Technically, anyone who wants a COVID-19 test can walk into a pharmacy or health care office and get one. In actuality, though, access to the tests has been uneven and questions remain about the accuracy of the various tests. “We know that molecular testing has the highest sensitivity for ruling out—for excluding—COVID,” says Nira Pollock, MD, PhD, a member of the Infectious Diseases Society of America (IDSA), which is keeping tabs on the state of COVID-19 testing. Pollock, who is the associate medical director of the Infectious Diseases Diagnostic Laboratory at Boston Children's Hospital, points out that questions also persist about “turnaround time, with cost, and with supplies facing both patients and laboratories.”

Even as testing has evolved, long lines at health care facilities may persist, Pollock says. It may be hard to get an appointment at a pharmacy, and fewer state testing sites remain open. Supply chain problems mean testing supplies are not always abundant. Samples may be sent to labs that have long turnaround times. And while the tests themselves are free to consumers, office visits may entail copays.

 offers many more conveniences with a potential pitfall: the possibility of a less accurate result. “Most of the available home tests are...antigen rapid diagnostic tests, or RDTs, 

and those have significant potential advantages,” says Pollock. These include fast turnaround time and lower costs, at least to third-party providers. Because home tests are relatively cheap and fast, they can be used for 

, although there is no consensus on the optimal interval between tests. However, the 

 the virus is somewhat reduced compared with that of PCR tests. “There’s still disagreement about whether a negative RDT can effectively rule out infection in a symptomatic individual,” Pollock notes, adding that a person can have a negative antigen test and positive PCR test and be infectious.

One problem with home tests is that people might administer them incorrectly, which could affect results. Another issue is that positive results may not be reported. “I think we will probably lose track,” says Dial Hewlett Jr., MD, FIDSA, an IDSA Fellow and medical director of the Division of Disease Control at the Westchester County Department of Health in New York. “We won’t have as accurate an idea in terms of what the prevalence of the disease is at any given time. On the other hand, I think that having access to these results in a very rapid way will be helpful in terms of the practical issues of 

Rapid testing may indeed be the key to keeping kids in school, although there are obstacles.

No agreed-upon definition exists that spells out exactly which symptoms trigger the need for a test. There also is no consensus about the need for school testing if transmission rates in an area are low. Pollock mentions the 

 program being piloted in certain districts by the Centers for Disease and Control and Prevention (CDC), which involves regular rapid onsite testing and contract tracing of potentially exposed children and staff so they don’t have to quarantine at home.

While PCR tests catch more positive results than do rapid tests, the lag time between testing and results can be as long as several days. This can be problematic if people don’t quarantine while waiting for results. Hewlett explains that under the vaccine mandate for health care workers, those in his county who receive exemptions must take molecular tests once a week. “The shortcoming of this is that an individual may test negative on Monday and then they may actually start to develop symptoms on Tuesday,” he says. Meanwhile, coworkers are potentially exposed during that time.

For vaccinated but asymptomatic individuals, when and whether to test is more of a nuanced discussion. If a group is planning to gather for the holidays and all are vaccinated, should they all take COVID-19 tests beforehand? The answer depends on whether anyone is vulnerable due to age or comorbidities, the experts agree. “[T]esting in vaccinated people really is a balance of risk--risk for those around you, risk for yourself and your health history, and also access and resources,” Pollock says. Hewlett says that if the gathering includes, for example, someone with Stage 4 cancer, it would be appropriate for all attendees to test before coming together.

The panel’s experts lamented that finances might factor into someone’s decision to get a COVID-19 test. While tests administered at an urgent care center or lab are free to the consumer, reports of third-party bills sent to insurance companies or the government are not unheard of. And rapid tests for home use can start at $25 for a 2-pack and run to $35 or more, which may be out of reach for many families, especially those with multiple children. “The fact that someone with means can more quickly get a test to exclude COVID in their child and get that child back to school than potentially someone without those resources--it just shouldn't be that way,” says Pollock.

Pollock adds that it has been difficult to find rapid tests of late, although the Biden administration has invested heavily in their development and availability, which should make them easier to obtain heading into the winter season.

Articles

No agreed-upon definition exists that spells out exactly which symptoms trigger the need for a test. One expert says that if a get-together includes, for example, someone with Stage 4 cancer, it would be appropriate for all attendees to test beforehand.

Consider COVID-19 Testing Before Holiday Gatherings

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

The public thinks so. The stock market thinks so. Many experts think so. They’re welcoming the post-COVID-19 world. In fact, many believe that we’ve already reached a place where COVID-19 stops being a pandemic that kills and becomes endemic, erupting in waves here and there—not deadly waves—but more like influenza and common cold waves. The sort of nuisances that aren’t going to kill you. (It must quickly be added that influenza does 

More and more, the consensus seems to be building toward what author Jason Tetro 

 in a Q&A on October 22. “Moving forward, I think we’re going to be going into this idea of seasonality, or as I like to say, cold, flu and COVID-19 seasons.” And the so-called “monster variant,” of COVID-19—a variant that would be immune to antibodies whether they’re produced by vaccines or prior infection? We’ve already been hit with the monster variant, Tetro said. It’s called the Delta variant and it’s burning itself out because it's not immune to the vaccines.

“That is our monster variant,” Tetro told 

. “We have seen other variants come out since Delta has taken over. They’re not doing anything. There’s even something called 

 that really isn’t doing much. In that light, I think we might be at the worst when it comes to what COVID-19 can offer.”

Scott Gottlieb, MD, the former commissioner of the Food and Drug Administration, certainly agrees with that assessment. On 

 Sunday, Gottlieb said that “we’re going to enter a more endemic phase and as things improve, cases may pick up. ... But that doesn't mean that we’re entering into another wave of infection.”

Gottlieb said that we can finally put this nightmare behind us thanks to the creation of a vaccine for children as young as 5 and pills in the pipeline, from 

 and Merck, that would allow people to treat COVID-19 at home.

“We’ve always said that two of the events that would demarcate the end of this pandemic was being able to vaccinate our children,” Gottlieb told 

. “We’re now able to do that down to age five. And also having a widely available or orally accessible drug that could treat coronavirus at home to prevent people from being hospitalized or dying.”

All of which gives credence to a prediction made by Monica Gandhi, MD, MPH, an infectious disease expert and a professor at the University of California, San Francisco. She predicted in a 

—that the “old normal” will return by January 2022.

“I think we’ll be going to movies,” Gandhi told 

. “That people will be going to the theater. People will be going to sports events. Will hug each other. Will hang out. We’re going to get back to normal, but it’s going to take a year and a half. January 2022. It’s so hard to say. But I do think it’s going to take until January 2022. We need to get the community transmission down. We need to get a vaccine. We will vaccinate the whole populace and then it will stop because it can’t go anywhere because we have immunity and we will get there.”

A good portion of the public in the United States thinks that we’re already there, according to the 

“A majority of Americans (55%) believe returning to their normal pre-coronavirus life right now is a small risk or no risk to their health,” according to the Index, a marked increase since the “Delta driven, late-August low of 40%.”

The stock market certainly agrees, according to 

“Stocks move for all types of reasons,” Axios reports. “But the declines reflect a shift that’s sticking: At-home workouts and remote learning are out. Travel and gyms are in.”

Ross Klein, a fund manager at Changebridge Capital, which is invested in gym chain Planet Fitness, told Axios that “Folks are saying, ‘Hey you know, I’m going back to the office two days a week, perhaps I should go back to my old gym routine.’”

Infection prevention and control expert Saskia v. Popescu, PhD, MPH, MA, CIC, a member of 

 that “giving thought to this rather unknown holiday season—now is the time to have conversations with staff about what can increase or decrease risk of COVID-19 during the holidays. These are especially important as more are getting boosters but may not necessarily realize that doesn’t suddenly make them Superman.”

All signs point to finally throwing off the dictatorship of the little spiky ball.

From Pandemic to Endemic: Post-COVID-19 Era Might Have Already Arrived

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.

Will Vaccinated Children Spell the End of COVID-19?

 for vaccines in children aged 5-11 has occurred. The Pfizer vaccine has just gained authorization and approval from the Food and Drug Administration (FDA) and recommendation from Rochelle Walensky, MD, of the Centers for Disease Control and Prevention (CDC). It became available over the weekend with a reduced dose of two 10-microgram shots given 21-days apart. As reported by CIDRAP, Walensky noted that “we have second graders who have never known a normal school year, middle schoolers who have missed out on sports. In the nearly 12 months since this group approved the use of vaccines in those 16 and older, we have been wondering when children vaccines were approved for younger children.”

 of pediatric vaccines is also being presented as a way to return to some sense of normal after two years of a pandemic. Over 6.4 million children have been infected with COVID-19 and over 101,000 cases occurred in the week from October 21 to 28. This is especially concerning as cases are on the rise across the United States—up in 23 states as 72,754 new cases were reported. President Biden has also noted that vaccine mandate for private-sector workers will begin January 4.

If you’re interested in a review of college football and COVID-19 transmission, check out this 

 regarding player contact events. Such interactions and the analysis for transmission-based studies are especially interesting in the world of health care and infection prevention and control. The authors note that “between September 26 and December 19, 2020, 1190 college football athletes had 109,762 opposing-player interactions over 64 SEC regular season games. Interactions were fleeting (median length, 6 seconds [range, 1-380 seconds]), and most (104 274 [95%]) were briefer than 26 seconds.”

 the first COVID-19 antiviral pill for treatment, Reuters reports. “Britain’s Medicines and Healthcare products Regulatory Agency (MHRA) 

 the drug, molnupiravir, for use in people with mild to moderate COVID-19 and at least one risk factor for developing severe illness, such as obesity, older age diabetes, and heart disease. It will be administered as soon as possible following a positive COVID-19 test and within 5 days of the onset of symptoms, the regulator said, citing clinical data.”

Giving thought to this rather unknown holiday season—now is the time to have conversations with staff about what can increase or decrease risk of COVID-19 during the holidays. These are especially important as more are getting boosters but may not necessarily realize that doesn’t suddenly make them Superman. As Katherine Wu, MD, 

, “for months, the CDC has been updating its 

Pfizer or Moderna dose, or two weeks after the one-and-done Johnson & Johnson). But no such instruction manual exists for the pre-to-post-boost transition, which 

 will be eligible to make in the next few months. I asked the CDC if those recommendations might appear soon. ‘Not at this time,’ Kristen Nordlund, an agency spokesperson, told me in an email. For now, ‘people who have received a booster should continue to follow CDC’s fully vaccinated guidance.’ (Nordlund did clarify that people shouldn’t consider themselves boosted until two weeks post-jab. They just aren’t being told to, you know, 

The availability of pediatric vaccines is being presented as a way to return to some sense of normal after two years of a pandemic.

Hot Topics in Infection Prevention: Vaccinate Children, Take Care Over the Holidays

Though to our knowledge there’ve been no studies to confirm this, it’s a safe bet that everybody in health care has had to work outside their comfort zones during the COVID-19 pandemic. There’s certainly Although, to our knowledge, there have been no studies to confirm this, it’s a safe bet that everybody in health care has had to work outside their comfort zones during the COVID-19 pandemic. There’s certainly plenty of anecdotal confirmation of that development. Experts have told 

® that IPs have had to quickly acquaint themselves with the infection prevention and control challenges that exist in each hospital department.

 Now, as the pandemic (hopefully) ebbs, comes a reassessment of the boundaries of an IP’s comfort zone in normal times. Crystal Heishman, MBA, MSN, RN, ONC, CIC, director of infection prevention and control and vascular access at UofL Health – Jewish Hospital, presented at the Cleaning, Disinfection, and Sterilization Conference last month, hosted by the Association for Professionals in Infection Control and Epidemiology. Her presentation was titled “From Concept to Reality: Development and Implementation of a Disinfection and Sterilization Program.”

 Let’s dive in. How do you go about developing and implementing a disinfection and sterilization program? What’s the first thing you must think about?

Crystal Heishman, MBA, MSN, RN, ONC, CIC:

 The first thing you [must] think about when [developing] a disinfection and sterilization program is the need. [Also] get a pulse check on what’s going on and how that’s being monitored. Once you get an idea behind that, work up a business plan. A lot of things compete for time and money. What we think is important…everyone else thinks their ideas and needs are important as well, and they are. How do we make [our idea stand out]? How do we show that business plan?

 Are these programs already in place in hospitals? Who’s your audience? Who are you gearing your message to?

Yes, some facilities already have this program started. Some are just beginning their journey on implementing a disinfection and sterilization program. When we’re working on that process, our key stakeholders are our procedural areas, our sterile processing departments, and those we’re working with to bring the program forward. It might be your quality directors, your CMO, your CEO, your CFO, surgical services leaders, [or] physicians. There’s a broad range of [people] you [must] work with to get these started.

 Have infection preventionists historically been involved in what goes on in the sterile processing department?

Over the years, the role for infection prevention has expanded greatly. Even in the time I’ve been in infection prevention—which has been over 10 years—that role has just gained momentum. Traditionally, infection prevention worked side-by-side with sterile processing, but it wasn’t something they had to delve into or know completely. It’s more of a collaborative environment these days. But they [must] know issues with sterilization and disinfection that they did not [previously] have to know as deeply.

 Unfortunately, COVID-19 crops up in almost every conversation about health care these days. Has COVID-19 made that partnership between infection preventionists and sterile processors stronger or even forced that partnership to happen in some instances?

No, I don’t think COVID-19 had a great role in that. This was already rolling before COVID-19. The pandemic may have delayed some progress. But…for at least 5 to 6 years, we’ve been partnering with sterile processing, learning more, helping each other, [and] monitoring those processes.

 You use the word partnering, so it’s not as if an infection preventionist will walk into the sterile processing department and say, “You’re doing this wrong. You’re doing that wrong.” What would be the proper approach for infection preventionists or an infection prevention department to monitor what’s going on?

 Let’s say I’m going to sterile processing. The first thing I do is talk to them about what they’re doing and ask the whys. Why do we do this as opposed to this? Why are we doing that as opposed to that? Let them walk through the process. You want to learn their role and why they do the things they do. Then you start looking for deviations in that process and investigating more. You don’t ever want to go into a sterilization department and say, “You’re doing this wrong.” Because they’re the subject matter experts. You want to learn. You want to learn the process. You want to work together because it makes a stronger partnership. You get a lot more accomplished.

 How much homework do infection preventionists need to do before they venture forth into a sterile processing department?

A lot of homework. Just starting off with the whys. You don’t have to know everything walking in. It’s more of an observation experience and just asking the whys, then you go back and learn those processes. There are a lot of resources out there on sterile processing [and] high-level disinfection. You don’t have to know it walking in, but you can’t walk in with the mentality that you’re doing this right or that wrong. It’s more of a collaboration. You’re learning from them. Then you go back and do your homework.

 What’s the question you get most after you do a presentation on this subject?

The question I receive the most is: How do we go about presenting the plan on how to create a disinfection and sterilization program? That’s usually my top question. And then: How do you go about it? How do you do these audits? How do you put those together? Putting the business plan together is probably the easy part for me, personally. Just because we’re using data [and] presenting the plan. Putting together the program is the hard part because you have to figure out: Where are all these processes occurring? What are all the regulations and guidelines behind these processes? And then the larger facilities. The more you expand, the harder that is because you are going to see those deviations clearly between different facilities. I think that’s the hardest part; actually putting the program together.

 Wherever there are departments, there are inevitably turf battles. Is that something infection preventionists who want to follow your guidance and implement a sterilization and disinfecting program have to look out for?

 It can be. But if you come in with an open mind and let them know you’re there as a resource to help them make their workflow easier [and] to help be their voice for whatever they need, they’re going to tell you what their barriers are. You don’t see that as much. It’s more like a collaborative environment because you are helping them. You’re being their voice and helping escalate the needs of their departments.

 Is there something I neglected to ask you about this subject that you want your fellow infection preventionists or other health care professionals to know?

When putting together a proposal for a program—whether it be disinfection, sterilization, construction and renovation, anything like that—having that data together and having that initial pulse check [is crucial]. What’s actually going on? What’s that gap look like? What’s the impact? Is it on patient safety [and/or] employee safety? How does it tie into those organizational goals and strategic plans? That’s usually the 1 piece of information I like to provide. Then just believe in yourself and your capabilities. Excitement is contagious. If you are excited and passionate and you can show the value in something, other people are going to see it as well.

This interview has been edited for clarity and length

Diamond F. Infection preventionists will be needed even more after COVID. 

®. March 31, 2021. Accessed November 2, 2021. https://www.infectioncontroltoday.com/view/infection-preventionists-will-be-needed-even-more-after-covid

Videos

Crystal Heishman, MBA, MSN, RN, ONC, CIC: “You don’t ever want to go into a sterilization department and say, ‘You’re doing this wrong’. Because they’re the subject matter experts. You want to learn. You want to learn the process. You want to work together because it makes a stronger partnership.”

How IPs Can Better Monitor Sterilization, Disinfection

Everybody is looking toward a future where COVID-19 doesn’t dominate. Lately, all the metrics look good. Great, even. Vaccinations are up, and infections, hospitalizations and deaths are down. Way down. When that future comes—hopefully soon—what will it look like? At the Cleaning, Disinfection, and Sterilization Conference, hosted by the Association for Professionals in Infection Control and Epidemiology (APIC), Doe Kley, RN, CIC, MPH, T-CHEST, senior infection preventionist with Clorox Professional Products Company, tackles that question head-on. The title of her presentation was “The Next Normal: Cleaning and Disinfecting in a Post-Pandemic World.”

Before working for Clorox, Kley was a practicing IP in hospitals. She knows what IPs are up against. “I don’t know a more complex job than what we do in infection control and the breadth of what we have to know and understand,” Kley tells 

. “Everything from microbiology, surveillance, health care–acquired infections (HAIs), and statistics, to the opposite end, which is construction and facilities management, how HVAC systems work, and water systems.” When the next normal arrives, Kley has this advice for IPs: “Get out there. Get to know people in these departments. Find your champions in these departments. Go with the spirit of curiosity and learn.”

 What’s the next normal going to look like when it comes to cleaning and disinfecting?

 I love that question. Because, yes, things are going to change. The first thing is we’ve got to get back to some semblance of normal, whatever that normal is going to be. For cleaning and disinfection, that is going to mean that we need to take a step back. A lot of products were brought in when the supply chain was challenged, and IPs were so busy with the COVID-19 stuff that they [couldn’t] do their usual thoughtful vetting of these products. A lot of these products were probably brought in without them even knowing. We’re going to have to go back and take an inventory of what we’ve got in-house because I suspect 

we’re going to find some things that shouldn’t even be in a hospital, to be honest. That’s one place they need to start looking; at their products and deciding what’s going to go [and] what can be kept. [Then they need to go] back to their products or their value analysis committees and get those products vetted and [properly] approved. The other thing is where the IPs’ attention has been so much on the COVID-19 control—the surveillance and screening and all of that—they also need to go back and start collecting their data and doing observations. Watching people do the work. Have environmental services (EVS) teams been diverted from their usual ways? Is everyone cleaning the same way? Are they following our policies and practices? Now that no one is watching, are they still cleaning equipment that comes out of those rooms? We need to look at our products and our practices, then hit the reset button, if you will.

 When should that reset button be hit? And you mentioned a few things they should do. Is there an order in which they should do them? Should they start doing them now?

That is the question. I personally think [they should start] now. Of course, this virus has fooled us many times. I know when I submitted my abstract for the APIC talk, the pandemic was going down, [and] we were starting to loosen up in the community. I thought “OK, good. The perfect time to talk about the next normal.” And within a few weeks the Delta variant slammed us. This virus is unpredictable. I’m sure that over the next many years, we are going to continue to see waves. We can’t wait that long to start to establish what our next normal is. Now is the proper time. We’ve got almost 2 years under our belt with this virus. We just can’t keep doing what we’ve been doing with our singular focus on 1 pathogen. We know that while we were so busy with COVID-19, other dangerous and emerging pathogens got a foothold. The one that scares me the most is 

 I thought we were doing OK. The numbers were low, but now the cows are out of the barn on that one. Because, again, we were so focused on COVID-19 that we weren’t doing our usual surveillance. We may have lightened up on our cleaning activities once we found out COVID-19 is spread primarily by the respiratory route. We kind of backed off on all the hypervigilance cleaning, but we forgot 80% of the pathogens that cause infections are transmitted by contact or touch. That means there is still a place for cleaning and disinfection. So yes, we need to get away from that singular pathogen focus.

 I think that I recently read somewhere that the Centers for Medicare and Medicaid Services (CMS) fined over 2500 hospitals for high readmission rates for Medicare patients.

I do know that CMS had waived surveillance—the requirement for HAI surveillance—during the [first 6] months of the pandemic. [But] I also know that a recent study, looking at the [National Healthcare Safety Network] data from 2020,

 surprisingly [showed that], even though CMS had waived that requirement, 87% of IPs were still doing their surveillance and reporting their HAIs. The problem is that, with 

, you don’t know what you don’t know. Most clinical laboratories at the hospital level—unless you’re a large academic center or research center—their labs don’t have the capacity to identify that pathogen. You may just be seeing 

 on your lab result, and it’s wrong. It could be 

 The trick is knowing when to speciate [and] when to be suspicious. If I see 

on my microbiology list, the first thing I should be thinking is: “OK, but this can be 

. Is this patient at risk?” Then you need to know the risk factors, [such as] recent travel [outside of the country] in the past year. Long-term [International Early Lung Cancer Action Program patients] are at super-high risk. You need to know when to be suspicious [and] when to speciate. You also need to know…OK, you’ve got to talk with your laboratory and confirm what test we [are] using. Then you’re [probably] going to need to submit specimens to the public health laboratory to get that confirmation.

I [recently] heard of a hospital that did not identify a 

 case they had in-house until day 30. Of course, you know that patient had been everywhere. I guarantee you—I haven’t heard this yet—but I guarantee you there are other cases now in that hospital, and 1 case of 

 is an outbreak. The hard thing about C auris is it acts like a bacteria. It’s very easily transmitted from person to person, but it also is very difficult to eradicate from the environment once it gets a foothold. So, yes, a very scary pathogen.

 In your experience, how much authority do infection preventionists have? As far as saying, “OK. Stop everything. We need to close up this room. We need to do this. We need to do that.” Does it depend on the institution? Or on how much authority hospital administrators give them?

That’s a great question. I think it’s multifactorial. For example, an experienced IP probably carries a little more authority than a newer IP. That just comes with confidence. When I was a practicing IP in the hospital, [I always liked to say], “We have full authority, right?” We’re the ones in charge of making sure all the regulations are being met, the policies are being followed, and our practices are evidence based. Yet I can’t fire somebody for breaching a policy. I can certainly escalate it to their manager, and if it keeps escalating—the same name—then things can happen. But if an IP is competent, stays ahead of the game, [and] stays educated, they will have that respect of their staff and the other health care [personnel] on the team. When they say, “Hey, this is what we need to do for this patient,” people will do it. If not, if an IP is newer—which I know there are a lot of newer IPs out there—then you’ve got to build your team around you. Know who you can go to, to get that help and authority when you need it. Get your leadership involved if you have to until you get to that point where [people] know that when you say something, it’s the right thing.

 Do you think states should mandate that infection preventionists be certified? That anybody who’s called an infection preventionist in any health care facility is certified?

Yes, I think they should be [certified]. I’ve done this for 20 years. I’m a registered nurse by practice. I also have a microbiology background. I don’t know a more complex job than what we do in infection control and the breadth of what we [must] know and understand. Everything from microbiology, surveillance, HAIs, and statistics, to the opposite end, which is construction and facilities management, how HVAC systems work, and water systems. There is so much we need to know, and [what we know and do] is so important. Patients’ lives depend on decisions we make. So absolutely, I think certification should be mandated.

 There is such a breadth of what we [must] know that truly we can’t be the complete experts in each one. I’m not a sterile processing expert. I know the basics they’re supposed to be doing. I [also] know who to go to, and I befriend those [people]. My sterile processing manager, my OR [operating room] manager. I pick my battles wisely.

I can give you an example. There was a woman I worked with, she was new, and she would go around in the morning on her rounds and throw away everybody’s coffee from the nurse’s station. That’s not a good way to make friends. To me, coffee at the nurse’s station is a low-risk infection control issue. When you need those [people] for something important, are they going to listen to you? You’ve got to choose your battles.

I also always went in inquisitively. [I’m] not there to judge [or] to say what you’re doing is wrong or right. I would always give them a heads-up: “Hey, I want to come spend a couple hours in your department today, in the OR. Can you hook me up? Can I spend some time in the room? I’ll be a fly on the wall.” I’m inquisitive, and I ask questions and take notes, then I have conversations. I find my champions.

I remember I championed an anesthesiologist. [That was the] best thing I ever did because they are notoriously a tough group. But having him on my side and being a confidant I could talk to and learn from—and he could learn from me—that relationship was gold. If I was having a problem in the OR—he was also a medical director—I could call on him. And because he knew me personally, and he knew my motives, he would always help me.

I say get out there. Get to know people in these departments. Find your champions in these departments. Go with the spirit of curiosity and learn. That is the best way to put those inroads into those departments. Trust me, they start picking up the phone and calling, [saying], “I know they’ll help.” They know you’re not that person [who thinks they know] everything [or] that you have an answer to everything. [When you’re inquisitive], they learn real quick that you’re at least going to ask the right questions and find [the] answers. But you will never be the person who knows everything, and they trust you for that.

 Is there something that I neglected to ask you and that you think might be pertinent and that you want your fellow infection preventionists and health care workers to know?

Yes, there is. I hope we have learned from this pandemic that, just like with hand hygiene, everyone plays a role in cleaning and disinfection. I know it was a battle when I was a practicing IP to get nurses to clean things, like their equipment or the high-touch items in the room. It wasn’t their job. But I do hope now that they realize it’s everybody’s job. 

Dyer J. COVID unleashes ‘lurking scourge’ 

®. November 11, 2020. Accessed October 28, 2021. https://www.infectioncontroltoday.com/view/covid-unleashes-the-lurking-scourge-candida-auris

National Healthcare Safety Network: COVID-19 modules and dashboards. Centers for Disease Control and Prevention. Updated October 15, 2021. Accessed November 1, 2021. 

Ben-Ami R, Berman J, Novikov A, et al. Multidrug-resistant Candida haemulonii and C. auris, Tel Aviv, Israel. 

. 2017;23(1):195-203. doi:10.3201/eid2302.161486

Doe Kley, RN, CIC, MPH,T-CHEST:  “We just can’t keep doing what we’ve been doing with our singular focus on one pathogen. We know that while we were doing that—while we were so busy with COVID-19—other really dangerous and emerging pathogens got a foothold. The one that scares me the most is Candida auris.”

Prepare for the Post-Pandemic Normal, IPs

KEVIN KAVANAGH, MD, is the founder of the patient advocacy group Health Watch USAsm and a frequent contributor to 

For many who are concerned about the dismal rate of full vaccinations in the United States, as compared to even some third-world countries, such as Cambodia, the new study from the Centers for Disease Control and Prevention (CDC) regarding vaccine efficacy was 

. The study observed over five times the efficacy in the prevention of COVID-19 hospitalizations in those who were vaccinated as opposed to those who had a previous infection.

The CDC’s study had an unusual design. It evaluated patients being admitted to the hospital with COVID-19 like symptoms and then determined how many actually had COVID-19. The study also adjusted for sociodemographic and health characteristics. The study was able to identify 6382 individuals who were fully vaccinated with 2 doses of an mRNA vaccine and admitted with COVID-19 like illness, and another 1020 individuals who had a previous laboratory documented 

COVID-19 infection and later admitted to the hospital with another infection with COVID-19 like symptoms. The number of individuals in our society who are vaccinated without a previous SARS-CoV-2 infection is far greater than the number of unvaccinated individuals who had a previous COVID-19 infection which had documentation of a previous SARS-CoV-2 molecular test. (Unlike other countries, the US does not have a unified national health care record system to allow easy availability of a patient’s medical history.)

The CDC’s study found that the unvaccinated, but previously infected group had 5.49 times more infections than the vaccinated group (adjusted odds ratio of 5.49). And comparable results were obtained pre and post Delta variant. Similar to the 

, the Moderna vaccine was found to have a higher protection effect than the Pfizer/BioNTech vaccine (7.3 versus 5.11 adjusted odds ratio, p = 0.02). Also, individuals 65 years and older received more benefit from vaccination (19.57 versus 2.57 adjusted odds ratio, p = 0.05).

In addition, there is a large psychological overlay in reinfections versus vaccination breakthrough studies. Those vaccinated may lead a less cautious life, feeling that they are impervious to the virus; and those who have had a previous COVID-19 infection have often been through hell and may be more cautious, not wanting to be reinfected and wishing to safeguard their loved ones. Thus, the behavior may be much different between these 2 groups. In a pandemic, following public health advice matters and can lessen infections. Despite these concerns, the CDC study still observed less of a chance of becoming infected in those who were vaccinated versus those with “natural immunity.”

This finding is in stark contrast, to the 

 which reported that those vaccinated with the Pfizer/BioNTech were 13.06 times more likely to have an infection than those who were previously infected. It should be remembered tha the Pfizer/BioNTech vaccine’s protection wanes faster than Moderna’s and this efficacy is during a time period greater than 3 months to 5.5 months post vaccination. When the analysis included infections that occurred at any time after vaccination, there was a 5.96-fold increased risk of reinfection, a 7.13 increased risk of symptomatic infection and a 7 to 8 times increase risk of hospitalization. The study eliminated those patients who received a third dose of Pfizer/BioNtech booster. Importantly, the authors noted that the study suggested waning of natural immunity against the Delta variant and that “individuals who were both previously infected with SARS-CoV-2 and given a single dose of the vaccine gained additional protection against the Delta variant.”

 that those who were unvaccinated and had a SARS-CoV-2 infection were 2.34 times less likely to have another infection if they became vaccinated. Another 

 by Assis, et al. documented the types of antibodies produced in SARS-CoV-1 infections. In that study, 3347 specimens were analyzed, and the authors concluded that the “anti-receptor binding domain (RBD) reactivity was low and there was no cross-reactivity against SARS S1 or SARS RBD.” RBD is the portion of the virus which needs to be deactivated in order to prevent replication and spread of the virus. The authors also concluded that once vaccinated, previously infected individuals develop higher antibody levels than those not previously infected and that mRNA vaccination induces a stronger and broader antibody response than SARS-CoV-2 infection.

All of the above has led up to the discovery of “super immunity.” Many now believe that super immunity can develop in those who have had SARS-CoV-2 infections and have become vaccinated. They develop a much more robust and diverse antibody response which should be “effective to any future variant that SARS-CoV-2 throws 

Finally, after all of these mental gymnastics, one realizes that of course vaccines are better than being infected with SARS-CoV-2, besides virtually avoiding the risk of disability and death from the infection, you can also obtain boosters if your immunity wanes.

The CDC is currently considering changing the definition of fully vaccinated to 3 doses of the 

. Greater than 2 vaccine doses in a vaccination schedule is 

. Diphtheria, tetanus, polio, H. influenza, S. pneumoniae, pertussis and Hepatitis B all require 3 to 4 doses in the first year and a half of life. No one is advocating becoming reinfected with COVID-19 to maintain your immunity.

SARS-CoV-2 hits some very hard with a life-threatening disease which will augment their immunity. Other patients will have a less severe illness and will achieve a less 

. Vaccines build up durable immunity more slowly with repeated vaccinations. This mitigates side effects and allows for the attainment of immunity with almost no risk as compared to natural infection.

The bottom line is that all need to be vaccinated, even those who have had previous infections. The definition of fully vaccinated for mRNA vaccines needs to be changed to 3 doses, making previous comparisons of infection versus 2 doses of a vaccine moot. In addition, those previously infected should also become vaccinated. How many doses and the exact vaccination schedule is still 

. But for now, those receiving 2 doses of an mRNA vaccine should obtain a booster and those with a previous infection should become “super-immune” with a vaccination.

Many believe that super immunity can develop in those who have had SARS-CoV-2 infections and have become vaccinated. Meanwhile, fully vaccinated might mean getting 3 doses, not 2.

Natural Immunity vs. Super Immunity: Only a COVID-19 Vaccination Away

 that environmental services (EVS) teams play in thwarting the spread of infection in hospitals and other health care settings. Darrel Hicks, a past president of the 

 that it’s time to create a certification process for these health care professionals. “And if we certify them, then we need to 

 than we do,” says Hicks, who will be a presenter at the 

, which will be held in Las Vegas from November 15 to November 18. “They’re the lowest paid people in the hospital and they have such an important role in patient care.” The title of Hicks’s presentation is “Safe/Clean/Disinfected Procedures in Health Care.” ISSA has existed under several different names 

. One of those names was the International Sanitary Supply Association. In 2005, when the association branched out to include cleaning service providers, the name was officially changed to ISSA—The Worldwide Cleaning Industry Association. One of the things Hicks would like any certification to pin down is exactly what we mean when we say that an area is clean. In fact, he argues that maybe we should get rid of “clean” as a designation because “it means different things to different people. And ultimately, the person that’s doing the cleaning and disinfection needs to understand that it’s two separate operations. And too often, we interchange those terms.”

What were some of the changes caused by COVID-19 when it comes to procedures for safe and clean disinfection in health care that you think will last after the pandemic?

Well, it changed a lot of things. It was a time of shortages, with the supply chain shortages of disinfectants. Certainly shortages of personal protective equipment. It was a very difficult time for the first few months. It seemed to level out after that. But because there wasn’t PPE for those who weren’t doing direct patient care, they’re trying to reserve what they have. They’re burning through isolation gowns and masks so quickly that the environmental services team was in many cases not involved with cleaning that patient’s room unless it was a 

. One of the things that I think the COVID-19 brought out was the need for educating environmental services about how things get transmitted. Initially, we thought it was being transmitted on surfaces and the air droplets that fall on high touch-surfaces, especially in 

Darrel Hicks will be one of the presenters at the ISSA Show North America 2021 

and around the patient bed. I call that patient bed the hot zone in the patient’s room. It’s more contaminated than the restroom is. And so that patient bed and the 36 inches around it… Just think about the shedding of these organisms. That was the hot zone. And in many cases the nurses were expected to maintain that environment. And only on discharge or terminal cleaning was EVS [environmental services] brought into the picture. So, that was different at first. And I think a lot of that leveled off later on. I think it really brought to fore the essential workers that EVS are in health care. What I have said for many years is that when this pandemic would come, that we need to have people who are environmental services workers who are certified to some level of knowledge about the transmission of disease, and their role in breaking that chain of infection. Too often, we just told them you use the pink stuff on this and here’s the color-coded microfiber wipes and here’s how you do it. And it was the how-tos without the why behind it. I think that we still need to certify that these workers that now we’re short of…. It used to be that they would come to work from a quick food service drive-through. And now they’re going to be cleaning patient rooms or possibly even the operating room this week when they were stuffing hamburgers into a bag last week. What has prepared them to protect the patients and the staff if we don’t have some level of certification for those workers?

When you say certification for EVS, what do you mean by that?

I believe that they should be certified to a certain level of knowledge. In order to be certified, they need to be well trained. They need to be equipped with the necessary tools and equipment to do the job. They need to be allotted the right amount of time to do the task. And you can’t rush the process. They need to be…. We need to be measuring clean in those areas. So that we know that the products and the process and the person doing the job are validated. We audit the cleanliness of the area. And finally, that they’re being educated about the prevention and transmission of disease. That we are not just cleaning toilets and mopping floors. We have to be infection prevention on that frontline. Because it’s so important that we break that chain of infection. And you know that terminal cleaning is probably the one opportunity, but yet we find that wherever we scientifically measure the room after it’s been terminally cleaned, in many cases, fewer than 50% of those surfaces that are points of transmission were properly cleaned and disinfected. We have a long way to go to get to the point where we’re confident that [pathogens] don’t get passed from the previous patient to the next patient. But beyond COVID-19, we know that just with 

…. That if we don’t break that chain of infection with that terminal clean that the next patients are put in much greater risk, sometimes 100% more risk of getting 

, if we don’t do a proper job of removing the spores and then disinfecting with the right disinfectants. And during COVID-19 I think we were so focused on getting products that were on EPA’s [Environmental Protection Agency’s] 

…. There are 576 products on that list. And manufacturers are rushing to get their products tested and certified to make the list. But as we know, this envelope virus [SARS-CoV-2] is the lowest rung of the difficult-to-hard-to-kill organisms. The disinfectants that were effective against COVID-19 may not necessarily … probably aren’t registered for killing 

 spores, and even MRSA [Methicillin-resistant 

]. We saw MRSA rebound during this time. And from what I’ve seen, MRSA in hospitals jumped 32%, just in the 

 from the previous 2019. All the previous five years of gains of reducing MRSA in that environment [were lost and] now it’s a problem again. And then 

 is really more difficult to kill in the environment. But while we were watching COVID-19 and making sure that we have COVID-19 disinfectants, we took our eye off of some of these other organisms that proliferate in the hospital environment.

When you talk about certifying EDS teams, are you saying that each hospital system should basically educate them better? Are you thinking about some kind of national certification process?

I think that we first of all need to agree on what that education should consist of. There are some good education programs out there, whether APIC [Association for Professionals in Infection Control and Epidemiology] put them out. But even when I see CDC’s…. Wherever I watched their information videos on COVID-19 cleaning and disinfection, I find that…. First of all, the terminology. It’s important that we agree on the terminology. And that we first get rid of the term clean or cleaning, because it means different things to different people. And ultimately, the person that’s doing the cleaning and disinfection needs to understand that it’s two separate operations. And too often, we interchange those terms. We have to come to an agreement—whatever certification program there is—about terminology. And we have to agree that these terms have gotten to be used in the education of the frontline workers doing that task. I think that we need to bring the stakeholders to the table. And I think that APIC, and 

, which is the American Hospital Association’s Environmental Services Group, would need to collaborate and come up with a certification program. EVS teams work around professionals who are certified—whether it’s respiratory therapists, physical therapists, the RNs, the doctors—and I think if we ever hoped to elevate their status that we need to certify environmental services workers to a certain level of knowledge before they even start cleaning patient rooms. They might clean offices. They might clean public areas. Unless EVS workers are certified, I don’t think they should be cleaning and disinfecting patient care areas. We need to certify their knowledge of disease transmission. How things get passed around, and that we don’t clean just for appearance sakes, but we clean for health. And that health is the health of the staff, as well as the visitors. Anyone who comes into that hospital environment, whether it’s even an ambulatory surgery center. We are educating and certifying those workers so that the confidence of those who work around them and the patient in the bed is that they are certified. And if we certify them, then we need to pay them better than we do. They’re the lowest paid people in the hospital and they have such an important role in patient care. And they should be educated and certified in order to perform that task to a level that makes those surfaces safe, clean, and disinfected.

Do you think infection preventionists should monitor EVS departments?

I do. And I think that [IPs should audit] that surfaces are indeed safe for patients. And I’m not going to say disinfected, because disinfection takes a great deal more effort. And to get surfaces to that level, then it’s going to take more time in that room to do that. Right now, the EVS person on a regular daily cleaning, if it’s a semi-private room and a restroom, they’re allotted 12 to 15 minutes in that room to do the daily cleaning and disinfecting. And on a terminal cleaning, it’s maybe 30 minutes, but that 30 minutes includes stripping the bed, washing the bed, cleaning all the surfaces in the room and making the bed. Depending on the length of stay of that patient—some of these patients during COVID-19 were in there for 30 to 60 to 180 days. And so I guarantee that environment in that patient room is going to take longer than 30 minutes to do a terminal cleaning. But I think that those two groups, the AHE and APIC, they’re the stakeholders. I believe that infection preventionists do need to be involved in auditing of the rooms. And that there is a way of tracking all of that. So, you know, 

 is one of those methods. But you have to realize that there are things that affect ATP readings, and we haven’t come to an agreement about what constitutes a safe surface. We haven’t even agreed on the RLUs [relative light units] that are acceptable in a patient care environment. There are no national standards for auditing. And we need to come to that some say no more than, you know, one Cfu [

] per centimeter or centimeter squared. That’s what’s been used in the food production industry for years. And if it’s good enough for food production, it ought to be the standard for operating theatres and for patient rooms as well. One Cfu per centimeter squared is attainable, but it takes time and effort and education of those EVS workers to attain that. I seem to be out there on the edge of the frontier. And I think that we have made this whole thing way more complicated than it ought to be. And too often we depend on these room disinfecting systems—[such as] UV light—to take care of the human error part of things. Anytime you introduce a human into the process, then there are opportunities for failures. And I think that what we have in this country right now is a situation where patients are going back and forth to the nursing homes. The CDC 

 that 99,000 …. Americans die every year [from HAIs]. I think the numbers are much higher, because what we’re counting is just while they’re in the hospital. But they go back and forth to nursing homes, they go home, and they’re discharged. And then we have people walking around with MRSA and some of these MDROs [multidrug resistant organisms] that will be with them for the rest of their lives. And they’re shedding these organisms as they’re out there in the public. It’s a much bigger problem than what we’re conveying, but we need to get better at what we’re doing. I feel like I’m out there on the edge of the frontier trying to educate anyone who will listen. We need to do better in order to prevent these MDROs. They are going to be a much bigger problem for longer term. And since there are no new antibiotics really being developed, then proper cleaning and disinfection of surfaces in the future may be one of the only things that saves mankind.

This interview has been edited for clarity and length.

Darrel Hicks: “EVS teams work around professionals who are certified—whether it’s respiratory therapists, physical therapists, the RNs, the doctors—and I think if we ever hoped to elevate their status that we need to certify environmental services workers to a certain level of knowledge before they even start cleaning patient rooms.”

Environmental Services Workers Need to be Certified

When it comes to what circumstances help breed 

 infection (CDI), there are some that could be called the usual suspects. They include increased age, hospitalization, use of proton pump inhibitors, and use of antibiotics, according to a recent study out of Pakistan. That study, published in 

 looked at data from 200 patients diagnosed with


–associated diarrhea (CDAD) at a tertiary care hospital in Pakistan between June 2020 and March 2021, along with 200 patients without CDAD in a control group.

“Identifying and addressing the risk factors associated with CDI will help [reduce] the incidence of infection and associated complications,” the authors, led by Aarzoo Gupta of Vardhman Mahavir Medical College and Safdarjung Hospital in Faridabad, India, wrote.

The study included detailed histories of patients’ use of treatments (antibiotics, proton pump inhibitors, and histamine 2 receptor antagonists), previous CDI diagnoses, and hospitalization in the past 30 days. Investigators also noted patients’ body mass index (BMI) and comorbidities including diabetes, chronic kidney disease (CKD), hypertension, and malignancy.

In the case group, 31 patients were older than 65 (15.5%), compared with 16 (8%) in the control group (OR [odds ratio], 2.10 [1.11-3.99]; 

 = .02). “This age group is not only termed as a risk factor for CDI but such patients also demonstrate poor prognosis, leading to increased clinical severity and death rates,” the authors wrote.

Patients with CDI also had significantly higher hospitalization (25.5% vs 6%; OR, 5.36 [2.75-10.42]; 

 < .0001), use of proton pump inhibitors in past 30 days (23.0% vs 10.5%; OR, 2.54 [1.45-4.45]; 

 = .001), and use of antibiotics in the past 30 days (36.0% vs 10.5%; OR, 4.76 [2.80-8.19]; 

“Studies have suggested that almost every antibiotic results in an increased chance of developing CDI,” the authors wrote. “This also includes the drugs that are used to treat CDI, namely metronidazole and vancomycin.”

Other risk factors included a BMI above 25 kg/m2 (31% vs 21%; OR, 1.69 [1.07-2.65]; 

 = .02), diabetes (27% vs 16%; OR, 1.94 [1.18-2.17]; 

= .008), CKD (19% vs 9.5%; OR, 2.23 [1.23-4.03]; 

= .007), and malignancy (6% vs 2%; OR, 3.12 [0.99-9.86]; 

“Given the findings [above], our study suggests that the use of acid-suppressive agents should be carefully considered, and the over-the-counter availability of these agents should be discouraged,” the authors wrote. “This would help the doctors to keep a check in order to avoid overdose. Moreover, hygiene practices, such as hand washing practices, sterilizing used [equipment] at the hospital, using clean medical devices, etc, should be adopted to avoid infection risk. Maximum management of antibiotic intake should also be taken into consideration.”

CDI is the leading cause of health care–associated infections, causing about a half million infections and $1 billion in health care costs each year. Although CDI is often associated with health care settings, a recent study by investigators at the University of Houston found that the bacterium is prevalent in a variety of settings, including on 45% of shoe soles.

 Healthy people can carry CDI without illness or symptoms.

Gupta A, Savanti F, Singh B, et al. Risk factors associated with Clostridium difficile-associated diarrhea. 

. 2021;13(9):e18115. doi:10.7759/cureus.18115

Alonso CD, Kelly CP, Garey KW, et al. Ultrasensitive and quantitative toxin measurement correlates with baseline severity, severe outcomes, and recurrence among hospitalized patients with Clostridioides difficile infection. 

Lorenz, J. Risk factors associated with C diff infection. 

. October 31, 2021. Accessed November 1, 2021. https://www.contagionlive.com/view/risk-factors-associated-with-c-diff-infection

The use of almost every antibiotic increases the chances of Clostridioides difficile infection, and that includes the drugs that are used to treat C diff, a study states.