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

Jan Dyer

Last spring, investigators with the Centers for Disease Control and Prevention (CDC) had some good news to report about an infection that had for years sat at the top of the threat list: 

 infection (CDI) and associated hospitalizations, they said, had dropped 24% between 2011 and 2017, “owing to a decline in health care-associated infections [HAIs].”1

Despite that welcome decline, though, recurrent CDI remains one of the most important treatment challenges. In 2017, for instance, there were an estimated 38,500 health care–associated cases.2 Since the early 2000s, CDI has multiplied in incidence and severity, becoming the most common nosocomial infection.3 Part of that increase is due to more sensitive testing, which can contribute to higher case detection. And although health care-associated 

 has been trending downward, the same is not true of community-acquired 

 infection is costly—both in economic and human terms. Between 1986 and 2013, CDI was among the top 5 most expensive HAIs in the United States.3 The burden of CDI adds an estimated 3 to 20 extra hospital days per patient with an additional cost of $1 billion in the US.3

Avalere Health, a health care consulting firm, conducted a retrospective cohort study of more than 268,000 Medicare recipients diagnosed with 

 and recurrent CIDs (rCIDs) from 2010 through 2016. The investigators evaluated health care resource utilization and all-cause, direct medical costs associated with the infection. They found that 1 in 3 patients with 

 had a recurrence within 12 months, and more than half of the patients with at least 1 recurrence experienced 2 or more after that first episode. Patients with 

 spent 18 days in the hospital on average compared with 13 days for those with no recurrence.4

Total all-cause, direct medical costs per patient over 12 months were highest in those with 3 or more recurrent episodes, primarily driven by hospitalizations. Inpatient costs were $31,614 per patient with 3+ recurrences versus $22,722 per patient without an rCDI episode. Recurrent CDI was also associated with higher overall health care costs and higher out-of-pocket costs for patients.

“Significantly,” the Avalere investigators say, “during the 12-month follow-up period, hospital admission rates increased in parallel with the number of recurrences”: 13% of patients with CDI experienced 4 or more hospitalizations within 12 months, while 25% of those with 3 or more recurrences were hospitalized 4 or more times.

 carries a hefty price tag: $5 billion in direct health care costs annually.5 Most of the cost is due to morbidity and mortality. Between 1998 and 2008, the proportion of patients with complicated disease (eg, megacolon, perforation) jumped from 7% to 18%, and 30-day mortality nearly doubled, from 4.7% to 13.8%.3 More than 15,000 people die of CDI every year in the US; CDI and recurrent CDI is the seventeenth leading cause of death in people 65 and older.4,5

Co-infections are another complicating factor. COVID-19, for instance, manifests with GI symptoms similar to those of CDI.6 In a small Mayo Clinic study of 21 patients given a diagnosis of COVID-19 and CDI within 4 weeks of each other, 30-day mortality was 19%, mostly in the elderly. “Whether co-infection results in worsening mortality or more complications remains unanswered,” the investigators write. They note that the patients were not treated with antibiotics for COVID-19, and CDI seemed to have developed due to prior antibiotic exposure for other indications.

 and turbocharges it. In an online interview with 

7 about an Avalere study of patients with CDI, economist Christie Teigland, PhD, vice president, Advanced Analytics, Avalere Health, said, “The main takeaways [from the study] were really the very high rates of sepsis among patients who get 

 and particularly those who have recurring instances of 

. And that carried through with all of the health care resource utilization metrics we looked at, from inpatient stays to post-acute care use, lots of skilled nursing facility use, where they also have a high risk of sepsis and 

“The costs are strikingly high for these patients—$42,000 a year for patients with recurrent 

, with sepsis, and those were the patients who died, but the costs were even high in patients who did not die. For those who died, the follow-up was really short. I think the shortest was 12 days. These patients, once they have 

 and sepsis, have higher odds of dying. So, the whole message here is what can we do to, number 1, prevent 

 and number 2, sepsis, because the combination of those two is deadly.”

Many current estimates of the poor outcomes and costs associated with CDI “do not take into account the underlying severity of illness among patients who develop CDI and may overestimate the true attributable outcomes,” according to a 2020 meta-analysis that found a pooled incidence of hospital-onset CDI of 8.3 cases per 10,000 patient-days.8

This June, the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) released a new clinical practice guideline on management of CDI in adults. Since 2017, the authors say, when the guideline was last published, “new relevant evidence has emerged for treatment options.” This 2021 “focused update” specifically addresses the use of fidaxomicin and bezlotoxumab (a monoclonal antibody that targets toxin B produced by 

). Both agents have increased clinical efficacy and other advantages over older agents, the authors say, but implementation may be challenging because of initial monetary cost and logistics.

The new guideline also notes that the FDA has published 3 separate safety alerts on fecal microbiota transplantation (FMT) (which is recommended, although only for patients with multiple recurrences of CDI for whom antibiotic treatments have failed, and where appropriate screening has been performed). Two alerts document transmission of pathogenic 

 from donor to FMT recipients. The other alert concerns the potential for transmission of SARS-CoV-2. According to researchers from Mayo Clinic, with appropriate screening, FMT is safe to perform during the pandemic. In their study of 57 patients who underwent FMT for rCDI, none developed COVID-19.9

CDI is an old enemy and health care professionals have gathered an armamentarium of weapons against it, but it can be relentless. “Clearly,” says Teigland, “we know that hospitals and nursing homes take precautions to prevent sepsis and prevent 

.… The impact is just so devastating in this frail elderly population, you know, they’re already suffering from multiple chronic conditions, hypothyroidism, hypertension, diabetes, asthma, COPD, many comorbidities. 

 and sepsis on top of all that is just devastating. Ultimately, more attention needs to be paid to those high-risk patients.” But, she adds, “We can predict who’s high risk because we know what the preceding risk factors are. Our study even looked at what the risk factors were in the most recent 7 to 12 months, right before the 

 happened. Their conditions got much worse in the 6 months right before they had their first case of 

. So when you see those worsening effects happening, you really need to pay much more attention to the protocols that they have in place already. We know hospitals have protocols in place to prevent sepsis and 

, you really need to pay attention to these patients because it’s still happening way too much.”

The bedside is still a good place to keep watch. A paper-based bedside 

 screening tool to reduce inappropriate testing could make a big cost difference to the 25% of hospitals that don’t use clinical decision support in their electronic health records, say investigators from Adventist Health-Simi Valley. Nurses used the screening tool to determine whether stool should be sent for 

 testing. The researchers collected data on the number of 

 stool tests performed before and after the intervention: They found a 31% drop in the mean monthly number of tests performed and a 56% reduction in CDI diagnoses.10

In an intervention tested at Hospital General Universitario Gregorio Marañón, in Madrid, after a positive 

 test, patients immediately received a bedside visit from an infectious disease physician. The timely visit allowed for more targeted treatment, reducing overdiagnosis. Identifying the patients who do not meet the criteria for diarrhea and are simply carriers makes it possible to withdraw treatment from a large contingent, the researchers say.11

The ID physician was instrumental in identifying 29 cases as only colonized with 

, in which fecal sample collection was unnecessary. In 22 of those cases (76%), physicians in charge accepted the ID consultants’ recommendations to stop or not initiate CDI treatment in asymptomatic patients. Unnecessary non-CDI antibiotics were discontinued in 19% of cases. Only in 13% of the 214 cases were the ID recommendations not accepted by physicians in charge.

The cost of the intervention was estimated at €6800 (approximately $7800) during the study period, while the estimated costs of savings from antimicrobial discontinuations only were estimated at €1799 (approximately $2000).

The CDC investigators who reported on the decline in health care-associated 

 infection say several factors were probably involved, including a decline in the epidemic strain ribo-type 027, which might be partly driven by reduced fluoroquinolone use.1 They cite a 2020 study that found hospitals that reduced fluoroquinolone use by 30% also saw a 19% reduction in hospital-onset CDI. They also point to a “greater emphasis on diagnostic stewardship” and reducing inappropriate testing.

Sometimes, less is more. Most hospitals implement interventions simultaneously in “bundles,” say researchers from the University of Michigan and the University of Wisconsin, and more than half of the bundles in a recent review included at least 6 components. But that may be costly overkill.

In their economic evaluation study, these researchers used an agent-based simulation of 

 transmission at a 200-bed model tertiary acute care hospital to compare the cost effectiveness of nine single-intervention strategies and 8 multi-intervention bundles. They defined cost effectiveness by two measures: cost per hospital-onset CDI averted and cost per quality-adjusted life-year (QALY).5

Five of 9 enhanced-level strategies were “dominant,” reducing cost, increasing QALYs and averting CDI: Daily cleaning was the “most clinically effective and cost-effective intervention by far,” saving $358,268 and 36.8 QALYs annually, while averting 26 CDIs. Next came health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. (Daily cleaning prevented more than 16 times as many infections as the patient transfer intervention.) Contact precautions, while a mainstay of CDI prevention programs, are based on slim evidence, the researchers say, given that 

-targeted studies are lacking. In their study, they found neither health care worker nor visitor contact precautions were cost effective. Enhanced-level health care worker contact precautions cost $123,264 per QALY, and the ideal-level implementation $136,135 per QALY. “The results were even worse,” they say, for the visitor contact precaution interventions, with the ideal level costing $1,669,089 per QALY.

The bundles were only as cost effective as the parts they assembled. For instance, adding patient hand hygiene to the health care worker hand hygiene intervention saved a mean of $32,588 and 4.2 QALYs annually. When screening, health care worker hand hygiene and patient hand hygiene interventions were sequentially added to daily cleaning to form bundles, the incremental cost-effectiveness ratios for the additions were $29,616, $50,196, and $146,792 per QALY, respectively. Patient hand-hygiene, which, the researchers point out, is “rarely incorporated into 

 bundles,” was cost saving at both the enhanced and ideal levels. Their back-to-basics advice: Institutions should “seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions.” Daily sporicidal cleaning, for example, they suggest, might be more useful and money-saving than minimally effective, costly strategies, such as visitor contact precautions.

Suggesting using fewer (albeit highly effective) interventions “runs contrary to the current infection control climate,” the researchers acknowledge. And while many of the interventions in their study saved money, they were not without upfront costs. Even at the enhanced level, each intervention required additional infection control nursing staff.

“Hospital administrative buy-in and financial support is key,” they emphasize, “to both the initial implementation of an intervention and sustaining its long-term success.” Throwing more money at the problem isn’t the solution—but throwing the right kind of money could be.

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

Guh AY, Mu Y, Winston LG, Johnston H, et al. Trends in U.S. Burden of 

 2020; 382:1320-1330. doi: 10.1056/NEJMoa1910215. Accessed 07/26/21.

Johnson S, Lavergne V, Skinner AM, Gonzales-Luna AJ, Garey KW, Kelly CP, Wilcox MH. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of 

Gupta A, Ananthakrishnan AN. Economic burden and cost-effectiveness of therapies for 

Teigland C, Parente A. The burden and costs of recurrent 

.https://avalere.com/insights/the-burden-and-costs-of-recurrent-clostridioides-difficile. May 7, 2020. Accessed 07/26/21.

Barker AK, Scaria E, Safdar N, Alagoz O. Evaluation of the cost-effectiveness of infection control strategies to reduce hospital-onset 

. 2020;3(8):e2012522. Published 2020 Aug 3. doi:10.1001/jamanetworkopen.2020.12522. Accessed 07/26/21.

Sehgal K, Fadel HJ, Tande AJ, Pardi DS, Khanna S. Outcomes in patients with SARS-CoV-2 and 

. 2021;14:1645-1648. Published 2021 Apr 28. doi:10.2147/IDR.S305349. Accessed 07/26/21. Published online.

Walter K. Christie Teigland, PhD: The cost of c difficile and sepsis.HCPLive.Accessed 07/29/21. Published online 05/21/21.https://www.hcplive.com/view/teigland-cost-c-difficile-sepsis

Marra AR, Perencevich EN, Nelson RE, et al. Incidence and outcomes associated with 

infections: A systematic review and meta-analysis. 

. 2020;3(1):e1917597. Published 2020 Jan 3. doi:10.1001/jamanetworkopen.2019.17597. Accessed 07/26/21.

Khanna S, Tande A, Rubin DT, Khoruts A, Kahn SA, Pardi DS. Fecal microbiota transplantation for recurrent 

infection during the COVID-19 pandemic: experience and recommendations. 

. 2021;96(6):1418-1425. doi:10.1016/j.mayocp.2021.04.005. Accessed 07/26/21.

Lenz A, Davis G, Asmar H, Nahapetian A, Dingilian J, Nathan RV. Using a nurse-initiated bedside tool to decrease inappropriate testing for 

Olmedo M, Valerio M, Reigadas E, Marín M, Alcalá L, Muñoz P, Bouza E. Clinical impact of a 

bedside infectious disease stewardship intervention. 

, Volume 2, Issue 3, September 2020, dlaa037, 

Articles

C. diff infection is an old enemy and health care professionals have gathered an armamentarium of weapons against it, but it can be relentless. 

Can We Ever Get Rid of C. Diff?

First came COVID-19; then, blessedly, the vaccines. But then…vaccine resistance.

About 47.7% of Americans 12 years and older are fully vaccinated as of this writing but—doing the math—that leaves about 52.3% who are not.

 The holdouts offer a variety of reasons for delaying or refusing vaccinations, so states and communities are dangling a variety of carrots, according to their means and what their reluctant residents are likely to respond to.

Most incentives are relatively low-key: free beer in New Jersey, a complimentary beverage in Connecticut, and free weed in Washington state. In New York, New York, the vaccinated can opt for free tickets to Lincoln Center and the Bronx Zoo, among other offers. Maine residents can choose from a free park pass, a hunting or fishing license, or an L.L.Bean gift card. In Alabama, vaccinated residents can drive 2 laps on the Talladega Superspeedway.

At UCLA, investigators have interviewed more than 75,000 people over the past 10 months, testing the effectiveness of different messages about getting vaccinated. For example, framing the benefits as “It will protect you” or “It will protect you and those around you” produced similar results: About two-thirds of each group said they intended to get the shots.

For some, like the vaccine hesitant, money talks loudest. In the UCLA study, roughly one-third of 7249 respondents said a cash payment would make them more inclined to get a shot. Interestingly, the percentages were close, whether the amount was $25, $50, or $100, although willingness did increase in the $100 group by 6 points over the $25 group.

Early on, payments seemed to have a negative effect on some people. With the hesitant group, however, payment has an edge, and some states are getting creative—maybe desperately creative—to take advantage of that. In parts of Alaska, getting vaccinated might get someone $500 for groceries or food. In Ohio, it could earn a person a million bucks.

In a press conference in May, Gov Mike DeWine (R) of Ohio said, “Now, I know that some of you are shaking your head and saying, ‘That Mike DeWine, he’s crazy!’ Why? ‘Because he had just announced 5 Ohio Vax-a-Million drawings—a lottery for vaccinated residents.’ ”

Asked at a mid-May press conference whether the $5 million might have been better spent in some other way—public service announcements, for instance—Ohio Health Director Stephanie McCloud said that, in fact, the previous Friday the state had seen its highest vaccination numbers since April 23. Specifically, she pointed to a 6% increase in vaccination rates among people aged 30 to 74—and this was after 3 weeks of steady decline.

 “I don’t know for $5 million…that this would be something we could have spent in other ways to get this much attention, interest, uptake.”

It seems to be working just fine. In the week following the lottery launch, vaccinations in Ohio increased 94% among those 16 and 17 years old, 46% among those aged 18 and 19, and 55% among those between 20 and 49 (the first lucky winners were announced May 26), according to a statement from DeWine’s office.

In the spirit of one-upmanship, Gov Larry Hogan (R) of Maryland launched a $2 million lottery on May 20, with dozens of $40,000 cash prizes for vaccinated state residents, as well as 1 grand prize of $400,000.

The push to vaccinate is now targeting teens and young adults. A College Finance survey of more than 1000 college students found that although 88% said they are planning to get vaccinated, 8% said they’re unsure and 4% said they won’t.

 A little more than 7 in 10 believe it should be compulsory for college admission. Those who don’t often mirror an opinion found in the general US public: One junior at Rutgers, The State University of New Jersey and the first university to mandate COVID-19 vaccination, said, “I’m not antivax, I’m antimandate. My education should not be restricted based on my personal decision to receive the COVID-19 vaccination.”

What happens on college campuses may seem somewhat far afield of what infection preventionists (IPs) do in hospitals except that—as 

® reported in our March 2021 issue—there may be a growing demand for IPs outside traditional health care settings such as hospitals. Businesses, public health departments, and schools, including colleges and universities, all need infection prevention guidance. 

Unfortunately, although young adults have been the source of some of the worst spikes in COVID-19 cases, until recently, they have been last on the priority list for vaccination. In April, Rochelle Walensky, MD, MPH, the director of the Centers for Disease Control and Prevention (CDC), said that more younger adults are being admitted with COVID-19 as more contagious variants spread.

 In New York State, the COVID-19 positivity rate among people aged 18 to 24 years is on the rise, as of this writing. In Michigan, case rates are at an all-time high for those aged 19 years and younger.

Not incidentally, given the young age of many vaccine-unsure people, Ohio is also giving away 5 full college scholarships to vaccinated students. And in West Virginia, everyone aged 16 to 35 will get a $100 savings bond for getting vaccinated.

In a press briefing in late April, Gov Jim Justice announced that the median age of West Virginians testing positive for COVID-19 had dropped to 34. “When it recently came down to 44 years of age, we thought, ‘Uh-oh. We’ve got a problem,’” he said. “But now we’re down to 34, and that means we’ve got a ton of young people that are testing positive. We’ve absolutely got to get our young people vaccinated.”

As part of the “Call to Arms” vaccine initiative, state COVID-19 pandemic response leaders set a goal of administering at least 1 dose to 65% of all eligible residents by West Virginia’s 158th birthday on June 20, 2021. “We are at 57% right now, so we’ve only got 8% to go,” Justice said 2 weeks ahead of the deadline.

 (As of this writing on July 12, 2021, the number stood at 58%, according to the CDC.)

To help move the needle on the number of young, vaccinated people, schools, like states, are offering rewards, bribes, and outright cash, no strings attached—other than getting vaccinated. The intent is to not only encourage vaccination but also make it easier for schools to get back to normal, with in-person classes and some form of regular school activities.

Rowan University in Glassboro, New Jersey, is planning an in-person commencement for the Class of 2021, with 20 ceremonies. To help make that possible, the university is offering a $500 credit to full-time students who show proof of vaccination; residential students will receive an additional $500 credit to their housing bill. The school is also developing incentives for employees (in compliance with union regulations). “Our message today is simple,” Ali Houshmand, PhD, the university’s president, said in a letter to the college community. “We believe the path to normalcy is through widespread vaccination, and we want our entire community to commit to reaching the goal of widespread vaccination. If we work together, we can reach this goal and offer the Rowan University experience that we all deserve.”

A senior admissions information coordinator at Bucknell University, a well-respected liberal arts college in rural Pennsylvania, says her school is mandating vaccination for the students. Staff and faculty will have to wear masks and get tested every 2 weeks. When asked how Bucknell will manage having half the school community (the students) inoculated and the other half (staff and faculty) not, she laughs. The incentive for staff: “If you get vaccinated, you won’t have to get tested every 2 weeks.”

All 50 states have at least some vaccine mandates for elementary and high schools, and colleges often require vaccinations for certain diseases, such as measles and meningitis. Those mandates all have medical exemptions and sometimes religious or even philosophical exemptions. The American College Health Association has recommended that colleges require all students on campus to receive a COVID-19 vaccine, calling it “the most effective way for institutions of higher education to return to a safe, robust on-campus experience.”

2 So far, hundreds of colleges and universities have said vaccinations will be mandatory for the fall 2021 semester.

Schools are walking a tightrope, though, and it’s wrapped in thorns. There’s a downside to virtually every choice. If they demand vaccination, they’re bound to lose some prospective students, and the past year has made the coming year critical for enrollment. According to the National Student Clearinghouse Research Center, spring undergraduate enrollment is down 5.9%—the steepest decline since the beginning of the pandemic. Overall postsecondary enrollment is down 4.2% from a year ago.

If schools don’t mandate vaccination—well, consider the fact that rising infections among young adults create a “reservoir of disease” that eventually “spills over into the rest of society,” Judith Malmgren, PhD, an epidemiologist at the University of Washington, said in an NPR interview.

Implementing vaccine coverage comes with a multitude of practical headaches. “At this point, I would like the reassurance that anyone I come in contact with at the college has been vaccinated,” said Patricia Johannsen, PhD, professor and coordinator of graphic design in the Media Arts and Technologies Department at Montgomery College, a community college in Rockville, Maryland, that enrolls more than 50,000 students each year. “But how do you enforce that every day and night? Guards to check everyone as they drive or walk on to campus or get off the buses? Our campus boundaries are too porous. Guards at every entrance to every building—on all 3 of our main campuses and our numerous auxiliary sites.”

College administrators have yet another balancing act to perform: keeping students and staff safe while offering the activities that make campus life enjoyable. Older teens and young adults are more likely to be involved in high-risk behaviors, such as going out to bars.

Johannsen added this point: “What about the college’s on-campus activities for the community? It’s more than students coming for classes and employees coming to work.”

Then there’s the issue of whether the college or university should provide the place to get vaccinated. Nearly all the college-attending respondents to the College Finance survey believe colleges are responsible for the well-being of their students, but only those at the larger schools are likely to get the shot where they attend classes. Smaller colleges were least likely to offer vaccines and vaccination sites, and only about 35% and 46%, respectively, of larger universities were likely to offer those services, according to the survey.

Not surprisingly, the pushback through lawsuits and legislation began almost preemptively and largely on political divides. Whereas blue states like California and Maryland are encouraging state schools to require vaccination and some New York lawmakers are considering legislation requiring vaccinations for private and public colleges, several typically red states are actively moving in the opposite direction. For instance, in Utah, Gov Spencer Cox (R) signed legislation prohibiting colleges or universities from requiring proof of vaccination to enroll. Gov Ron DeSantis (R) of Florida signed legislation preventing businesses from requiring vaccines, which is having a knock-on effect among higher education institutions. In Texas, Gov Greg Abbott (R) issued an executive order prohibiting state-funded organizations—including colleges receiving state aid—from requiring vaccinations. Their decisions meant schools such as St Edward’s University in Texas and Nova Southeastern University in Florida, which had announced a mandatory vaccine policy, were forced
to backpedal.

However, other colleges and universities with mandates are holding their ground. For one thing, mandatory immunizations during a public health crisis were approved 100 years ago by the US Supreme Court (

). And the ground has been tested with influenza vaccines for health care workers—21 states have a law in place. Similarly, employers in general have the right to require influenza shots unless an established exemption is present.

 Mandates have been effective: For the 2013-2014 influenza season, the highest coverage of health care workers was nearly 98%—where vaccination was required. Elsewhere, coverage among health care workers in general was 75%.

Requiring vaccination for staff raises both legal and ethical concerns. On one hand, sharing vaccination status with an employer is legal. On the other, employers cannot always ask about vaccination status. “I’m sure [our] college is concerned about the bottom line, if we lose students who won’t or can’t get vaccinated,” Johannsen said. “And then there are all the employees. Do you fire the ones who won’t or can’t get vaccinated? Sounds like lawsuits in the making.”

When it’s necessary for the job, it’s legal for employers to require vaccination, but according to health care labor and employment attorney Kevin Troutman, interviewed for the

, “They’ve got to be able to establish and prove why it’s a job-related requirement.” Employers can not only ask whether a job candidate is vaccinated; they can require proof. But if a potential job candidate is qualified but unvaccinated, the employer might not know that it’s because of a disability or religious beliefs and cannot pry to find out.

Lawyers have OK’d the legality of mandating vaccines, but the largest schools with the safest bank balances (like Harvard and Yale) are the ones that can probably defend the decision most easily. Other smaller, less well-endowed schools have to weigh the risk of lawsuits and effects on enrollment with the benefits of requiring vaccinations.

Some schools have already been sued for vaccine mandates. The University of California was sued after mandating the influenza vaccine for the 2020-2021 influenza season. It won the case, but universities should note a key distinction, wrote Michael Vernick, Brennan Meier, Molly Whitman, and Jessica Mannon in 

: “Historically, only vaccines with full FDA approval have been mandated. There is little precedent indicating whether mandatory COVID-19 vaccines will receive the same treatment in court; the available vaccines currently have only FDA emergency use authorization.” (In early May, Pfizer and its vaccine partner BioNTech started an application to request full FDA approval.)

The authors said that some states are considering or have enacted legislation providing universities with limited legal immunity for claims related to COVID-19, and some legislation includes protection related to claims for tuition and fees.

However it pans out and whatever new rules they have to satisfy this year, students are eager to get back to the nonvirtual college experience—that heady mix of study and social whirl—that they missed so much this past year. The respondents to the College Finance survey were cautiously optimistic: About 70% were at least somewhat hopeful that things would get back to normal this semester, but about half really thought it would take until spring 2022.

An admissions officer at a liberal arts college in central Pennsylvania, who did not wish to be identified, has 3 children, 2 of whom are college age. One is starting at Hawaii Pacific University this fall, and another is going back to Stetson University in Florida. Neither school is requiring vaccinations at this point. But it doesn’t matter—the kids would be fine with it, they say. “I’m OK if it gets mandated. They make us take other vaccines before we can attend, so this is just another one,” the college freshman said. “But I know some people think this is different since it’s so new.”

As for the high-school senior heading to Hawaii—well, he’s a high school senior heading to Hawaii. But that actually isn’t the best part, he says: “I’m excited about going since it will be my first year at college and I’ll have 2 roommates in my dorm.”

Roommates in a dorm. Just like the old days.

COVID-19 vaccinations in the United States. Centers for Disease Control and Prevention. Accessed June 7, 2021. https://covid.cdc.gov/covid-data-tracker/#vaccinations

Vavreck L. $100 as incentive to get a shot? Experiment suggests it can pay off. 

. May 4, 2021. Accessed May 27, 2021. https://www.nytimes.com/2021/05/04/upshot/vaccine-incentive-experiment.html

Ohio vaccine lottery: how to sign up for $1 million prizes, scholarships. NBC4 Columbus. May 17, 2021. Accessed May 27, 2021. https://nbc4i.co/3eQAU4n

Ohio's vaccine lottery proves an effective incentive. WBUR News. May 30, 2021. Accessed June 7, 2021. https://www.wbur.org/npr/1001684830/ohios-vaccine-lottery-proves-an-effective-incentive

Ohio announces winner of first vaccination lottery. BBC News. May 27, 2021. Accessed May 27, 2021. https://www.bbc.com/news/world-us-canada-57264045

Pilgrim K. College students on the COVID-19 vaccines. College Finance. April 21, 2021. Accessed May 27, 2021. https://collegefinance.com/covid-19/college-students-on-the-covid-19-vaccine

Dickler J. Students protest mandatory Covid vaccinations at colleges. CNBC.com. May 19, 2021. Accessed May 27, 2021. https://www.cnbc.com/2021/05/19/students-protest-mandatory-covid-vaccinations-at-colleges.html

Ward-Fore S. Infection preventionists can help the non-health care sector thrive. 

Lovelace Jr. B. More young people are getting hospitalized as Covid variants spread. Here’s what we know. CNBC.com. April 16, 2021. Accessed May 27, 2021. https://www.cnbc.com/2021/04/16/covid-more-young-people-hospitalized-as-more-contagious-variants-spread.html

COVID-19 Update: Gov. Justice announces West Virginia now just 8% away from reaching vaccination goal for eligible population. Press release. Office of the Governor Jim Justice. April 30, 2021. Accessed May 27, 2021. https://governor.wv.gov/News/press-releases/2021/Pages/COVID-19-UPDATE-Gov.-Justice-announces-West-Virginia-now-8-percent-away-from-reaching-vaccination-goal.aspx

Houshmand AA. Commitment—and incentives—to get vaccinated. Rowan University. Press release. May 6, 2021. Accessed May 27, 2021. https://today.rowan.edu/news/2021/05/rowan-offers-vaccination-incentives.html

American College Health Association recommends COVID-19 vaccination requirements for all on-campus college students in Fall 2021. News release. American College Health Association. April 29, 2021. Accessed May 27, 2021. https://www.acha.org//ACHA/About/ACHA_News/ACHA_Recommends_COVID-19_Vaccination_Requirements_for_Fall_2021.aspx

Burt C. State-by-state look at colleges requiring COVID-19 vaccines. 

. May 11, 2021. Accessed May 27, 2021. https://universitybusiness.com/state-by-state-look-at-colleges-requiring-vaccines/

Sedmak T. Spring undergraduate enrollment down 5.9%; steepest decline so far since the pandemic. National Student Clearinghouse blog. Published April 29, 2021. Accessed May 27, 2021. https://www.studentclearinghouse.org/blog/spring-undergraduate-enrollment-down-5-9-steepest-decline-so-far-since-the-pandemic/

Stone W. COVID ‘doesn’t discriminate by age’: Serious cases on the rise in younger adults. NPR. May 1, 2021. Accessed May 27, 2021. https://www.npr.org/sections/health-shots/2021/05/01/992148299/covid-doesnt-discriminate-by-age-serious-cases-on-the-rise-in-younger-adults

Stratford M. Colleges weigh vaccine mandates amid some political backlash. Politico. May 19, 2021. Accessed May 27, 2021. https://www.politico.com/newsletters/weekly-education-coronavirus-special-edition/2021/05/10/colleges-weigh-vaccine-mandates-amid-some-political-backlash-795174

Vernick M, Meier B, Whitman M, Mannon J. Mandatory COVID vaccines for students: legal pain point or panacea? 

. April 16, 2021. Accessed May 27, 2021. https://universitybusiness.com/mandatory-covid-vaccines-college-students-legal-akin-gump/

Brent N. Can a facility’s administration force nurses to take the flu vaccine? what are my rights? Nurse.com blog. Published March 9, 2015. Accessed May 27, 2021. https://www.nurse.com/blog/2015/03/09/can-a-facility%C2%92s-administration-force-nurses-to-take-the-flu-vaccine-what-are-my-rights/

Bever L. Your employer can ask whether you’ve received the coronavirus vaccine—and even require it. 

. March 6, 2021. Accessed May 27, 2021. https://www.washingtonpost.com/lifestyle/2021/03/06/workplace-covid-vaccine-policies/?utm_source=rss&utm_medium=referral&utm_campaign=wp_homepage

One junior at New Jersey’s Rutgers University, the first to mandate COVID-19 vaccination, said, “I’m not antivax, I’m anti-mandate. My education should not be restricted based on my personal decision to receive the COVID-19 vaccination.”

College Guidance Counseling: Get the COVID-19 Vaccine

Never has the phrase “necessity is the mother of invention” been truer than in the past year. For beleaguered hospitals, not always known as early adopters of change, the need to cope with an unprecedented pandemic has led to (maybe 

 is the better word) an exceptional openness to inventive ways of delivering health care services.

And everything is happening at maximum velocity. Changes that once would have taken months, if not years, are now being deployed while the ink is still wet. “The urgency of decision-making and new ideas…has led to so much change that we now refer to it as ‘COVID time,’” writes Emily C. Webber, MD, chief medical information officer at Riley Children’s Health and Indiana University Health.

Some of the changes have been sticking-the-finger-in-the-dike–type solutions: Whatever works, do it, and do it fast. This includes nurses wearing garbage bags because they don’t have enough personal protective equipment, for instance.

Some changes will not only have staying power, but spur innovation; say, in technology.

Health care has already realized what technology can do. According to Zebra Technologies’ 2019 Intelligent Enterprise Index survey, health care facilities were among the 17% of businesses that self-identify as fully “intelligent enterprises.” In other words, they have “connected the physical and digital worlds” by, for example, digitizingworkflow and using cloud computing.

The Atlantic Council GeoTech Center surveyed more than 100 technology experts on the impact of COVID-19 on 5 key fields: the future of work, data and artificial intelligence (AI), trust and supply chains, space commercialization, and health and medicine. Nearly all respondents believe that the coronavirus pandemic will “accelerate invention significantly” in 4 of those fields, with “little impact” on space tech innovation

 (quite a statement, considering we’re now getting weather reports from Mars).

“As the virus imposes heavy demands on health care systems, strains international supply chains, and changes the way we work, it will spur innovation in those areas,” the report says. “Likewise, as cloud infrastructure is forced to cope with increased traffic and public health professionals strive to harness massive data sets to fight the pandemic, developments in the fields of data and AI will accelerate.”

For institutions, initiating change is often like trying to turn an ocean liner around. But in an interview with 

, Bill Cox, director of quality at Hospital Sisters Health System in Springfield, Illinois, said, “Over the past year, we quickly learned that implementing technology during a pandemic required us to be as fluid as possible. We couldn’t be locked into a strict timeline with no flexibility or willingness to shift key milestones. Once lockdown began, we had to rethink our timing and learn to plan for uncertainty.”

Being constantly in crisis mode has meant maximizing and repurposing existing technology. And the advanced-tech innovations are coming fast and furious from around the world. But what if the appropriate technology isn’t ready yet? Individuals and institutions step up.

Consider Manan Gandhi. In India, where the situation is now so dire that people are dying in hospital parking lots if they aren’t dying at home, Gandhi teamed up with Amit Sarda, an app developer, to tackle the problem of finding COVID-19 essentials such as medicines, oxygen cylinders, and hospital beds. They created a free online app, Covid Resource, that collects all the information into 1 uniform platform. The developers have crowdsourced a user-friendly way to search, with information created from Google Docs shared on social media and regularly updated by a Twitter community.

The staff at Massachusetts General Hospital also took the initiative. They repurposed nearly 600 iPads from closed outpatient units to create video portals to communicate with patients in isolation rooms.

 First, though, they had to figure out the most efficient way to display the iPads, which turned out to be on poles for intravenous (IV) therapy. “We had to pull together things we had on the shelves, like clamps to secure the iPads to the IV poles, and repurpose and reconfigure that equipment, and it takes a lot of work to take something to go from zero to 100 and implement [it],” said Keith Jennings, chief information officer, in one of the hospital’s publications. The devices reside on bedside tables; patients can initiate a conversation without having to push buttons. The hospital also reprogrammed secure phones and iPads so patients can receive video calls from family and friends.

Video capabilities and telehealth, already in use since 1959, became an even more essential connection between doctors and patients during the pandemic, particularly for patients who did not have COVID-19 but still needed care. With strict isolation, video and “chatbots” have allowed caregivers to keep track of signs and symptoms from a distance. Northwell Health in New York added thousands of Amazon Echo Show smart displays to its facilities, 2-way video-calling devices for providers and patients (and configured the devices to comply with federal telehealth guidelines on privacy and data protection).

A top priority everywhere has been to ensure that staff and patients are as safe as possible. Hospital Sisters’ 15-hospital system has, for example, implemented SwipeSense electronic hand hygiene monitoring systemwide. “Change is always difficult—and change across 15 hospitals is change magnified times 15,” Cox said. “Since electronic hand hygiene was a new technology, the culture change and education was really about the value of moving from a manual process to an automated process…. We had to get staff [to] buy into the rationale for a new electronic process and emphasize that it’s best for our patients.”

He adds, “With any technology or culture change, there will always be people who don’t like the new process and question everything.” The answer, he believes, is to engage in the conversation and show how the process is valuable and how it changes outcomes. It’s also important, he says, to reward compliance and success.

“COVID-19 actually surfaced a very challenging issue—the dependence on manpower,” said Ng Kian Swan, chief operating officer of the National University Health System (NUHS) in Singapore, in an article for channelnewsasia.com.

 Many hospitals have been “hiring” extra help in the form of robots for years, but the pandemic has pushed robots to the front line of the front line, so to speak. Robots don’t need personal protective equipment (PPE) and they don’t get sick. Nor do they mind endlessly going from room to room doing repetitive tasks such as bringing supplies, so they free up staff to focus on caregiving. They also keep human interactions to a minimum, reducing the chance of virus transmission.

Take Moxi, for instance. Moxi has been working full time at Medical City Heart Hospital and Medical City Spine Hospital in Dallas, Texas, for more than a year now. It delivers PPE, coronavirus and other lab samples, and COVID-19 tests. It picks up and delivers things dropped off for patients. “When you add [everything] up, …it could add maybe 10 to
15 minutes per task,” the hospitals’ chief operating officer, Josh Kemph, told KXAN Austin, an NBC affiliate in Texas. And with Moxi running anywhere from 50 to 75 tasks during a shift, “it’s hours and hours back to the staff.”

 At one of the hospitals, Moxi delivered more than 4000 items of PPE in a month. “[E]very one of those is something that a nurse did not have to run down to another unit to grab,” Andrea Thomaz, CEO and cofounder of Diligent Robotics, which built Moxi, told KXAN.

Robots are used to disinfect patient rooms with equipment using UV light. One type of bot uses UV-C lights to destroy the genetic material of viruses in minutes. Others enforce social-distancing rules. In Belgium, Antwerp University Hospital employs robots that speak more than 53 languages and determine whether face masks are being worn appropriately.

In a “smart” field hospital in China, robots backed up exhausted staff by flagging patients with fevers, measuring blood oxygen levels via smart bracelets, delivering medications, and cleaning infected areas. They even provided exercise lessons and entertainment for quarantined patients.

 Drones also have been pressed into service, for jobs such as building inspections.

Some fear that hospitals will become “Robots R Us” environments, but that is unlikely. Health care is, at its core, in the business of connecting people to people. Chatbots, although useful, are poor stand-ins for an in-depth, in-person conversation with a health care provider. And if COVID-19 did anything, it put a million faces to the tragedy of what it’s like to die without human contact.

“Quit trying to get robots to replace people,” said Robin Murphy, PhD, Raytheon Professor of Computer Science and Engineering at Texas A&M University, speaking to the Robotics for Infectious Disease consortium last year. Robots should not (and cannot) take the place of skilled workers and should not be used in situations where human empathy is important, she stated. Instead, they should be used to protect human workers and help them by minimizing the time they waste on unskilled tasks.

The most sensible way to use robots in a pandemic, Murphy advised, is to use the ones that already exist, that people are already comfortable using, and that can scale up to be immediately useful. The middle of a pandemic—or anytime during a pandemic for that matter—isn’t the right time to drop a new bit of technology into the mix. The people needed to operate the robot (most need adult supervision) are already exhausted and stressed. They shouldn’t have to take valuable time to get up to speed on the robot.

John Wall, principal technical adviser at Metro North Hospital and Health Service in Brisbane, Australia, observed that the pandemic has caused a number of changes there too. Leading IT design for redevelopment for hospitals, he has found that with COVID-19 “everyone’s had to learn to adapt and be agile. Normally in health care, staff are too busy, but there’s been a real change in the dynamic over the past 6 months. There has been so much more ownership and interaction, and people are more open to working through the solutions and being a part of them.”

Many tech-driven systems and ways of providing care have proved their worth during the pressurized time of COVID-19 and have a guaranteed future in health. Telemedicine, so crucial, has received a tremendous leg up in the past year. The CARES Act, for example, delivered $200 million to start the COVID-19 Telehealth Program.

 The funding will support broadband connectivity and telemedicine kiosks, among other things.

The pandemic also revealed yawning gaps in infrastructure. Many facilities have been working on becoming more agile, making it possible to switch spaces from purpose to purpose more fluidly. “One of the many lessons of this crisis is that flexibility of space is paramount to enable optimum resilience and provide readiness for the unknown,” said Suzanne MacCormick, global health care business growth lead at WSP, a professional services firm. “Smart” building solutions, such as a system that combines various technologies to monitor power, lighting, patient logistics, and air quality, all in real time, can support that resilience.

This month, the VA Palo Alto Medical Center began rolling out Bitscopic’s Praedi-
Alert clinical surveillance tool, which includes a dashboard for automatically monitoring patient blood samples for COVID-19 infection. “Many infection control processes in hospitals are still done manually,” said Farshid Sedghi, Bitscopic’s chief operating officer and cofounder, “which means that problems are detected only after they occur and countless hours of manual work is done, which could have happened automatically, 24 hours a day, with the right software system.”

Then there’s the tech tool that bridges many different health care areas: barcoding. From keeping track of patients throughout their hospital stay to labeling specimens, barcoding can help manage surges in volume, such as when a pandemic arises.

Ng Kian Swan of NUHS says leveraging the new types of technology “helps us to drive efficiency, productivity, safety. Most importantly, it also provides a platform for us to upskill our fellow colleagues…it is actually preparing a future-ready workforce.”

Knowledge is power, and data of all kinds have become a powerful weapon against future crises. Capturing data from this pandemic could mean that the next one is much more easily managed. Health informatics, the clinical application of data and digital technology, is one of the fastest growing fields, according to WSP.

 article warns, “Some AI systems could also be susceptible to overfitting, meaning they’ve modeled their training data so well that they have trouble analyzing new data—which is coming constantly.…”

 And according to Wall, “Smart projects fail because they don’t get to the heart of the way that humans do things.”

The pandemic’s impact has been massive, in lives lost, services rendered, and money spent. Now, (hopefully) on the downward slope of the mountain, we can begin to act on lessons learned and incorporate the most useful into the so-called new normal. Identifying at-risk patients, screening staff and patients, distinguishing COVID-19 from other respiratory illnesses, predicting which patients will get worse, and tracking supplies are all things that can be improved and adapted for postpandemic use. They’re not just here for the pandemic, they’re here for the future.

In 1942, Isaac Asimov defined the Three Laws of Robotics, the first being: 

A robot may not injure a human being or, through inaction, allow a human being to come to harm

. Technology at its best serves us well and health care will always be people based. But technology will always have to make room for the individual, like Manan Gandhi, who just wants to help people live.

Webber EC. How COVID-19 changed technology adoption, speed and agility in health care. Cerner. June 15, 2020. Accessed April 29, 2021. 

https://www.cerner.com/perspectives/how-covid19-changed-technology-adoption-speed-and-agility-in-health-care

Schmitz J. How technology is changing healthcare, driven by the pandemic. 

. July 29, 2020. Accessed April 29, 2021. 

https://www.forbes.com/sites/forbescommunicationscouncil/2020/07/29/how-technology-is-changing-healthcare-driven-by-the-pandemic/?sh=44ee3de0361d

Expert survey series: COVID-19’s potential impact on global technology and data innovation. Atlantic Council. April 13, 2021. Accessed April 29, 2021. 

https://www.atlanticcouncil.org/blogs/geotech-cues/covid-19s-potential-impact-on-global-technology-and-data-innovation/

Some fear that hospitals will become “Robots R Us” environments, but that is unlikely. Chatbots, although useful, are poor stand-ins for in-depth, in-person conversation with a health care provider. And if COVID-19 did anything, it put a million faces to the tragedy of what it’s like to die without human contact.

Jan Dyer

Articles

Can We Ever Get Rid of C. Diff?

College Guidance Counseling: Get the COVID-19 Vaccine

High Tech in a High-Touch Environment: Keeping the Best of Both

How to Keep COVID-19 From Becoming a Health Care–Acquired Infection