment its spread in the general population. A recent report from the United Kingdom’s NHS England Airborne HCID Network found significant surface contamination and the 

n of the monkeypox virus “during certain activities,” stating:

“We identified widespread surface contamination (66 positive out of 73 samples) in occupied patient rooms (MPXV DNA Ct values 24·7-38·6), on health care worker personal protective equipment after use, and in doffing areas (Ct 26·3-34·3). Five out of 15 air samples taken were positive. Significantly, 3 of 4 air samples collected during a bed linen change in 1 patient’s room were positive (Ct 32·7-35·8).”

At this point some leaders feel it is 

too late to successfully contain monkeypox

, a situation that may well become much worse if the disease finds a sustainable host by entering our rodent population. 

, there were 16,836 confirmed cases of monkeypox worldwide and 2890 cases in the United States.

The World Health Organization’s leadership has just declared 

, overruling an indecisive WHO advisory panel. Only 2 other diseases have had this level of alert, polio and SARS-CoV-2. The United States’ Department of Health and Human Services is also considering 

declaring monkeypox a public health emergency

.

Unfortunately, I fear large portions of our public are not convinced. For example, 

 that monkeypox “will become established in the pediatric and general population and will transmit through daycares and schools” similar to MRSA. She was promptly criticized as “promoting hysteria” by a prominent journalist. I would not call such a statement hysteria but a genuine concern which needs to be monitored closely.

Despite public reluctance, infection preventionists must maintain a clear and public voice that promotes the principles of preventing the spread of disease. Monkeypox is fast becoming entrenched in our communities. Along with the newly 

 in an unvaccinated individual in New York City, a disease quiescent in the United States since 2005, necessitates that now more than ever the voice of infection preventionists needs to be heard. 

Articles

With the World Health Organization declaring monkeypox a global emergency, Infection Control Today® looks at what lessons SARS-CoV-2 gave but were not followed, and what could be next. 


The Public Ignores Warnings from Infection Preventionists, but at What Cost? 

 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.

Infection Control Today's® Product Locator is a monthly column highlighting some of the latest advanced technology in the infection prevention field.

The Role of Health Care Laundry in Infection Prevention

Environmental sources of pathogen organisms can sometimes be difficult to narrow down in a health care facility. One possible source of transmission is the laundry used, and not maintaining strict cleanliness attention can put both patients and workers at risk.

Read about a lady with white hair, being human, and how infection prevention needs to transform.

Bug of the Month: I May Be Rare, but You’ve Known About Me for Centuries

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today.

Infection Prevention: A Collaborative Effort Among Patients, HCPs, and Family Members

Infection preventionists are not alone, despite how the COVID-19 pandemic has often made them feel. They are one point of the patient's triad--and the bonds within the triad are vital for the patient's outcome.

Take 5 minutes to catch up on Infection Control Today’s highlights for the week ending July 22.


Weekly Rounds: Product Locator, Role of Health Care Laundry in IP, and More

Ion AmpliSeq SARS-CoV-2 Insight Research Assay GX on the Genexus Integrated Sequencer

The Ion AmpliSeq SARS-CoV-2 Insight Research Assay GX is a next-generation sequencing (NGS) assay that is quick, accurate, and comprehensive, enabling research and surveillance of the SARS-CoV-2 virus and variants through complete genome sequencing. The intelligent assay design includes new primers that broaden the coverage for variants of concern and increase the sensitivity of the assay for improved detection from lower viral titer samples.

Features include greater than 99% coverage of the SARS‑CoV‑2 genome, covering all potential serotypes; samples with cycle threshold values greater than 28 can be used for preparing libraries, SARS‑CoV‑2 variant announcing, lineage identification, and reporting with Genexus software. 

The assay helps broaden NGS epidemiological surveillance to cover emerging SARS-CoV-2 variants through panel design improvements. It also has an improved limit of detection from various sample types due to increased sensitivity. It enables greater access to NGS to rapidly obtain epidemiological insights with quick turnaround time, workflow automation, smooth informatics, lineage identification, and data uploading to public SARS-CoV-2 data sources for viral surveillance.

The Ion AmpliSeq SARS-CoV-2 Insight Research Assay GX should be stored in the freezer (–5 °C to –30 °C) and is compatible with Genexus Software 6.2 and later.

Purell CS4 All-Weather Dispensing System is a hand hygiene dispenser that performs in extreme weather and high-traffic settings. Traditional dispensing solutions are commonly designed for indoor settings, but this innovative dispenser enables commercial and municipal buyers to offer hand sanitizer and hand soap in outdoor or high-traffic areas. 

The Purell CS4 All-Weather Dispensing System is made of engineered resin that is more than 3 times stronger than materials used in most other dispensers. Its advanced design is water resistant to help keep the rain out and prevent vandalism or refill theft, and its special graphite paint makes the dispenser resistant to UV fading to preserve its performance and appearance in a wide range of extreme conditions and temperatures—from –40 °F to 122 °F.

“With more than 80% of the public now expecting hand sanitizer to be offered in public places, access to hand hygiene is more important than ever before, so we must offer reliable Purell dispensing options suitable for any environment,” said Jessica McCoy, chief solutions officer at GOJO Industries, in a news release. “The addition of this groundbreaking dispenser means Purell hand sanitizer or soap can now be offered in any location. The Purell CS4 All-Weather Dispensing System underwent over 5400 hours of internal, third-party, and live field testing.”

Sereneview Custom Curtains feature striking landscape photography printed directly on the curtain facing the patient, drawing the viewer into the photograph to encourage a tranquil state of mind, which, according to the company, releases serotonin and reduces blood pressure and stress without having to medicate a patient during observation or painful procedures. Patients remember remote details when asked about their recent visit. In addition, studies have shown that staff is more engaged and efficient working in a clean and nurturing environment.

Medical team also appreciate the Armor finish that includes AEGIS Shield antimicrobial, which has been tested and proven to repel methicillin-resistant 

, severe acute respiratory syndrome, bacteria, mold, and most microorganisms within 1 hour of contact. Armor finish also has a stain guard that resists bodily fluids, betadine, oil, grease, dirt, and ink pen marks from becoming permanent stains. A stain guard combined with AEGIS Microbe Shield system provides antibacterial properties, an additional level of protection for patients and staff. Even after the stains have dried, they will wipe clean with a typical nonbleach cleaner without having to remove the curtains, reducing laundering frequency, saving time, reducing laundry costs, and extending the functional life of the curtain.

Sereneview Custom Curtains are available as hospital curtains, overheads, and wall treatments.

Infection Control Today's® Product Locator is a monthly column highlighting some of the latest advanced technology in the infection prevention field. 

Infection Control Today's® Product Locator

As the NIH Clinical Center Director of the Hospital Epidemiology Service, Dr. Brooke K. Decker collaborates with both clinical and non-clinical services to prevent hospital-acquired infections.

Do these linens have pathogens? (Adobe Stock) 

The hospital is a busy place, full of myriad devices and complex situations. Preventing hospital-associated infections feels like it requires an encyclopedic knowledge of every new and complicated health care intervention. Potential sources of transmission in the hospital include a remarkable array of specialized risks, but there are mundane, everyday risks like health care laundry too.

Which textiles are reused and laundered varies from health care facility to health care facility. Typical health care linens include patient and staff bedding, towels, clothing (scrubs, coats, uniforms, patient pajamas, and gowns), surgical drapes, curtains, and reusable mop heads. Hospital linens can harbor a significant density of pathogenic organisms, from 106 to 108 colony-forming units/100 cm2. Those most commonly isolated include gram-negative organisms (

Despite this noteworthy pathogenic burden, the significance of linens in health care transmission is unclear. When an infection occurs, it may not be possible to identify the exact environmental source of transmission because multiple potential environmental reservoirs exist in parallel. Although health care linens are not often implicated, it makes intuitive sense that they are a potential reservoir for transmissible organisms.

Workers who handle laundry are at increased risk of transmission, including gastrointestinal pathogens.

 Definitive associations between linen contamination and patient infections are harder to parse. Nevertheless, there is a need for meticulous attention to maintaining linen cleanliness.

It may be simplest to separate hospital linen–associated risks into 3 distinct sections: 1) removal; 2) cleaning; and 3) storage.

Ensure linens are removed, stored (if necessary), and transported safely to the cleaning facility. Soiled linen poses a danger to health care staff and possibly to patients. All used linen should be considered potentially infectious. Linen should not be shaken or disturbed in a way that could aerosolize infectious particles. Personal protective equipment that would be worn around the patient should also be worn when removing and packaging soiled linen for transport. If there is gross contamination without transmission-based precautions, standard precautions will necessitate the use of additional personal protective equipment.

 Some infections, including orthopoxviruses, are transmitted by contaminated linen.

 Linen should be contained before removal from a patient’s room, taking care not to disturb or aerosolize any infectious particles. Note should be made that the exterior of bagged linens may become contaminated, even with double bagging.

 In many health care settings, soiled linen must be gathered and transported to an off-site location.

Adequate cleaning and disinfection is essential. The 2003 Guidelines for Environmental Infection Control in Health-Care Facilities from the CDC and the Healthcare Infection Control Practices Advisory Committee provides detailed standards for health care laundering, including achieving minimum temperatures and disinfection concentrations that ensure pathogens will be inactivated.

 In most cases, processing according to these standards should be effective, even with 

 A few organisms may resist disinfection in the laundry. A study looking at the relative thermotolerance of 

 showed that they were inactivated during the washing cycle, despite tolerance to the high temperatures alone.

 spores inoculated into cotton sheets and run through a simulated hospital linen washing cycle were noted to remain viable after cleaning.

 An obvious potential pitfall during cleaning is failure to achieve intended time, temperature, or disinfectant concentration minimums. Excursions may be difficult to detect if laundry is managed off site or by a contractor. A busy infection prevention service may not have the bandwidth to survey off-site or contracted linen services more than once or twice a year. Trust and communication with those responsible for linen processing are critical to ensuring prompt notification and resolution if an issue is discovered.

Clean, processed linen should make it to the patient’s bedside clean. The quintessential infection prevention standard—separation of clean and dirty—must be baked into the management of clean linen. A unidirectional flow at the laundry processing facility will help prevent pathogens from soiled linen coming into contact with the clean linen, even indirectly from the hands or clothing of workers. Laundry surfaces should be routinely disinfected, and hand hygiene should be monitored for compliance.

 Laundering requires both heat and water—prerequisites for the growth of pathogenic mold. Health care outbreaks of mucormycosis have been linked to linens.

 In a vulnerable patient population, mold exposure is associated with severe or life-threatening infections. If linen must be transported from an off-site facility, it should be covered during transport to prevent contamination. Linens still warm from processing should be allowed to reach ambient temperature before covering, lest condensation and reduced airflow promote mold growth. Once linen arrives in the hospital, it should be unloaded promptly and stored in a manner that prevents contamination.

Within the clean linen supply, contamination may occur from hands of health care workers accessing clean linens without first performing hand hygiene. Clean storage rooms should be protected and monitored for excursions of temperature, humidity, and damage associated with floods. Costorage with soiled items or devices like refrigerators that include fans, condensation, or generate heat should also be avoided. Prevent contamination by ensuring covers or cabinets are kept closed. Methods of storing and using linens may vary. The astute infection preventionist may need to use shoe-leather epidemiology to identify how linens make it “the final mile” if there is a concern for potential transmission.

If there is a delay from when a bed is made to when a patient occupies the room, how long before linens would be replaced? Is there a mechanism to identify if a bed is used surreptitiously? This may not be a concern for busy facilities with high occupancy, rapid turnover, and adequate call room space, but with the change in elective procedures during the COVID-19 pandemic, there may have been changes to patient and employee flow. A process to ensure linens are freshly made immediately before patient arrival would reduce the risk of contamination.

There are many ways for pathogens to hitch a ride in the hospital environment. Linen is only one of many potential fomites that could be implicated in environmental transmission of hospital pathogens. Ensuring soiled linen is appropriately contained, transported, cleaned, and stored is essential to preventing transmission from this easy-to-overlook aspect of the health care environment.

1. Blaser MJ, Smith PF, Cody HJ, Wang WL, LaForce FM. Killing of fabric-associated bacteria in hospital laundry by low-temperature washing. 

1984;149(1):48-57. doi:10.1093/infdis/149.1.48

2. Ellsbury E, Owosekun O, Mackey K, Ten Eyck D, Mahoney LE. Outbreak of viral hepatitis in the staff of a pediatric ward — California. 

3. Borg MA, Portelli A. Hospital laundry workers--an at-risk group for hepatitis A? 

1999;49(7):448-450. doi:10.1093/occmed/49.7.448

4. Standaert SM, Hutcheson RH, Schaffner W. Nosocomial transmission of Salmonella gastroenteritis to laundry workers in a nursing home. 

5. Fijan S, Steyer A, Poljsak-Prijatelj M, Cencic A, Ostar-Turk S, Koren S. Rotaviral RNA found on various surfaces in a hospital laundry. 

2008;148(1-2):66-73. doi:10.1016/j.jviromet.2007.10.011

6. US Department of Health and Human Services, Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-Care Facilities. 

Recommendations of CDC and the Health Care Infection Control Practices Advisory Committee (HICPAC) 

2003. Published 2003. Updated July 2019. Accessed June 27, 2022. https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf

7. Pauli G, Blümel J, Burger R, et al. Orthopox viruses: infections in humans. 

2010;37(6):351-364. doi:10.1159/000322101

8. Maki DG, Alvarado C, Hassemer C. Double-bagging of items from isolation rooms is unnecessary as an infection control measure - a comparative-study of surface contamination with single-bagging and double-bagging. 

1986;7(11):535-537. doi:10.1017/s0195941700065279

9. Infection prevention and control of monkeypox in health care settings. CDC. Updated May 22, 2022. Accessed June 29, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-health care.html

10. Orr KE, Holliday MG, Jones AL, Robson I, Perry JD. Survival of enterococci during hospital laundry processing. 

2002;50(2):133-139. doi:10.1053/jhin.2001.1137

11. Tarrant J, Jenkins RO, Laird KT. From ward to washer: the survival of Clostridium difficile spores on hospital bed sheets through a commercial UK NHS health care laundry process. 

2018;39(12):1406-1411. doi:10.1017/ice.2018.255

12. Fijan S, Sostar-Turk S, Cencic A. Implementing hygiene monitoring systems in hospital laundries in order to reduce microbial contamination of hospital textiles. 

2005;61(1):30-38. doi:10.1016/j.jhin.2005.02.005

13. Cheng VCC, Chen JHK, Wong SCY, et al. Hospital outbreak of pulmonary and cutaneous zygomycosis due to contaminated linen items from substandard laundry. 

2016;62(6):714-721. doi:10.1093/cid/civ1006

14. Sundermann AJ, Clancy CJ, Pasculle AW, et al. Remediation of mucorales-contaminated health care linens at a laundry facility following an investigation of a case cluster of hospital-acquired mucormycosis. 

2022;74(8):1401-1407. doi:10.1093/cid/ciab638

I’d like to tell you a story about a lady with white hair. At least I think she had white hair. It’s certainly one of the attributes I remember most about her. She was short, she had white hair, and she always had a scowl on her face that seemed to say, “Stay away, I bite.” She carried a clipboard with her everywhere, and her eyes would follow you like a hawk circling prey. She’d scribble furiously on the sheet of paper on the clipboard. And I remember always wondering what she was writing.

I was 20 years old at the time and, somehow, had landed myself a job in the emergency department as an ER and trauma nurse. ER nursing had been my first love, so I was surprised when I found a career that I loved even more. I sometimes wonder what my 13-year-old self would have thought if someone had told her that she would grow up to prevent and control infectious diseases. I don’t know that I would have believed them at the time; I was still convinced that I was going to be a musician. But I digress.

I had no idea what the lady with white hair did at our hospital, but she was absolutely adamant that I wash my hands every time I entered or exited a patient’s room. And that’s another thing—I couldn’t figure out whether she wanted me to wash my hands or use the hand sanitizer. Sometimes I would use the sanitizer, and she’d get mad that I hadn’t washed my hands. Other times I would wash my hands, and she’d remind me that I could have used the hand sanitizer. Because we didn’t know her name, we all endearingly referred to her as “the handwashing lady.” When she arrived on the unit, the charge nurse would send a message to everyone’s phone that read, “The handwashing lady has arrived.” This would cue all of us to make sure we paid attention to washing our hands as we went about our work.

It wasn’t until years later that I would understand exactly what the handwashing lady was doing during her visits to the ER. It dawned on me one day during my first year as an infection preventionist that I was now the handwashing lady. However, the issue is not so much 

 the handwashing lady was doing and the science behind it, but 

 she was doing it. What a shame that I didn’t know her name, the importance of her job, or the reason for her visiting the ER. Friends, if I’ve learned anything in my career, it’s that infection prevention is 20% science and 80% implementation of that science. If you want to succeed at preventing and controlling infections, you must master the art of implementation. I know that I washed my hands more because of the lady with the white hair, but my compliance was driven far more by fear than by recognition of the importance of hygiene.

I continue to see this scenario play out as a research nurse and consultant in infection prevention and control. We are trying to help people prevent infections who don’t even know we’re there to help them prevent infections. All they see is a man or a woman with a clipboard, telling them to wash their hands. Obviously, there is a huge disconnect here; something is missing, and that something is in our approach. We’re missing a fundamental understanding of human nature. I’m sure the lady with the white hair meant well, but we didn’t know that. I think she knew 

she needed us to do to prevent infections, but she didn’t know 

 to get us to do it. She didn’t take complicated, messy humanity into account.

Take a moment to think about one of your habits and what drives it. Would it be helpful if someone said to you, “Stop doing that. It’s bad for you.” Not really. But why? Because they are not addressing the underlying reason or reasons for that behavior. In health care, we must understand what drives compliance and noncompliance. Is it fear? Convenience? Money? Discomfort? A knowledge gap? Is it politics? Are past experiences influencing current actions? If we want to change behavior, we must recognize that people are complex. We cannot simply tell someone to do or not do something and expect immediate compliance. Instead, we must first understand the human factors that affect the behavior we’re seeking to influence.

My friends, this is why we need a revolution. We know 

we need to do to prevent infections, but we need to change 

 we do it. We’re forgetting that to prevent infections we must change the habits, perceptions, and knowledge ingrained in people and institutions. And people are so incredibly complex. I’ve already mentioned this, but I want to emphasize it. People are messy and complicated and confusing. We are filled with fear, insecurities, opinions, and habits. If we want to prevent infections, we must get to know and understand people, not just the science of infection prevention. On the surface, infection prevention and control is just science, but it’s really an art more than a science. The science of preventing infections is merely the tip of the iceberg. Underneath are people—complicated, messy people—and our approach to helping them prevent infections is key.

We need to change that approach. We talk a lot about what people must do: wash the hands, take the medicine, clean the hub, wear the mask. But we need to better understand 

 to get them to do those things. This is what I like to call “the art of prevention.” In this series of articles, art will meet science. Learning to practice this art requires us to continue learning about science because, regardless of how well one understands people, one must first understand the discipline of infection prevention. We’ll also explore human factors, psychology, and finally—possibly most importantly—personal growth. I know what you’re thinking: “What does personal growth have to do with preventing and controlling infections?” Quite frankly, everything. Infection prevention is not an easy job. To be successful in this career, we must have strong interpersonal skills and be able to handle conflict and defeat, competencies everyone can develop with time and guidance.

I’m eager for you to join me as we explore the complexities of being human in the context of infection prevention and control. My hope is that you’ll grow as a person and as a professional. This month, I want to challenge you to become known. Get out there and introduce yourself as the infection preventionist. Strike up a conversation with the environmental services worker. Tell them your name, make small talk, and share with them why you love what you do. Commit to not being known as “the handwashing person.”

Read about a lady with white hair, being human, and how infection prevention needs to transform. 

We Need a Revolution

.  She has been a writer and editor for over 30 years, and she has an MA and BA in English Composition/Literature from the University of Akron in Akron, OH. She lives in Ohio with her fiance; 2 tiny dogs, Selena Brigid Sophia and Doctor Danger Dog; and a big black cat, Freya. She loves reading, writing, gardening, and spending time with her loved ones.

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

Click here to guess the July/August Bug of the Month!

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. 

SASKIA V. POPESCU, PHD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities.

Infection prevention has never been a “one-person show,” even if it often feels that way. Many of us who work in infection prevention and control (IPC) look at things not only through the lens of an infection preventionist (IP), but also through those of family members, friends, and even patients. This vantage point helps us to better implement prevention efforts and to see things from perspectives that often are not incorporated into traditional IPC protocols.

Collaboration is key. It’s that simple—and yet not that simple. Full transparency requires I disclose that I’ve also been an infection patient and a relative of such patients. But as someone who utterly loves what she does, I have seen the worst and the best parts of the job, particularly during the COVID-19 outbreak. Before delving into the topic of collaboration, it’s important to address what is palpable in our community right now: fatigue and a feeling of disconnect and discontent.

After more than 2 years, the pandemic has shed light on how ill-prepared hospitals are for such events, let alone our capacity to handle the fatigue that comes with the marathon that a public health crisis entails. I also want to say what generally goes unsaid: IPs have been wildly overlooked during this pandemic. We are the first advocates for health care workers (HCWs), but we often feel that our role is seen as that of an adversary rather than an ally. IPs are the ones doing the training on personal protective equipment (PPE), translating new guidance into practice, working with families and patients, in short, implementing COVID-19 IP measures on top of our daily work.

I share this because it can be isolating to feel as though your role is ignored even though it supports the response to a global event. This sentiment and our experiences during COVID-19 will likely impact the face of IPC in the future. We’re in uncharted territory; we’re not out of the pandemic, but everyone seems to have decided it’s over. The changes in public perception and sentiment toward COVID-19 are telling in terms of how we handle health, infection prevention, and nonpharmaceutical interventions.

It is obvious that IPC cannot be accomplished by any one group, but too often we forget the critical nature of collaboration. There is a triad, which is made up of the health care worker, the family/support system, and IP, and the patient sits within that triad. From prevention to response to follow-up, one of IP’s most important partnerships is perhaps with the patient. Outside of rounding, I often felt that my time with patients wasn’t really the main focus of my work. The truth is that taking the time to discuss isolation status, strategies for discharge, and safety once at home can go a long way to prevent the spread of any infection. It’s very important to talk to patients about why they’re in isolation and how they can keep their loved ones safe.

IPC has a unique role to play in that we not only liaise with community-based infection prevention but also advise on alternative hospital practices. For instance, we work with patient, child life, and social services to ensure that a patient who is feeling lonely owing to isolation can video chat with family or have window-based visits and sometimes to teach the family to properly don PPE for special visits. Helping patients understand the importance of proper infection prevention habits for the invasive devices they may be discharged with is also a way to prevent both health care–associated infections and community-associated infections. Although IPC may not be directly involved in patient care, we can give them the tools to stop the spread of germs, even if it’s only by handing out masks or sanitizer. In the case of younger patients, we have a great opportunity to collaborate with their family members.

Having relatives or caregivers on the IPC team can keep the patient safe, but that person can also serve as a good resource to remind patients or to ask important questions. Engaging with children is necessary, of course, but much pediatric care and support is achieved by interacting with their family or guardians, who are often the first to know when something is “off” with a child. Working with them to incorporate IPC strategies in the hospital—and at home—is vital. From line care to surgical wound cleanliness, and even hand hygiene, having a comprehensive approach that involves family and caregivers ensures that there is a team rallying around the patient. IPC can help discuss immunizations, at-home measures like chlorhexidine gluconate baths if needed, and infection prevention.

As Koutlakis-Barron and Hayden note, there must be awareness outside the health care setting: “Minimizing exposure to infectious organisms in the home, childcare/daycare/school settings or recreational centers will help reduce risk. Supervisory rules include the type/number of visitors with associated restrictions as applicable, preventing exposure to children with childhood illnesses being brought into the home or childcare setting. Ensuring sufficient supervision is provided by the handling of pets or animal-assisted interventions/therapy.”

 Personally, I liked rounding with pet therapy services and using that time to chat with patients and families while handing out hand sanitizer and discussing infection prevention. You’d be surprised how many people don’t realize IPC is a discipline in itself and are eager to ask us questions.

The HCW side of the triad is so essential that it feels almost comical to discuss it. Chapters could be written on the importance of their role in IPC, from perioperative care to PPE use to hand hygiene and antimicrobial stewardship. Did I mention proper cleaning and disinfection? Those are also obvious requirements, so I want to highlight another equally indispensable factor: sustainable IPC. Nearly 30 months into the pandemic, the appetite for PPE and for dealing with infectious diseases has waned. But the diseases haven’t gone away. In fact, we’re now facing the largest global spread of monkeypox ever seen, continued COVID-19 transmission alongside a diminishing interest in vaccines and nonpharmaceutical interventions, and an exhausted health care and public health workforce. So I want to spend time talking with health care workers, not at them, asking them what their concerns are and where they feel we can improve or have excelled.

Donning PPE before entering a room or waiting for a disinfectant wipe will never be the most fun thing in the world, but COVID-19 has shown us that sustaining these interventions will be our biggest hurdle. How do we get HCWs to continue caring while managing all their other work? I’ve asked them this very question. Building trust and empathetic relationships is critical for IPC-HCW collaboration and success. We depend upon them to remember the importance of infection prevention, and it’s OK to remind them of it, but without placing yet another burden on them. This is also why I like taking time to talk to patients and families, as it often lightens the health team’s duties. After all, if one side of the triad is weak or fails, the rest collapses. It takes all of us to protect patients.

Collaboration in this area calls for continuous work, not just interaction with teammates in health care, but also with patients and their families/support system. It is not easy, and it often requires us to adjust our communication strategies. Although communication, conflict resolution, and discussion of the science are vital components of IPC, we rarely talk about them. When considering collaboration as a means to prevent infections, we must look at every side of the triad and the bond between them. This quote by Epictetus should resonate with us all as we work to build these crucial relationships: “We have 2 ears and 1 mouth so that we listen twice as much as we speak.”

Koutlakis-Barron I, Hayden TA. Essentials of infection prevention in the pediatric population. 

. 2016;3(4):143-152. doi:10.1016/j.ijpam.2016.10.002

Infection preventionists are not alone, despite how the COVID-19 pandemic has often made them feel. They are one point of the patient's triad--and the bonds within the triad are vital for the patient's outcome. 

How to Protect Infection Preventionists’ Mental and Physical Wellbeing From COVID-19 Burnout

Bernadette Mazurek Melnyk, PhD, and her colleagues examined how COVID-19 affected infection preventionists’ mental and physical health, and in an exclusive interview, she discusses how facilities and IPs themselves can mitigate burnout.

CDC's Antimicrobial Resistance Special Report Details Dramatic Increases

The report addresses how the US’s decisions on the pandemic generally increased antimicrobial resistance, and the Centers for Disease Control and Prevention (CDC) recommendations for the future.

Do Ultrasound Probes Require High-Level Disinfection?

While a few ultrasound procedures suggest increased instances of patient infections due to low-level disinfection techniques, statistically, results from peer-reviewed studies do not confirm this idea.

Terminal Cleaning, Including UV Sterilization, Effectiveness in Mitigating Pathogen Transmission

For terminal cleans, investigators studied the effect of UV-C disinfection added to chlorine-based disinfectants on the likelihood of MDRO transmission from the source occupant to subsequently exposed occupants.

Inconsistent Ultrasound Transducer Disinfection Procedure Guidelines Confuse Processors

Improper standards complicate cleaning and disinfecting and can represent a wasteful use of resources, specifically when facilities also may lack access to high-level technology.

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


Weekly Rounds: Protecting IPs’ Wellbeing, CDC’s Special Report, and More

Without infection preventionists (IPs), the COVID-19 pandemic would have been far worse and lasted far longer. But at what cost to the IPs? To address the impact of COVID-19 on IPs’ mental and physical welfare, Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN, chief wellness officer and College of Nursing dean at The Ohio State University, and lead author on a study recently published in the American Journal of Infection Control spoke with 

 asked Melnyk what definition of “burnout" is: “Burnout is a state where people are physically or mentally exhausted; they begin to get somewhat cynical about work, and begin to disengage. All the studies that I've done on clinician burnout, if clinicians are burned out, they make more medical errors. So it really does negatively impact health care quality and safety.”

In the exclusive interview, Melnyk describes the study’s recommendations for facilities to help their employees to fight burnout. She also promotes for health care workers to take care of themselves to fight against burnout. 

“Professionals do a great job caring for everybody else. But they often don't prioritize their own self-care. So I tell everybody, 1, you’ve got to advocate for system change because those system issues cause so much burnout. But [2] you also need to build your own resiliency skills because we know people who are more resilient are more protected against physical and mental health problems.”

Across the country at O’Connor Hospital, Santa Clara Valley Health System in San Jose, California, the infection prevention team was led by Priya Pandya-Orozco, MSN, RN, CIC, infection control manager. She told 

what she and her team did to prevent burnout at her facility. 

“Our infection prevention team connected with our frontline teams and leaders as we rounded daily,” said Pandya-Orozco. “We audited PPE practices and served as subject matter experts for any questions that came up. I remember helping comfort staff who felt scared or were fearful of what COVID-19 could and did bring to the world. Sometimes when I sat and listened to their concerns; it was all that was needed to support them and let them know they were not alone. I am grateful for how our health system pulled together and was transparent with the rapid changes, and how we never faced the challenges alone.”

“Associations among infection prevention professionals’ mental/physical health, lifestyle behaviors, shift length, race, and workplace wellness support during COVID-19.”

Videos

Bernadette Mazurek Melnyk, PhD, and her colleagues examined how COVID-19 affected infection preventionists’ mental and physical health, and in an exclusive interview, she discusses how facilities and IPs themselves can mitigate burnout. 


Clinicians have ever-increasing choices to cleaning and disinfecting ultrasound transducers. Choosing the correct procedure is vital for patient safety, instrument longevity, and unnecessary costs. However, the requirements of which cleaning procedure should be used is often confusing and inconsistent. So, 

The American Institute of Ultrasound in Medicine (AIUM)

 introduced "Disinfection of Ultrasound Transducers Used for Percutaneous Procedures:

" on February 19, 2021. This statement was created with input from members from the American College of Emergency Physicians, American Institute of Ultrasound in Medicine, Association for Professionals in Infection Control and Epidemiology, Association for Vascular Access, and the Society of Healthcare Epidemiology of America. Lately, however, the confusion continues to grow due to inconsistencies from various regulatory agencies. 

 is a research associate professor of radiology, biomedical engineering, and applied physics at the University of Michigan.

This is the second in a series of articles based on 

’s exclusive interview with Krifgans on ultrasound transducers. 

): There are many different types of ultrasound procedures. What options do clinicians have for cleaning and disinfecting ultrasound equipment, and which options do you recommend?

 As the coordinator of AIUM’s taskforce on the cleaning and disinfection of ultrasound transducers used in percutaneous procedures, naturally, I recommend that practitioners follow the AIUM guidelines that apply to their procedures. 

 that focuses on percutaneous procedures now has the support of 22 health professional organizations representing more than 800,000 members. It gives me goosebumps to realize how much uncertainty existed among so many individuals and organizations, and how appreciative they have been to have an authoritative clarification about proper disinfection practices for these procedures.

But as chair of AIUM’s technical standards committee, I also recommend that practitioners speak with the manufacturers of their ultrasound equipment because the work of this committee has revealed that practitioners sometimes improperly clean their equipment with agents that are not compatible with their ultrasound transducers. Incompatible disinfecting agents can damage transducers and other components, leading to equipment malfunctions.

AIUM’s guidelines are very specific about the steps involved in disinfecting transducers. The process begins with a simple cleaning—that is, removing any remnants of gel, tape, or other debris—until the transducer appears clean to the naked eye. Next, the transducer must be inspected for any crazing, cracks, or fogging that might have been caused by the use of disinfecting agents not approved by the manufacturer (damaged units should, of course, be removed from service). And, finally, the practitioner should use an approved process to disinfect the transducer in accord with its clinical application. Devices used in noncritical applications should receive low-level disinfection (LLD); devices used in semicritical applications should receive intermediate-level disinfection (ILD); and devices used in critical applications should receive high-level disinfection (HLD).

It is worth noting that the Intersocietal Position Statement does not use the term “intermediate-level disinfection.” We were advised to avoid that term because none of the relevant regulations currently provide an operational definition, leading to confusing interpretations in the guidelines issued by various associations. Instead, as a self-defining equivalent, we were encouraged to use the term “LLD effective against bloodborne pathogens.” This formulation makes a lot of sense and is roughly the same as the definitions used by Centers of Disease Control and Prevention, Food and Drug Administration, and Environmental Protection Agency. In effect, ILD is a method of processing that uses disinfectants proven to be effective against bloodborne pathogens.

After high-level disinfection, the next level of disinfection would be sterilization, which is almost never appropriate for ultrasound equipment. There have been some instances where novices have placed a transducer into an autoclave to perform sterilization, but afterward the transducer would not work anymore. To my knowledge, there is only 1 ultrasound unit—a transesophageal transducer—whose manufacturer has certified that it can be sterilized.

The level of disinfection should correspond to the criticality of the procedure, as outlined in the 

. Ultrasound procedures that are performed over intact skin, or percutaneous procedures for the placement of vascular access lines, dictate the use of either LLD or ILD. ILD would be appropriate in the case of percutaneous procedures where the transducer might become contaminated with blood or other body fluids. Instances where aseptic technique is not followed, or where a transducer cover or barrier fails, would each call for the use of ILD.

By contrast, intraoperative and endocavitary (oral, transrectal, transvaginal) procedures call for the use of HLD. For my research on periodontal ultrasound, for instance, we have developed our own ultrasound probe. When disinfecting that probe before and after periodontal procedures, our residents are required to use HLD.

Practitioners who do not perform intraoperative or endocavitary procedures are not prohibited from using HLD, and some experts have suggested that doing so could provide an "extra margin" of protection against infection. But in the case of percutaneous procedures, there is no evidence to support the notion that HLD offers greater safety, and many experts have concluded that unnecessary use of HLD is generally not a prudent application of a facility’s resources.

Very few providers are so unconcerned about costs that they would not take action to reduce any unnecessary expenses. Procedure costs are important to providers, who would prefer to reduce those costs so that they can purchase the equipment needed to increase their ultrasound procedure throughput.

But in 2020, many practitioners were expressing their concern that requirements to perform HLD for transducers used in percutaneous procedures represented an imprudent and wasteful use of resources. Moreover, many people worried about facilities that lacked access to HLD technology, fearing that practitioners might continue performing their procedures—but without the benefit of ultrasound guidance.

s how the Intersocietal Position Statement came about; is that correct?

 Yes, it was these types of concerns that brought together the 5 associations that became the initial signatories of the position statement. All of these associations were very worried, because their members were receiving communications from either their local infection control boards or from the Joint Commission to the effect that practitioners should be using high-level disinfection even in the case of percutaneous procedures. Those instructions were controversial from the very beginning, as both individual practitioners and their professional associations agreed that the practices being required didn’t make any sense.

As the nation’s leading authority on medical applications of ultrasound, AIUM was brought on board to coordinate the efforts of a taskforce drawn from the signatory organizations. Our approach was to review all of the relevant peer-reviewed literature, assess the evidence in those publications, and develop recommendations for cleaning and disinfection that would not represent an undue burden on practitioners. We also looked at the recommendations of CDC and other authoritative bodies to see what they required for the cleaning and disinfection of other devices that are in the same situation as the ultrasound transducer.

Based on these reviews, in February 2021, the taskforce published the Intersocietal Position Statement in order to clarify what cleaning and disinfection procedures are actually needed in order to promote safe percutaneous procedures. And we considered the issue of safety in 2 ways: first, that the disinfection procedures should eliminate the risk of cross-contamination; and second, that the procedures should not inhibit the use of ultrasound for percutaneous procedures. Based on comments from some providers, there was great concern that if HLD were to be required, some practitioners might be left in the position of having to perform their procedures without ultrasound guidance. Such a change would have represented a significant reduction in patient safety, and greatly increased risk for patients.

Improper standards complicate cleaning and disinfecting and can represent a wasteful use of resources, specifically when facilities also may lack access to high-level technology.  
