REBECCA LEACH, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, currently works at a healthcare system in Phoenix, Arizona, that includes 5 hospitals and more than 100 outpatient treatment centers.

As we engage in the world, it appears the public considers the COVID-19 pandemic to be over or not as pressing. For those still working the front lines of COVID-19 response, we know that it is not over and could very quickly escalate again. Additionally, the threat of a tripledemic is very real for many health systems, with increasing influenza and respiratory syncytial virus cases across the country.

Since the beginning of 2020, infection preventionists (IPs) have been tackling the pandemic, working as subject matter experts for their facilities to educate staff and providers on the latest guidance, training on the continuously changing isolation and personal protective equipment (PPE) guidance, and working with administrators to coordinate operational efforts to handle massive influxes of infectious patients. As the initial months of pandemic response moved forward, the work of IPs also transitioned into sustaining efforts while considering how COVID-19 would become a routine part of health care.

As IPs were working tirelessly on the front lines, state and federal requirements started trickling out. Often the responsibility of responding to those requirements fell under the role of the IP. Federal reporting mandates for daily numbers of patients, deaths, admissions, discharges, PPE burn, and supply and ventilator utilization all became something the IP was tracking and reporting. These federal reporting requirements continue for the foreseeable future and have been transferred to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network.

 This move into the NHSN—where all other mandatory patient and health care worker safety measures are submitted—squarely puts the IP at the center of this federal reporting.

Many states have also instituted mandatory reporting. Communicable disease reporting is already a responsibility of IPs, and COVID-19 cases were included in that daily reporting. This created a large burden, especially during the surges, as daily case counts multiplied. Additionally, the Occupational Safety and Health Administration had set forth a temporary ruling that left IPs scrambling to pull together and implement the guidance, which included specifying all measures taken by the health care institution to protect employees, reporting of employee exposures, and employee hospitalization and mortality.

IPs often shuffle priorities as part of daily workflow management. However, during the initial COVID-19 response, all efforts and time were focused on that one issue. All other initiatives and workloads were put off as much as possible. Now, with pandemic response in the sustain-and-maintain mode, we’re noticing that all these other responsibilities are showing signs of neglect. 

Vaccines—the long-awaited tool that brought hope—also came with reporting and tracking requirements. COVID-19 vaccination administration and tracking for health care workers were required, as well as a Center for Medicare & Medicaid requirement to report, at minimum, a monthly count of all staff, providers, contractors, students, and volunteers who have received a COVID-19 vaccine.

 As the booster doses and vaccine eligibility change, the components of required reporting also change. The result: What was collected one month will have to be amended for the next month. This
creates challenges with developing reliable reports and data collection methods, pulling from several sources to gather the aggregate data.

Many of these additional reporting requirements are still in place, and all this does not begin to consider local or facility-specific reporting and surveillance that the IPs are performing.

The news released from the CDC about the significant increase in health care–associated infections during the COVID-19 pandemic likely came as no surprise to IPs working in the field.

 In my own practice, I saw an increase of central line-related bloodstream infections and catheter-associated urinary tract infections in our patients being treated for COVID-19. Ventilator-associated events were a major concern because the patients were often on ventilators for extended time and secondary bacterial infections were common. Patients were placed in the lifesaving prone position, which has an impact on the ability to maintain a central-line dressing and keep it clean, dry, and intact. Foley catheter utilization increased as the acuity of patients increased and the need to monitor strict input and output continued.

IPs often shuffle priorities as part of daily workflow management. However, during the initial COVID-19 response, all efforts and time were focused on that one issue. All other initiatives and workloads were put off as much as possible. Now, with pandemic response in the sustain-and-maintain mode, we’re noticing that all these other responsibilities are showing signs of neglect. All the other work and responsibilities of an IP storms back into focus and require attention, so again, IPs are overwhelmed. Further, a frustrating effect of the pandemic is that much progress that had been made in years prior was lost, and it feels as if efforts must start from the beginning.

Triage of work often will follow a pattern—first, anything related to regulatory bodies or government requirements. This includes all public reporting efforts, followed by The Joint Commission or other accrediting bodies requirements as well as maintaining surveillance for communicable diseases. Second, what are the priorities of your local facility? An annual risk assessment is to be completed by the infection prevention program, and if that risk assessment is used to truly drive action, then the priorities need to be reflected in that risk assessment document. This is an opportunity to make some of these administrative tasks of an infection prevention program actually work in favor of the IP team. Third, tackle the fires that come up every day, and be very selective of what the team agrees to take on. Many times, infection prevention can be a catch-all for issues not under the umbrella of the program. This is the time to learn to respectfully decline or suggest a more appropriate department to address.

If a new project is requested that must be taken on, it is imperative that the IP advocate for their program and make it clear that a shift away from other work will be required. Burnout of IPs is just as big of an issue as with other clinical health care staff.

 Electronic surveillance programs and medical records need to be optimized to decrease manual efforts of surveillance and increase efficiency. Working with local clinical informaticists can help drive efforts to improve the capabilities of electronic reporting. Tying these requests to the organizational goals will also give some importance to the requests.

As with other large-scale biopreparedness events in the recent past (ie, Ebola virus, novel influenza A, and anthrax terrorist attacks), this is a time for the larger infection prevention force in the United States to advocate on behalf of local practitioners. 

The COVID-19 pandemic has been a time for IPs to show their value in their organizations. And with this recognition comes an opportunity and platform for the often-overlooked needs of the infection prevention program to be brought forward for discussion.

Also, how does infection prevention integrate with other facility initiatives? How can we piggyback with those efforts to put an infection prevention spin on it? Resources are tight across the health care industry with many organizations laying off workers and cutting hours. Infection prevention programs need to be strategic and find partners to collaborate with, help drive efforts in HAI prevention bundle implementation, and find innovative ways to tackle the increase in health care–associated infections. Sepsis teams, pressure injury teams, and even patient experience teams provide opportunities for an IP to become involved and influence change.

As with other large-scale biopreparedness events in the recent past (ie, Ebola virus, novel influenza A, and anthrax terrorist attacks), this is a time for the larger infection prevention force in the United States to advocate on behalf of local practitioners. Our professional organizations need to step up and work with agencies to address the diminishing workforce and the increased workload and expectations.

Because the pandemic influenced so many aspects of our professional lives, the role of an IP seems to be at an evolutionary point. No longer are we just the hand hygiene police, but we have emerged as key leaders for our organizations and gained social capital as experts and guides through the pandemic. Now with this increase in workload and decrease in resources, we must be selective and creative in how we navigate the short-term future of infection prevention, and we must focus efforts on where we can make the most impact in patient safety and contributions to overall improvements in health care quality.

Popescu, S. V. Hot topics: 2022 holiday season begins: rsv running rampant, covid-19 spiking. Infection Control Today. Accessed November 5, 2022. 

https://www.infectioncontroltoday.com/view/hot-topics-2022-holiday-season-begins-rsv-running-rampant-covid-19-spiking

NHSN | Centers for Disease Control and Prevention. Published November 4, 2022. Accessed December 9, 2022. https://www.cdc.gov/nhsn/index.htmlOccupational Safety and Health Administration. Accessed November 5, 2022.

Interim Final Rule (IFC), CMS-3401-IFC; Requirements and Enforcement Process for Reporting of COVID-19 Data Elements for Hospitals and Critical Access Hospitals. Accessed November 5, 2022. 

https://www.cms.gov/files/document/qso-21-03-hospitalscahs.pdf-0

COVID-19 impact on HAIs. Centers for Disease Control and Prevention. Updated June 10, 2022. Accessed November 5, 2022. 

https://www.cdc.gov/hai/data/portal/covid-impact-hai.html

Whitacre Martonicz, T. How to protect infection preventionists’ mental and physical wellbeing from covid-19 burnout. Infection Control Today. Accessed November 5, 2022. 

https://www.infectioncontroltoday.com/view/how-protect-ips-mental-physical-wellbeing-covid-19-burnout

Articles

How do infection preventionists navigate the many—and often contradictory—requirements that fighting the COVID-19 pandemic has brought upon them?  

Simplifying Infection Preventionist Requirements From the COVID-19 Pandemic

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 focused 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.

Very good and exciting news – the outbreak of Ebola Sudan has officially been declared over in Uganda. Four months of containment efforts helped keep the cases at 143 and deaths at 55. First identified in September, this is the eighth outbreak the country has experienced since 2000. The director-general of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus, “

praised Uganda for its response to the virus.

 ‘Uganda has shown that Ebola can be defeated when the whole system works together, from having an alert system in place, to finding and caring for people affected and their contacts, to gaining the full participation of affected communities in the response,’ he said in a statement.”

Ebola outbreaks will continue to occur, stressing public health efforts, but the capacity for rapid response and international support speaks to our increasing skills in containment and collaboration.

We couldn’t have a “Hot Topics in IPC” without addressing the coronavirus in the room, right? As January is in full swing, it appears we may have avoided a harsh COVID-19 surge this winter. I’m surprised, as I think so many infection prevention specialists were, given the lax public health restrictions and sluggish desire for boosters. 

 2% in the United States within the last 2 weeks, with a daily average of 63,000 cases. Test positivity is up 8%, hovering around 15%, and roughly 46,000 people a day are hospitalized with COVID-19 in the US, which is an increase of 12% in the last 2 weeks.

Immune system evasion and a high transmission capacity mean that scientists are closely watching XBB1.5.

Frustratingly, deaths are higher, sitting at 555 per day, which is an increase of 61%. If we look at a state-by-state example, Florida is seeing a spike in cases and is up by 90%, whereas California’s cases are down 33%. The US is a patchwork of both dropping and rising cases, with some states showing improvements. Washington, DC had a 53% decline in cases, whereas Alaska is experiencing an increase and has seen a 43% rise in cases.

Many conversations in the media and infection prevention circles have centered around the latest variant–

, which some individuals have dubbed “Kracken,” which isn’t very scientific. While XBB1.5 is rapidly spreading and is considered to be very transmissible, we’re still learning about how this new subvariant will behave. “By contrast, XBB.1.5’s defining feature and its main difference from XBB is a spike protein mutation known as F486P. This mutation gives XBB.1.5 a significant advantage, boosting infectivity while retaining XBB’s ability to sneak past human defenses. In other words, it’s less of a trade-off and more of a turbocharge.” Immune system evasion and a high transmission capacity mean that scientists are closely watching XBB1.5.

However, much of the hysteria is unnecessary and should be met with skepticism—including calling the subvariant “Kracken.” While it is a worrisome variant, it’s not one that entirely evades our immune system. As 

, “For Stephen Goldstein, an evolutionary virologist at the University of Utah, the new names are not just unnecessary but potentially harmful. ‘It’s absolutely crazy that we’re having random people on Twitter name variants,’ he told me. For Goldstein, dressing up each new subvariant with an ominous monster name overplays the differences between the mutations and feeds into the panic that comes every time the coronavirus shifts form. In this view, distinguishing one Omicron sublineage from another is less like distinguishing a wolf from a cow and more like distinguishing a white-footed mouse from a deer mouse: important to a rodentologist but not really to anyone else.” In short, if “Kracken” is on the brain, perhaps turn to 

Did you listen to music during COVID-19 lockdowns

Saskia v. Popescu, PhD, MPH, MA, CIC, discusses the great news about Ebola in Uganda. She also covers COVID-19 news, and what it has to do with the Clash of the Titans.

Hot Topics in Infection Prevention: Uganda Declares Ebola Outbreak Over, and “Kracken” Subvariants of COVID-19

Matthew Pullen, MD, is a clinical researcher at the University of Minnesota Medical School and an assistant professor of infectious disease and international medicine. He practices at M Health Fairview University of Minnesota Medical Center. He attended medical school and completed a residency in internal medicine at the University of Tennessee Health Science Center, after which he pursued a fellowship in infectious diseases and international medicine at the University of Minnesota. His research focuses on tuberculosis, fungal diseases, and COVID-19.

The Genetic and Rare Diseases Information Center of the National Institutes of Health (NIH) defines a rare disease as one that affects fewer than 200,000 people.

 According to the NIH, there are more than 7000 rare diseases in the United States, affecting more than 30 million—approximately 1 in every 10—people in the country.

Given that February is Rare Disease Month, it seems appropriate to discuss how a physician or scientist may go about diagnosing a disease that is not common. When I suspect a patient may have an infection, I first consider whether it is likely to be bacterial, viral, fungal, or parasitic. Sometimes a condition may fit in more than 1 etiology, but you can usually narrow it down at the outset and focus on more likely etiologies for the initial workup.

Often, it’s helpful to look at individual risk factors:

Have they traveled to an area where specific infections are endemic?

Do they have occupational risks for infection?

Do they have immune deficiencies that put them at risk for uncommon infections?

The clinician must consider these factors, and if nothing jumps out immediately, start a fairly broad workup of the more likely infectious agents. A common first step is to collect cultures of blood and fluid from parts of the body thought to be involved in the infection (urine, sputum, or cerebrospinal fluid, for example) to see whether causative organisms are present For example, I had a brucellosis patient who had been experiencing fever and fatigue for several weeks. He had just traveled to the US from Mexico, where he had been consuming raw milk and fresh cheese almost daily. Brucellosis is not an infection we often see in Minnesota (only 26 were reported in the state between 2007 and 2019),

 but this patient had the right risk factors for it.

If the initial workup doesn’t explain the condition and you still think the patient has an infection, there are specialized tests to consider, like the 16s and 28s rRNA polymerase chain reaction (PCR) assays. For these, a sample of a normally sterile bodily fluid in which infection is suspected (blood, cerebrospinal fluid, joint aspirate) is sent to a specialized lab, which amplifies any RNA present in the sample and compares it to a database of bacterial (in the case of 16s) or fungal (28s) genetic sequences to see whether any organisms of interest are present. If the organism is difficult to grow or detect with standard laboratory measures, these assays can often provide more insight and help diagnose uncommon infections. PCR-based testing and other molecular techniques have become a mainstay of diagnostics for infections in the US, and they are typically fast and specific.

Sometimes, however, even a broad and aggressive workup won’t yield an answer. For example, my colleagues at M Health Fairview University of Minnesota Medical Center and I saw an elderly man with a dramatic neurologic presentation that included muscle weakness and waxing and waning confusion. He was positive for insect- and tick-borne infection risk factors: he lived in a rural area, went hiking/camping frequently, and had recently been bitten by insects and exposed to ticks. We performed a broad infectious workup, looking for common tick- and insect-borne infections, as well as more routine bacterial and viral etiologies of meningoencephalitis, but nothing came back positive. The patient seemed to get a little better with a treatment targeting Minnesota’s common tick-borne diseases but reversed course soon after.

We sent blood samples and cerebrospinal fluid samples to the Centers for Disease Control and Prevention (CDC) and the Minnesota Department of Health. We sent blood samples and cerebrospinal fluid samples for this testing, but no convincing etiology could be found. I suspect that the man’s condition could have been a rare arthropod-borne virus, like a mosquito-borne virus, that either we don’t have a name for or couldn’t identify. This sort of etiology is higher on my differential because of how similarly it presented to other conditions caused by such viruses and how he failed to respond to aggressive antibiotic therapy, which would not treat a viral infection. Unfortunately, often there are no effective, targeted therapies for viruses. The patient ultimately transitioned to an assisted care setting and, over time, had some improvement of symptoms but has not made a full recovery to date.

What Precautions Medical Professionals Should Take

Ironically, we benefit from living in the post–COVID-19 era because, although the virus is still with us, we are more aware of infectious diseases than we used to be. Today, it’s common to see hospital staff wearing masks, gowns, and gloves to prevent infection. Before the pandemic, it was atypical for clinicians to walk into a patient’s room with a mask on unless the person had a history of or significant risk for an infection subject to droplet or airborne transmission. Back then, if a patient were to have a rare or unknown infection that could spread by those routes, there was a greater risk that the medical personnel in charge of their care would also become infected.

As a side effect of the global spread of COVID-19, today we have a good amount of protection in place against rare diseases that may potentially be droplet borne or airborne. When mpox (formerly 

) first popped up in the US, I was quite often on call for curbside consultations from hospitals in our area that don’t have dedicated infectious disease staff. I received a few calls from frontline doctors asking what special precautions they needed to take. Before the recent outbreak I had not dealt with mpox, but I told them that if they were taking appropriate COVID-19 precautions (like wearing a mask in the patient’s room and putting on gloves before touching a suspected lesion), they were probably already within the guidelines for protecting themselves against mpox. Our universal precautions do a pretty good job of protecting us from most diseases.

In many instances, as the saying goes, people tend to be afraid of what they don’t know or don’t understand. When they hear “rare disease,” they take it to mean “deadlier” or “more transmissible.” But that’s not necessarily the case; the fact that they’re rare means that they are not easily transmissible. If they were, they would not be rare.

However, that’s not a hard-and-fast rule. Sometimes it’s simply that the disease hasn’t yet found the perfect ecological niche. We saw this during the recent mpox outbreak; a few high-level transmissions (along with some possible genetic changes that are still being studied) allowed the virus to spread more widely and rapidly than in the past. But for the most part, rare diseases either have a difficult time spreading or have a narrow ecological niche. A good example is endemic fungi like Histoplasma and Blastomyces, which are becoming an increasing problem because their geographic reaches are spreading as a result of climate change.

When trying to determine how best to prevent infection in your unit, hospital, or clinic, consider the precautions the facility must take to protect not only patients, but staff as well. The CDC and the Society of Healthcare Epidemiology of America

 both offer guidelines. If you’re unsure what needs to be done for a given organism or infection, a safe strategy is to use the highest level of protection available until you know it’s safe to reduce it.

If I have a patient with a rare infection and I’m not sure what precaution sare necessary, either due to lack of data or clinical uncertainty, I wear a gown, gloves, and a mask until I know it’s safe to de-escalate. Overusing personal protective equipment can put a strain on supplies, but infecting staff and patients would strain them much further. Fortunately, apart from novel diseases, we typically have good, evidence-based guidelines for the level of protection necessary in health care settings.

Some rare diseases may require very specific treatment or isolation conditions, like a negative pressure room. If you have diagnosed or strongly suspect such an infection, you must be sure that you’re equipped to handle it or that you can move the patient to a facility that can. A good example is Ebola. Our regional special pathogen unit at the University of Minnesota is specially equipped to handle Ebola should a case be detected in this part of the country. It takes specialized training, equipment, and protocols to handle the infection risk of a patient with severe Ebola. If you were to identify that kind of rare disease in your hospital, you would want to be sure that you can send the patient to such a facility.

We can always use more funding for rare disease research. As the human population density continues to rise, particularly in previously unsettled areas, and climate change alters the global environment, new or uncommon diseases have become more frequent. In recent years, we have seen this with the Nipah virus, Ebola, SARS-CoV-1, MERS-CoV, SARS-CoV-2, and mpox. Despite this, many of these diseases remain “neglected,” receiving little in the way of funding and research. There needs to be a push for more funding so that we can tackle these diseases now, while their impact is lower, rather than waiting for the next outbreak or pandemic.

1. About GARD. Genetic and Rare Diseases Information Center. Accessed December 7, 2022. 

2. Rare Diseases at FDA. FDA. Published September 21, 2022. Accessed December 7, 2022. 

https://www.fda.gov/patients/rare-diseases-fda

3. Brucellosis, 2019. - Minnesota Department of Health. Accessed December 7, 2022. 

https://www.health.state.mn.us/diseases/reportable/dcn/sum19/brucellosis.html

4. The Society for Healthcare Epidemiology of America. SHEA. Accessed December 7, 2022.

What do clinicians, infection preventionists, and environmental hygiene personnel do when faced with rare infectious diseases? Matt Pullen, MD, gives ICT® readers a tutorial. 

Rare Infectious Diseases: A Tutorial 

Tori Whitacre Martonicz is the editor of 

.  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 husband; son; 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.

At the start of the COVID-19 pandemic, questions asked among environmental hygiene personnel were “Did the CDC and the EPA give enough guidance on how to use the proper cleaners? Were the disinfectants they recommended safe? Or were they dangerous and ineffective if not used correctly and with the proper personal protective equipment (PPE)?”

) spoke with ArrowClean CEO Rayne Guest, who wrote to the Centers for Disease Control and Prevention (CDC) and the Environmental Protection Agency (EPA) about their suggestions for products to use during the COVID-19 pandemic. Guest said that neither governmental agency has responded to the core questions of the letter or any of the many letters she has written to the agencies on infection prevention topics.

Introduction and description of the letter Rayne Guest, CEO of ArrowClean, wrote to CDC and EPA. 00.00

How does the “on-site” generation of disinfecting products benefit hospitals and the environment? 04:40

How would Guest describe proper disinfection protocol, and how specifically does this differ from what the CDC is currently recommending? 07:03

How is ArrowClean disinfectant different than leading chemical disinfectants, and what problems does Guest see with traditional chemical disinfectants? 09:01

What does Guest see as the possible issues that could come from traditional cleaners? 09:56

What does Guest see as the future of disinfectants? 13:31

What Guest wants infection preventionists and EVS teams to take away from this interview. 15:36

In this exclusive interview, Guest explained that one “main point of the letter is that the EPA and the CDC told everybody that they should be using products that were on their list, which was kind of the holy grail of products that they said were safe and effective for use against COVID[-19]…Most of the products on the list cause respiratory issues, making people more susceptible to getting respiratory illnesses like COVID[-19] on the list. [The guidelines] listed the contact time it took to kill COVID[-19], an enveloped virus that is easy to kill. So [individuals] were only letting a product sit for more than just a spray and wipe. If they were letting it sit for a certain amount of time, they were letting it sit for the amount of time it takes to kill COVID[-19], which is not hard to kill. But the reality is [that] to use a disinfectant properly, you have to let it sit for the proper full contact time for its disinfection claims.”

What Guest wanted to accomplish with her letter to the CDC and the EPA was for the agencies to acknowledge and change their guidelines to the public about what disinfecting products to use and how to use them. She told 

, that the she believes CDC guidelines were “very misleading to the public. [They] went against infection prevention 101 in every way. So it was hard to see their public guidance because it was so fundamentally flawed.”

 that her concerns and questions stem from her 15 years in the infection prevention and control business on the ground up and developing a technology attempting to help fight against infectious diseases and do something good for the environment. The products her company manufactures are not tested on animals.

In the interview, she also described what she considers proper disinfection protocol and how it differs from what the CDC is currently recommending.

“Before COVID came around, you heard the CDC say, 'Look, people need to use a disinfectant with the shortest contact time possible because as a society we're conditioned to spray and wipe, spray a product on a surface and wipe it up,'” Guest said. “Most disinfectants have a 10-minute contact time, meaning you have to let them sit on the surface for 10 minutes to be effective. Most of the products in our homes are this way, and a lot of products in healthcare are this way. During the pandemic, though, none of that guidance was given. [It was as if] they just forgot to tell [the public] about it. The only guidance they said is 'Be sure you follow the manufacturer's instructions.'

"But most [individuals] don't even comprehend the concept that something could take 10 minutes to work on a service. It's not how [companies] market their products and commercials. It's not what we grew up to see. So proper disinfection depends on the product. Some disinfectants are limited spectrum; some are broad spectrum, some are health care grade.”

"[The CDC’s and EPA’s guidance on disinfection products] went against infection prevention 101 in every way."

Guest describes her thoughts on what correct and careful disinfection means to health care professionals: “I would say proper disinfection means you use a health care-grade disinfectant, which is the most effective. It's tested against the toughest gram-negative and gram-positive bacteria. And you choose one that is safest for your patients, for your employees, for your customers, for your staff. And you, hopefully, find one that's cost-effective, and you let it sit for the contact time, preferably the shortest contact time possible. And you follow those instructions. 

"So proper disinfection is following the protocols that the disinfectant was tested to. And in order to do it properly, you want to choose the one with the shortest contact time and is safest for everyone,” Guest said.

 has contacted the CDC and EPA for comment and will post if there is a response.

Videos

Have the CDC and EPA given enough correct guidance on how to use cleaning products during the COVID-19 pandemic, or is it “fundamentally flawed”?  


How Dangerous Are Cleaning Products Environmental Hygiene Personnel Use? 

Heather Saunders is an experienced and motivated registered nurse with a master’s degree in public health and a certification in infection control. Striving for excellence in the prevention and control of infectious disease, Heather believes in using innovative and strategic leadership methods to achieve program goals.

Heather first discovered her love for infection control (and chai tea) during a short-term assignment in Nairobi, Kenya, where she worked to improve maternal and child health through the prevention of infectious diseases. After spending the first 6 years of her nursing career in busy emergency departments, Heather transitioned away from the bedside to join the work at the Johns Hopkins Hospital as an infection control epidemiologist. Following the completion of her master's degree in public health, Heather became the infection prevention and control nurse consultant for the State of Maryland, assisting healthcare facilities in their response to healthcare-associated infections. Currently, Heather is employed with Johns Hopkins University Division of Infectious Diseases as a research nurse program manager, using her expertise to guide research in the prevention and control of infections in healthcare settings. Additionally, Heather is the owner of Broad Street Prevention, where she serves as an infection prevention consultant.

During her off hours, Heather enjoys writing, reading, hiking, and spending time with her friends and family. She is the proud author of the blog, All the Lessons We Learn, where she gives a lyrical accounting of all the beautiful, painful, and transcendent lessons that we learn on this journey we call life.

https://www.facebook.com/thelessonswelearn/

I remember being the primary nurse for a patient who was critically injured in a car accident. I had never worked so relentlessly to save someone’s life. Surprisingly, we were able to successfully transfer him to the intensive care unit from the emergency department. A week later, I received an email from the facility’s quality department. They stated that we had failed to place an orogastric (OG) tube prior to transferring the patient to the intensive care unit.

I read the word “failed” multiple times that afternoon.

Education was attached to the email that reviewed the importance of placing an OG tube to prevent health care–acquired pneumonia. I felt crushed, insulted, angry, and defensive. How dare they point out the one thing that we did wrong when we had worked so hard to save this man’s life?

Now, obviously, insulting our efforts and putting us on the defensive were not at all the intention of that email. I know now that our quality department was trying to help us improve practices to better prevent infections, but in the heat of the moment, that goal was not obvious to those of us on the front lines. Instead of their email being a helpful reminder of best practices, our team was distraught that no one appreciated our efforts. What the quality department had attempted to accomplish—improving practice—was not fulfilled that day simply due to its incorrect formula for providing constructive criticism.

This memory has stuck with me throughout my years as a nurse and an infection preventionist (IP). As IPs, we are charged with improving the prevention and control of infections in health care settings. This is no easy task. For us to improve prevention, we must first identify opportunities for improvement. Then we need to present those opportunities to frontline teams and work with them to implement new workflows. Often this goes hand in hand with needing to provide constructive criticism, such as when lapses in best practice lead to poor outcomes. And no one likes to hear bad news or criticism.

However, it not the receipt of constructive criticism alone that determines whether an individual will be receptive to implementing positive change and improved workflows. As with so many things in life, it is not so much what we say to someone but how we say it that matters most. Over time, I’ve realized that 3 key ingredients are necessary to successfully provide constructive criticism so that the message is heard, people feel empowered, and steps are taken toward positive change. Those ingredients are transparency, humility, and empathy.

When giving constructive criticism, I always start conversations with transparency—transparency about myself and my intentions for the interaction. Transparency means being seen through, readily understood, or visible. Before providing constructive criticism, I present myself so that the other individual can feel relaxed around me and understand my goal for the conversation. Obviously, this task is much easier to do when constructive criticism is provided in person rather than via email.

One example of how I present with transparency would be how I generally open a meeting to discuss new infections. I am always the first to introduce myself in a meeting that I’ve called together. I say who I am and why I’ve brought all of us to the table. It is as simple as letting the audience know my name, my role at the facility, the intention of the conversation, and that my favorite color is purple. My favorite color? Yes, when appropriate, I tell people random facts about myself when providing my introductions. I find that doing so humanizes me and puts others at ease. It allows participants in the room to see that I am, like they are, just another individual.

My introduction usually sounds something like this, “Hi. My name is Heather. I am a nurse and one of the infection preventionists here. I chose to be an IP because I’m very passionate about keeping you and our patients safe by preventing and controlling infections. I’m looking forward to working with all of you to find ways to improve infection prevention in [insert area.] And, in case you were wondering, my favorite color is purple, I have 1 cat, and 2 sons.”

Usually, following my introduction, the those in the room will laugh at the personal random facts that I’ve chosen to provide, and I can palpably feel the tension dissipate in the room. And usually as these introductions continue, everyone else will begin to share their favorite color, how many pets they have, or if their kids like tomato sauce or pumpkin squash. The air is always lighter when those individuals in the room are better acquainted with everyone’s favorite color. It’s amazing, but a little bit of transparency about yourself, your job, and your intentions can go a long way in preventing people from becoming defensive when providing constructive criticism.

This brings me to our second ingredient, humility. We must approach individuals with humility, acknowledging that we don’t know everything about their world, their experiences, their successes, or their challenges. We should always be a learner before we’re a teacher and compliment those we seek to influence when warranted. People will always be more likely to accept constructive criticism after you’ve first provided a compliment.

You never want to stroll into a health care area and immediately tell staff what they’re doing wrong. If you do, they will whisper to one another, “Can you believe the arrogance of this guy who told us what we should be doing when he doesn’t even know a thing about the challenges of our job?!” I know that this is what they whisper because it’s how my colleagues and I responded to poorly delivered constructive criticism. We were offended and defensive. Although the perceived goal was for the constructive criticism to be accepted and lead to change, what we wanted was for our perspectives to be appreciated, our efforts to be acknowledged, and our opinions to be considered.

It was, again, not what was being done (providing constructive criticism) that was the issue, but how it was delivered. Assumptions were made and solutions were created without any input from our team. In turn, as IPs, when providing constructive criticism, we must seek to listen and understand, with humility, recognizing that we do not know everything about the problem or the solution. And when we do, staff will be more accepting of implementing our suggested changes.

Finally, we should approach the delivery of constructive criticism with empathy. I once had the opportunity to work with a group of surgeons to reduce the rate of surgical site infections. These were horrific infections with often poor outcomes. After a meeting one day, one of the surgeons pulled me aside and shared with me something that I will never forget. She said, “You know, I remember every one of them. I know their names, and I can see their faces.”

As IPs, we could easily forget that these patients are not just infections or numbers calculated as rates. They are individuals. But our health care workers don’t forget that. They see their patients’ faces; they remember their names. We would do well to remember that health care workers also often take these infections personally. Therefore, we should never present news of new infections in an accusatory or flippant manner or without regard for the impact it has on the health care staff.

Rather, we should always discuss infections and provide constructive criticism with empathy. We should enter conversations with compliments before discussing opportunities for improvement. We should acknowledge how difficult it is to prevent these infections and invite collaboration around ways to improve prevention. We will connect with people more effectively if we come alongside them to celebrate their wins while we empathize with their losses.

Multiple times while responding to COVID-19 outbreaks, I had health care workers say to me “Heather, it’s so refreshing to talk with you because you’re the only one to acknowledge what we’ve done right instead of simply listing everything that we’ve done wrong.” Recognize everything your health care teams have done right. See their hard work and all they’ve accomplished. Take a moment to acknowledge the humanity in all of us and understand that it hurts to know that something we did or didn’t do might have resulted in an infection. That news should be delivered with grace and empathy and preferably from someone with whom you have formed a connection.

As IPs, we give people constructive criticism for a living. If we truly want to make an impact in the prevention and control of infections, we must be careful about how we approach the delivery of constructive criticism. Bad news ought to be delivered with transparency, humility, and empathy.

I would hope that this is how someone would approach you with constructive criticism. Let’s do better and approach our health care workers with the same courtesy.

How should health care workers, especially infection preventionists, give constructive criticism in their positions? 

 The Infection Preventionist’s Formula for Providing Constructive Criticism

’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.

In this third installment of 3, Infection Control Today

 continues the one father's story of how sepsis can enter central lines and how it affects the entire family.

When the Infection Prevention Epidemiologist Gets COVID-19

The public expects infectious disease experts to know how to protect them—and themselves—from getting ill from infectious diseases, including COVID-19. So, what happens when the infectious disease specialist gets ill herself?

The Problem(s) With Candida auris: What IPs and EVS Personnel Should Know

Even during the COVID-19 pandemic, infection preventionists, nurses, environmental services personnel, and other health care workers cannot forget about C auris.

Does SARS-CoV-2 Transmit From Humans to Their Pets?

A recent study attempted to estimate the transmission of SARS-CoV-2 from humans to their pets and identify the risk factors, including food and water bowls and human-animal contact.

See It Clearly: Central Sterile Processing’s Role in Reprocessing Eye Devices

Read about the sterilization process of eye instruments and devices.

Take 5 minutes to catch up on Infection Control Today®’s highlights for the week ending January 6, 2023.


Weekly Rounds: Sepsis Video Series, Candida Auris, and Eye Instrument Reprocessing

) has presented a personal story of how sepsis can enter central lines. One father tells the story of how his son lived through sepsis but how, in the end, it has taken an enormous toll not only on his son but on his whole family.

The father in question, David Jordon, BS, key account manager for US hospitals for Covalon Technologies, talks to 

® about his family’s story of how sepsis changed their lives. He describes his family’s pain, loneliness, and unbeatable strength to get through a trying time in their lives due to their son’s illness.

This story is also a tale of dedication, determination, and love.

In this third of 3 installments of David Jordan and his family’s story about his son living through sepsis and the aftermath, Jordan describes how it has affected his family’s life, his career, and what blessing they chose to do because of their son’s long-term illness. He discussed how his career has evolved into a position where he can work within health care to help prevent infections. Finally, Jordan covers how his personal story has changed how he approaches customers and patients about his product experience.

 in this exclusive interview that “When you're working with products that prevent infection, and you've been through that infection, you’re not talking about a clinical study. You're talking about a personal experience. And even if you don't get into your personal experience, there's a difference between talking about something that's preventing an infection when you've been through it versus ‘I heard about it.’”

In this third installment of 3, Infection Control Today® continues the one father's story of how sepsis can enter central lines and how it affects the entire family.

Sepsis: One Father's Story, Part 3

There’s something intrinsically ironic when you get an infectious disease…as an infectious diseases specialist. I’m an infectious disease epidemiologist and infection preventionist, so there are often jokes that range from opposite ends of the spectrum. Either our risk tolerance is so messed up with years of dealing with infectious diseases, that we become cavalier, or we are so hyper-sensitive to it all that when such events happen it’s indicative that no one can escape the illness. Like so many, I had made it a solid chunk of this pandemic without getting COVID-19. I feel confident in saying that too, as I was tested at least 1 to 3 times a week since early on for work-related reasons. I was diligent in masking and even had serology work done prior to the vaccines, again providing that I had been COVID-19-free even in the early days when testing was a luxury.

Funny enough, many friends and colleagues who had also managed to avoid infection for most of the pandemic have also been facing their first brush with the virus in the past few weeks. Personally, I’m not surprised.

In general, I vaguely know where and how I got COVID-19. I was at a meeting for several days, working long hours, jet-lagged, interacting with tons of people, and being imperfect with masking. I opted to err on the side of risk, knowing that statistically, the odds were higher given the time of year and volume of interactions. I tested daily with a molecular test, the Cue machine, and wore KN95 masks while traveling and in certain situations once I was in meetings. Even then, masking means you’re in the minority.

In short, I share this knowing some individuals will shake their fingers at me saying I was a poor public health advocate, but, ultimately, because it’s the truth and that we’re all at a point where we often end up weighing the risks in an increasingly post-COVID-19 world. More than anything, I’m not surprised and, of course, I beat myself up for knowing better. I also know the fatigue of wearing a mask indoors, working and socializing for 16 hours a day, and that even the eating situation meant there wasn’t a zero-risk scenario.

Have at it, hecklers. I could have done better; I know this. What I also know is many folks I interacted with were visibly ill. None of them masked or made a point to test or go home. At this stage, mostly on the last two days of my trip, I had a sinking feeling this would be that higher-risk situation that would lead to COVID-19, so a mask became a much more common occurrence for me.

On the last 4 to 6 hours of my flight home, I started to feel a scratchy throat and some mild back pain. Not totally abnormal right? I got home, tested–negative. I chalked up my symptoms to long days and jet lag…and, well, a long time on a plane in a mask and probably dehydration.

My symptoms started to worsen a bit, and yet, the next morning, I still was testing negative. I decided a few hours later to give it another go, and boom! A positive result. Symptom-wise, I’m not going to lie; I was miserable. I had the razor-blade throat, miserable hacking cough, sinus pressure and drainage, fatigue, and continued back pain.

After a few days, most symptoms went away except for the cough and sinus infection. (That turned out to be a secondary infection I had to later get antibiotics for. Oh, the joy!) I also learned the hard way, through too much garlic while I was cooking, that my senses of smell and taste were severely impacted. Roughly 6 and a half days after my symptoms started, I began testing negative but still had some symptoms, so I was diligent in masking when I made a run to the pharmacy.

Why do I share this? Mostly because it highlights a few things–masking is always the key preventative measure. I’m fully vaccinated (boosted a few months ago), tested daily, and ventilation was pretty good in the setting I was in…and yet it was the unmasked interactions I had that ultimately led to this infection.

Masking when you travel is especially important – no matter what, this is a hill I’m going to die on (at least for a while). Test…and then test again…and again if you’re negative but have symptoms. I had 2 negative molecular tests prior to my positive one, despite having worsening symptoms. We’ve seen this often with Omicron, so make sure a single negative test isn’t your gateway to forgoing the possibility of a COVID-19 infection. The non-specific symptoms are a pain, especially when you’re traveling or fatigued and not sure what’s causing that run-down feeling.

In all honesty, I work in infectious disease, and we’ve all felt run down for 2.5+ years, right? Lastly, just because the Centers for Disease Control and Prevention (CDC) says 5 days is enough for isolation doesn’t mean you’re truly not a risk to others on day 6. I was still testing positive until 6.5 days after symptoms, and I know so many individuals who have been consistently positive for 9+ days.

In this increasing post-COVID-19 world (meaning that people have decided to be over COVID-19 even if the pandemic isn’t over), we’re faced with making decisions on a sustainable scale. Masking especially is one that becomes a question of risk, choice, and situational awareness. Despite being a few weeks post-COVID, I still have a lingering cough and some fatigue, enough that exercise is tough, and brain fog comes a bit from time to time. After so many years of being hyper-vigilant and a growing array of daily decisions that include COVID-19-based calculations, our choice about personal infection prevention is only growing in importance.

Safety isn’t binary, but rather a spectrum of risk and choice, and ultimately, it’s important to consider those individuals around us. I wish I would have been more vigilant in masking but am grateful I had the resources and capacity to mask and isolate appropriately when symptoms began. A friend recently joked that I had lost my street “cred” as an infection preventionist, which was both comical and a bit eye-opening. Mostly, it highlights much of the guilt or even shame many of us experience when we feel as if we’ve failed at the very thing we specialize in. I still beat myself up at times for getting COVID-19 and knowing better as an infectious disease specialist, but I also don’t want to associate any sense of shame with an infectious disease. We have all learned lessons during this pandemic, and a sustainable approach to COVID-19 will likely be one of the most important in the greater context of public health and infectious disease response.

The public expects infectious disease experts to know how to protect them—and themselves—from getting ill from infectious diseases, including COVID-19. So, what happens when the infectious disease specialist gets ill herself? 


 continues its reign as the dominant COVID-19 strain, and its new subvariant, XBB.1.5, is now most prevalent in the US.

As of the end of December 2022, the Centers for Disease Control and Prevention (CDC) 

 found that XBB.1.5 was responsible for 40.5% of new COVID-19 infections. In the American Northeast, the CDC estimates XBB.1.5 is causing 75% of new infections.

Omicron BQ.1.1 and BQ.1, previously the reigning variants, are responsible for 26.9% and 18.3% of new cases, respectively.

XBB.1.5 swept across the country rapidly, making up only 1% of new infections a mere month ago. The subvariant appears to be 5 times more infectious than earlier Omicron strains, which were already 5 times more infectious than the original, wild-type COVID-19 virus.

Recent holiday gatherings, resistance to immune system antibodies, and an improved ability to bind tightly to the body’s ACE-2 receptors all likely contributed to the explosion of XBB.1.5 infections.

Although the World Health Organization (WHO) stated XBB.1.5 has a “growth advantage” above prior subvariants, there is currently no indication it will cause more severe or fatal disease. So far, symptoms of XBB.1.5 are believed to be consistent with earlier Omicron strains.

So far, symptoms of XBB.1.5 are believed to be consistent with earlier Omicron strains.

XBB.1.5 isn’t expected to cause more severe disease than prior COVID-19 variants, but it is still essential to take all available precautions to avoid getting infected. The anticipated surge of XBB.1.5 infections will overburden the health system once again, and as we know, COVID-19 vaccines are less effective at preventing mild disease.

 will remain an effective prevention strategy. Individuals who have received an updated bivalent COVID-19 booster will benefit from even more effective protection.

, also significantly reduces the risk of severe or fatal disease progression.

This story will be updated as we learn more about the XBB.1.5 COVID-19 variant.

The CDC genomic surveillance found that the XBB.1.5 variant has increased from causing 1% to over 40% in only a month. 

Omicron XBB.1.5: Yet Another COVID-19 Variant to Know

Doe is a registered nurse and is board certified in infection control and epidemiology. She holds a bachelor’s degree in microbiology and completed a master’s degree in public health at the University of Nevada. Doe has nearly 20 years of acute care infection prevention experience working in large health care systems such as Intermountain Healthcare in Utah and Kaiser Permanente in California.

Doe is a registered nurse and received her master of public health from the University of Nevada, Reno, as well as a bachelor of microbiology from Weber State University. For 4 years, she taught an infection control course for the Ohio State University from 2019 to 2022. She is currently dual-board certified in infection prevention and epidemiology in both acute and long-term care. She is also certified to train EVS through Association for the Healthcare Environment (AHE) and is currently a member of AHE, the Association for Professionals in Infection Control & Epidemiology (APIC), the Association of periOperative Registered Nurses (AORN), and the Society for Healthcare Epidemiology of America (SHEA). Doe is active on several committees including the Test Committee for the Certification Board of Infection Control & Epidemiology (CBIC), and the Advisory Council for the Pearce Foundation Environmental Services Optimization Playbook (EvSOP).

In 2009, the world was entrenched in another pandemic, albeit much smaller in scale than the current COVID-19 pandemic. It was novel swine-origin influenza A (H1N1) virus or “swine flu.” But this wasn’t the only pathogen to emerge that year. A new 

 species was isolated from a patient's ear in Japan–

 means “ear” in Latin, hence its name. Growth of this pathogen over the past decade has been exponential, and during the pandemic, while we were singularly focused on SARS-CoV-2, 

 rates (Table 1) were accelerated, with several outbreaks reported. This article will address the key problems with this newcomer, and solutions will be provided.

 species in that it behaves more like a bacteria than a yeast, and these traits include:

Indefinite colonization with no proven decolonization method,

Persistence in the environment where it spreads easily between patients and residents and health care facilities

*Clinical cases only (colonization excluded)

 species, specialized laboratory technology is required to identify this pathogen correctly. Additionally, many clinical laboratories do not routinely identify yeasts at the species-level when isolated from a non-sterile body site.

 to suspect and to seek out speciation for 

. There are essentially four situations in which this should be done, and these are when:

1. Yeast is isolated from normally sterile body sites such as the bloodstream or cerebrospinal fluid. Speciation guides appropriate initial treatment, which can be administered based on the typical, species-specific susceptibility patterns.

 is isolated from non-sterile body sites. In this scenario, consider species-level identification when:

a. It’s clinically indicated for the patient’s care, 

b. in the previous year, a patient has had an overnight stay in a health care facility outside of the United States

species is isolated from surveillance cultures collected when actively looking for additional cases when a case has been detected in a facility or a unit.

3. A fungal isolate is identified that is known to represent potential misidentification of

4. You are seeing an increase in infections due to 

 species in a given care unit or there has been an increase of 

Even during the COVID-19 pandemic, infection preventionists, nurses, environmental services personnel, and other health care workers cannot forget about C auris. 