Jan Dyer

Early in the COVID-19 pandemic, mysteries abounded about this ninjalike disease striking a defenseless populace seemingly out of the blue. Who was most at risk? What were the best steps for protecting the vulnerable—when those were identified? Epidemiologic data on transmission were scarce, consisting mainly of small case reports, cohort studies, and governmental reports.

 A review of 40 studies suggested 44% of COVID-19 cases worldwide were nosocomial, but many hospitals were still coming to grips with what exactly they could do to prevent spread.

As the pandemic took hold, some experts warned that rates of health care–acquired infections (HAIs) might rise because of patients with the virus being sicker, with longer lengths of stay, and other COVID-19–related factors. Over time, however, universal masking, “extreme” hand hygiene, and other intensified measures—when properly adhered to—were countering those predictions. Hospitals around the world were seeing striking drops in many HAIs.

A study at Kerman University of Medical Sciences in Iran, for instance, found the total rate of nosocomial infection for all illnesses was 3.7% during the first part of the pandemic, 20% lower than at the same time the previous year.

 A hospital in Spain saw the incidence of nosocomial Clostridioides difficile infection drop by 70% from March 11 to May 11, 2020, compared with the same time span the year before.

 In Singapore, investigators found enhanced infection prevention and control (IPC) measures had the “unintended positive consequence” of containing respiratory viral infections: Incidence shifted dramatically downward, from 9.69 cases per 10,000 patient days prepandemic to 0.83 cases.

It is not surprising that intense precautions would also reduce cases of nosocomial COVID-19. A comprehensive infection control program implemented at Brigham and Women’s Hospital in Boston, Massachusetts, in March 2020 included dedicated COVID-19 units, personal protective equipment (PPE) in accordance with Centers for Disease Control and Prevention recommendations, donning and doffing monitors, universal masking, visitor restriction, and reverse transcriptase–polymerase chain reaction (PCR) testing of symptomatic and asymptomatic patients.

 Despite the high burden of COVID-19 in the hospital, only 2 patients were identified as having HAIs, 1 of whom was likely infected by a visiting spouse before visitor restrictions and universal masking. Between March and June 2020, of 8370 patients with non-COVID-19–related hospitalizations, 11 tested positive for the virus. Only 1 of the 11 was deemed an HAI—but with no known exposures inside the hospital.

The protective precautions have become routine. At Penn State Health Milton S. Hershey Medical Center, in Pennsylvania, limited visitation, screening of all employees and visitors upon each arrival, universal mask wearing, contact tracing, hand hygiene, and equipment cleaning “are essential parts of our everyday work,” says Fibi Attia, MD, MPH, CIC, infection control coordinator, and a member of the Infection Control Today® Editorial Advisory Board. All those measures “are definitely working together to limit any exposure.”

The least, and potentially the best, of these measures is masking. According to Aaron Richterman, MD, et al in JAMA: “[M]ounting evidence supports the effectiveness of a relatively simple intervention in reducing hospital transmission of SARS-CoV-2: universal use of surgical masks by health care workers [HCWs] and patients,” even when physical distancing is not possible.

It did not take long to find out that masking was a simple but effective measure to flatten the curve of nosocomial COVID-19. From March 15 to June 6, 2020, investigators at Duke Health (a system of tertiary care academic hospitals, community hospitals, and clinics) assessed all HCWs—of 21,014—who had tested positive for the virus. Of those cases, 38% were community acquired, 22% were health care associated, and 40% had no clear source. Of note, the investigators said, 80% of the HCWs did not work in COVID-19 units.

Of the HAI cases, 70% were related to unmasked exposure to another HCW for more than 10 minutes, less than 6 feet apart; 30% were thought to be secondary (a non–COVID-19 infection) to direct care of patients who tested positive for the virus. However, only 1 week after the hospital system initiated universal mask wearing, the cumulative incidence rate of nosocomial COVID-19 dropped significantly, whereas the community-acquired cases and cases with no clear source continued to mirror the cumulative incidence rates in the communities surrounding Duke Health. At Mass General Brigham in Boston, a study involving more than 75,000 workers also found universal masking could quickly reverse the trajectory of nosocomial spread: Prior to the new rule, new infections among HCWs spiked from 0 to 21%; afterward, the positivity rate declined linearly from 14.65% to 11.46% during a 3-week period.

Similarly, results of a study at the German Heart Center in Berlin showed that measures including obligatory surgical face masks for patients and employees, SARS-CoV-2 screening for all patients, and symptom-based testing for employees led to an overall 0.4% prevalence of positive tests (5 of 1128 tests). The incidence of new infections was 0.5%. No nosocomial infections were found, despite a mean number of 14.8 in-hospital contacts.10 Notably, the investigators said, during the observation period the number of positive SARS-CoV-2 tests sharply increased in Germany.

Nonetheless, “[m]y experience tells me that nosocomial COVID-19 is rampant,” Manoj Jain, MD, an infectious diseases physician and contributing health writer for the Washington Post, wrote in a January 2021 op-ed, “and hospitals are not sounding the alarm.”

His concern was raised about a patient who died of nosocomial COVID-19. Jain was perplexed—how could the virus have reached the patient? It was not lack of handwashing. It was unlikely the virus had come from surfaces; the hospital’s environmental services staff had been diligent. All the family members who had visited the patient had tested negative.

That was not the only patient either. Jain said in his op-ed that he had seen 5 other cases of nosocomial COVID-19 in the previous 4 weeks.

Were the staff the reason? Jain said he “armored” himself with N95 masks covered with a surgical mask and a face shield, plastic gown, and gloves. Still, one of his colleagues, who was taking similar precautions, tested positive. Again, there was no discernable cause. However, Jain noted, in the doctors’ lounge food is served, and health care workers frequently gather, “often taking off their masks to share COVID-19 war stories.”

When outbreaks have been reported in hospitals that are using universal masking, unmasked exposure to other health care workers is often the cause. Transmissions have been traced to break rooms and cafeterias. Last November, more than 900 Mayo Clinic staff contracted COVID-19 in 2 weeks.

Amy Williams, MD, executive dean of clinical practice, in a briefing said 93% of staff contracted the virus in the community. Most of those who contracted it at work had been eating in a break room with a mask off. She later updated that to say they could have been exposed while eating with a mask off in campus cafeterias.

One of the ways to prevent these “breaches in now-routine preventive measures,” Richterman et al wrote in JAMA, would be to provide adequate, well-ventilated and, ideally, dedicated space for breaks and meal times, perhaps staggering times to minimize contact and conversation.7

The unprecedented demands of this pandemic call for unprecedented responses. Abbas et al, in their literature review, found that many hospitals are breaking with traditional management of respiratory viral illness, particularly nosocomial outbreaks. In a “paradigm shift,” they said, hospitals are expanding testing criteria: testing asymptomatic patients/residents and health care workers, as well as conducting serial testing or repeat point-prevalence surveys. When Brigham and Women’s instituted liberal universal testing on admission, the investigators observed fewer late-onset cases (diagnoses on hospital day 3 or later).

At 2 Minnesota skilled nursing facilities (SNFs), serial testing identified COVID-19 cases among 64% of residents and 33% of health care workers. Following up with genetic sequencing revealed facility-specific clustering of viral genomes from HCW and resident specimens, suggesting intrafacility transmission.

However, such information is not useful by itself: It needs to be supported by action. Although transmission was reduced by early identification of asymptomatic infections and prompt implementation of mitigation efforts, there were challenges. The Minnesota Long-Term Care COVID-19 Response Group found that, in the SNFs, continued SARS-CoV-2 transmission was “potentially facilitated” by “low baseline knowledge of and experience with [IPC] and PPE use,” delays of up to 12 days in receiving half of the HCW test results at one facility, and incomplete HCW participation.

The Minnesota study is an example of how none of the measures is entirely effective on its own (although masking comes close). For instance, serial testing, investigators said, needs to be done until no new cases are detected after 14 days—along with IPC strengthening. Testing should be accompanied by “IPC education, flexible medical leave, and PPE resources targeted to this at-risk workforce.”

Investigators at Changi General Hospital, Singapore, developed a prediction model to identify patients at low risk for COVID-19 to better guide resource allocation.

 They said that their risk prediction score would have obviated the need for isolation and testing in up to 41% of patients with pneumonia and acute respiratory infection. Missed cases of COVID-19 are “expected trade-offs” of their risk stratification strategy, they conceded, but they pointed to “reassuring reports” that basic infection control measures (eg, masks, hand hygiene) are effective in minimizing the risks of nosocomial spread.

Crucially, the precautions need to be carried out faithfully. As more viral strains evolve and people relax their vigilance because of the vaccines, more waves of the pandemic are only too possible. Can all this experience benefit hospitals and their workers in a future wave of this pandemic—or in a future pandemic?

Rhee et al said that their findings at Brigham and Women’s suggest that “robust and rigorous infection control practices” can minimize the risk of nosocomial spread of COVID-19, and “provide reassurance” as some health care systems reopen services and others continue to face surges.6

The basics can also be supplemented with more sophisticated tools. When there was no routine SARS-CoV-2 screening of asymptomatic HCWs, 5 hospitals in the United Kingdom assigned different locations within the hospitals as either green (virus negative) or red (positive) zones, combined with staff bubbles. That tactic helped keep nosocomial infections down. But as patients tested positive even after spending prolonged periods of time in green areas, the investigators realized that there were unrecognized transmission events between the 2 areas.

They turned to viral genome sequencing as a realistic possibility to track and identify root causes of nosocomial transmissions. They sequenced SARS-CoV-2 genomes for patients and HCWs, obtaining 173 high-quality genomes. They then integrated patient movement and staff location data into the analysis to understand spatial and temporal dynamics of transmission. They identified 8 patient contact clusters with significantly increased similarity in genomic variants, compared with nonclustered samples.

The investigators found that incorporating the location of the HCWs identified additional links in transmission pathways and enhanced identification of outbreak clusters. Looking forward, they said, adopting genomic approaches in real time (eg, within 48 hours) along with consideration of patient movement data sets will enhance rapid identification of linked nosocomial SARS-CoV-2 infections. Their approach, they suggested, could optimize infection control management strategies, lead to targeted interventions, and ultimately prevent avoidable harm.

In his op-ed, Jain said he told his regional Memphis and Shelby County COVID-19 Joint Task Force, consisting of hospital executives and mayors, that hospital staff need to be regularly tested through “the affordable technique of pooling up to 20 test samples.”

 Such PCR gold-standard testing, he said, would amount to the cost of a cup of coffee and a few doughnuts. Without testing, he said, “we are flying blind.”

Like other HAIs, COVID-19 can be prevented, Jain said: “Hospitals should be places where patients come to get better, not sicker; where diseases are treated, not acquired.”

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

Abbas M, Robalo Nunes T, Martischang R., et al

 Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both patients and healthcare workers. 

 2021;10(1):7. doi:10.1186/s13756-020-00875-7

Zhou Q, Gao Y, Wang X, et al; COVID-19 Evidence and Recommendations Working Group. Nosocomial infections among patients with COVID-19, SARS and MERS: a rapid review and meta-analysis. 

Jabarpour M, Dehghan M, Afsharipour G, et al. The impact of COVID-19 outbreak on nosocomial infection rate: a case of Iran. 

Ponce-Alonso M, Sáez de la Fuente J, Rincón-Carlavilla A, et al. Impact of the coronavirus disease 2019 (COVID-19) pandemic on nosocomial 

Published online September 8, 2020. doi:10.1017/ice.2020.454

Wee LEI, Conceicao EP, Tan JY, et al. Unintended consequences of infection prevention and control measures during COVID-19 pandemic. 

. 2021;49(4):469-477. doi:10.1016/j.ajic.2020.10.019

Rhee C, Baker M, Vaidya V, et al; CDC Prevention Epicenters Program. Incidence of nosocomial COVID-19 in patients hospitalized at a large US academic medical center. 

 2020;3(9):e2020498. doi:10.1001/jamanetworkopen.2020.20498

Richterman A, Meyerowitz EA, Cevik M. Hospital-acquired SARS-CoV-2 infection: lessons for public health. 

 Published online November 13, 2020. doi:10.1001/jama.2020.21399

Seidelman JL, Lewis SS, Advani SD, et al. Universal masking is an effective strategy to flatten the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) healthcare worker epidemiologic curve. 

. 2020;41(12):1466-1467. doi:10.1017/ice.2020.313

Wang X, Ferro EG, Zhou G, Hashimoto D, Bhatt DL. Association between universal masking in a health care system and SARS-CoV-2 positivity among health care workers. 

 2020;324(7):703-704. doi:10.1001/jama.2020.12897

Schöppenthau D, Weiß KJ, Estepa-Martinez M, et al. Preventing SARS-CoV-2 in-hospital infections in cardiovascular patients and medical staff: an observational study from the German Heart Center Berlin. 

. 2021;7:616648. doi:10.3389/fmed.2020.616648

Jain M. Patients are getting infected with covid-19 in the hospital. It happened to one of mine and killed him. 

. January 21, 2021. Accessed January 28, 2021. 

https://www.washingtonpost.com/health/acquiring-covid-19-in-the-hospital/2020/12/31/8cac8b82-3a50-11eb-9276-ae0ca72729be_story.html

Scott PJ. 900 on Mayo Clinic staff have contracted coronavirus in last two weeks. 

. November 17, 2020. Updated November 18, 2020. 

https://www.twincities.com/2020/11/17/over-900-mayo-staff-have-gotten-covid-19-in-past-two-weeks/

Taylor J, Carter RJ, Lehnertz N, et al; Minnesota Long-Term Care COVID-19 Response Group. Serial testing for SARS-CoV-2 and virus whole genome sequencing inform infection risk at two skilled nursing facilities with COVID-19 outbreaks — Minnesota, April-June 2020. 

 2020;69(37):1288-1295. doi:10.15585/mmwr.mm6937a3

A risk prediction score to identify patients at low risk for COVID-19 infection

 Published online March 12, 2021. doi:10.11622/smedj.2021019

Ellingford JM, George R, McDermott JH, et al. Genomic and healthcare dynamics of nosocomial SARS-CoV-2 transmission. 

Articles

When outbreaks have been reported in hospitals that are using universal masking, unmasked exposure to other health care workers is often the cause. Transmissions have been traced to break rooms and cafeterias.

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

There are dozens of sexually transmitted infections and diseases (STIs/STDs), running the gamut from A for asymptomatic chlamydia to Z for Zika. Here’s a poser. If you could magically erase any sexually transmitted infection or disease instantly, which one would you choose?

Michelle Collins-Ogle, MD, who spent 20 years as medical director of a dedicated HIV clinic, let out a little groan at having to decide, but took only a moment: “gonorrhea.”

That was also the top choice for Ina Park, MD, associate professor at University of California San Francisco School of Medicine; medical director of the California Prevention Training Center; and author of Strange Bedfellows: Adventures in the Science, History, and Surprising Secrets of STDs.

And, “gonorrhea,” says David Aronoff, MD, director of the Division of Infectious Diseases in the Department of Medicine at Vanderbilt University Medical Center.

On any given day in 2018, according to the Centers for Disease Control and Prevention (CDC), 1 in 5 individuals had an STI. Gonorrhea actually comes a low fifth on the CDC’s list of STI prevalence, but the number of cases had recently jumped 63% in only 4 years.1

April happens to be the CDC’s STD Awareness Month2 and the reason these infectious disease experts worry most about gonorrhea is primarily because of the fear that it’s becoming resistant to all antibiotics. “I need gonorrhea to go away before we won’t be able to treat it,” Collins-Ogle says. “So if I could wipe it off the face of the earth, I would.”

Aronoff classes it with those infections that “we thought we had control over—but then lost control. Gonorrhea is increasingly hard to treat, and increasingly easy to spread.”

A photomicrograph of a gram-stained specimen demonstrating the presence of gram-negative diplococci, indicative of gonorrhea infection.

We may be running out of time to stop it. “We’re down to 1 class of antibiotics left to treat it, and while there are a few others in the pipeline being studied in clinical trials, none is quite ready for prime time,” Park explains. In December 2020, she notes, the CDC modified its guidelines, which used to recommend dual treatment with ceftriaxone and azithromycin as first-line therapy for gonorrhea. Due to concerns over increasing antibiotic-resistance as well as stewardship, azithromycin was removed, and the dose of ceftriaxone was doubled.

“In the few cases of multidrug-resistant gonorrhea that failed all conventional therapies,” Park says, “patients had to be hospitalized and treated with broad spectrum IV antibiotics such as ertapenem. We really don’t want to have to resort to that for an infection as common as gonorrhea.”

Collins-Ogle, who’s now an assistant professor of pediatric infectious disease at Albert Einstein College of Medicine and an attending pediatrician for infectious diseases and adolescent medicine at Children’s Hospital at Montefiore, has a second reason for wanting to rid the world of gonorrhea: what happens when it’s untreated. “Gonorrhea is no joke,” she says. “It causes really harmful sequelae when it’s not treated. And complications of gonorrhea are more serious in women who aren’t treated. Women get [pelvic inflammatory disease] very easily. They can have scarring, they can have sterility. Genital gonococcal ophthalmia in newborns. It’s just a horrible bacterium.”

With gonorrhea gone, what would rise to No. 2 on the list?

After a near disappearance in the US in 1999-2000, Park says, “Syphilis has come back with a vengeance, and one of the biggest concerns I have is over the resurgence of congenital syphilis.” Indeed, according to the CDC’s 2018 STD surveillance report, cases of primary and secondary syphilis rose 71% between 2014 and 2018, and congenital syphilis cases increased dramatically, by 185%.1

“Syphilis, to me, is the most fascinating STI we have,” says Collins-Ogle. “It sort of quieted down, but then when its resurgence occurred, it occurred in a demographic we hadn’t seen before. The last time we saw syphilis rear its head it was in the ’80s, with pregnant women and newborns born to mothers who weren’t treated. Now we’re seeing it in men who have sex with men (MSM), particularly young men of color.”

This resurgence is completely different than in the 1980s to 1990s, she says, in part because of changes in screening. “I would say that because we had the resurgence of syphilis then, [obstetrician-gynecologists] did a better job of screening women for syphilis. And we all made sure that babies were tested as well, so I think we did a better job of screening, diagnosing, and treating in that demographic. But we didn’t see it coming when it happened in MSM.”

Screening is better now. “Now,” she says, “if you get diagnosed with HIV, you get screened for everything else. Or if you get an STI, you get syphilis or gonorrhea, chlamydia, you automatically—well, we don’t do a good job universally—but you should be screened for HIV.”

However, “I just saw a young guy a couple weeks ago who had gone to an emergency [department] with symptoms consistent with an STI. He got tested for STIs but he didn’t get an HIV test. So he came to our center and asked for an HIV test. We’re still not doing a good job of making those connections in that demographic.”

The problem is, we’re also still not doing a great job of emphasizing prevention, Collins-Ogle says. “Our health care system and education system lag behind reality and what’s happening in the real world. We lag in our understanding of even how to speak to the various demographics and how to educate them. It’s all of that, kind of wrapped into why we continue to see these epidemics the way we do.”

And the right messages aren’t getting to the right people. For instance, 30 years or so after the worst of the AIDS epidemic, “We still have a lack of understanding about the role of condom use,” Collins-Ogle says. “I keep telling people, if only they’d use condoms, we wouldn’t have this problem with HIV.”

Moreover, the messages aren’t targeted enough. “We’re taking one message and assuming that it’s well received and understood among all demographics—and it’s not. For example, for men in their 50s and 60s, their understanding of condom use was to prevent pregnancy. For women who are older, the purpose for having condoms was to prevent pregnancy, not STIs. And now we’re trying to tell young people that condoms are used to prevent STIs and can prevent pregnancies.” In other words, we’re trying to make one message fit all circumstances.

Age, culture, and education all make a difference. The issue, Collins-Ogle emphasizes, is that we aren’t talking about sex, and we aren’t talking about it in a comprehensive way, “to reach all the different ways people have sex. There’s no sex [education] for MSM, there’s no sex ed for lesbians, gay women, there’s no sex ed for bisexual people.” Depending on where you live, you’re going to get a different message about how infections are spread and how to prevent them, she says. “I find out from my young male patients: They don’t know how to use a condom! Nobody ever showed them how! I’m not kidding you.”

STI/STDs are a threat to all humans, but nearly half of new STIs in 2018 were in the age group of 15 to 24 years.1 “We’ve failed at making sure we’ve adequately prepared these kids to be safe,” Collins-Ogle says. “They don’t know, they’re only going by what they’re told by other people or what they’ve read online.”

One method of reaching them might be to use the social media they’re most comfortable with, as investigators in a 2019 study did.3 They found that MSM who used sex-seeking social media platforms were more likely to share HIV information than those who were mostly on generic platforms. This echoes what Collins-Ogle is fervent about: People are more willing to ask for help and receive help in a nonjudgmental, accepting environment.

Even with effective screening, treatment, and education, STIs can be like movie villains who just won’t die, who change form, and who keep coming back to wreak havoc. There are some bright spots, though. Syphilis is still very susceptible to penicillin, Collins-Ogle points out. And Park says, “We already have a fantastic vaccine against [human papillomavirus].” What’s more, she adds, “We’ve managed to nearly eliminate mother-to-child transmission of HIV in the [United States] through aggressive screening and treatment. But we also need to mobilize around reducing morbidity and mortality around congenital syphilis, [which] is preventable with screening and prompt treatment during pregnancy.”

Several drugs for gonorrhea have been studied, or are being studied in clinical trials, Park says, including zoliflodacin, closthioamide, gepotidacin, and solithromycin. “There’s also a very interesting study going on in the United States and Thailand looking at the meningococcal group B vaccine (which prevents against Neisseria meningitidis) that induces antibodies that may also protect against Neisseria gonorrhoeae. These are, however, still earlier-stage clinical trials.”

But why on earth can’t we get a vaccine for any of these infections and diseases? In short, “it’s complicated,” says Aronoff. “To get vaccines into trial you need unlimited money, interest in the disease, participants for the trials—and lots of disease.” All of those components were in place for coronavirus disease 2019, which is why vaccines could zip through (relatively speaking) to public distribution.

Also, he notes, “Some diseases lend themselves to vaccines. It’s incredibly hard to arm the immune system against HIV, malaria, tuberculosis, because they all have a different relationship to the immune system than do diseases that we’ve been able to develop vaccines for, like measles and smallpox. A complicated virus like HIV, for instance, integrates into the DNA.”

Which probably explains why Operation Warp Speed has not yet been translated into STI/STD vaccine research. “Operation Warp Speed had a $12 billion-plus price tag,” Park says. “If that much was poured into STI vaccine research, I’m sure we’d be much further along with various STI vaccine candidates than we currently are.”

Effective treatments may be on the way, but in the meantime, good reliable data are critical, especially when infections attack in packs. “Back in the ’80s, we didn’t have a direct correlation between STIs and AIDS,” says Collins-Ogle. “Now we know having syphilis predisposes you to HIV acquisition. We also know having herpes simplex virus [type] 2 predisposes you to HIV. When we started seeing syphilis in gay men it wasn’t necessarily equated to HIV. At that time, they weren’t going hand in hand. Now we definitely know they’re a couple. I think that may be why syphilis caught us off guard with men and HIV. We didn’t have the data to make that link.”

The resurgent STIs seem to be stronger than before, but in the last several years, the CDC has “embraced bigger, faster, stronger countermeasures” like the Sexually Transmitted Disease Surveillance Network (SSuN).4

SSuN, a collaboration of state, county, and city health department sentinel sites, allows health care providers to access and use updated, specific data to monitor and track rates for several STDs simultaneously. The “timely data snapshots,” as the CDC calls them, give users a comparison group for trends; if gonorrhea rates go up in one location, for instance, a public health expert can use the SSuN data to determine whether it’s a local or broader trend.

The surveillance system integrates data across multiple diseases. For instance, SSuN data offer an extensive breakdown of HIV co-infection rates among people diagnosed with gonorrhea or seeking care in STD clinics. Moreover, SSuN provides complete demographic, clinical, and behavioral information, helping clinicians and investigators monitor and combat emerging antibiotic resistance.

The ongoing fight to eradicate (or at least prevent, or at the very least control) STIs is a little reminiscent of the story of poor Sisyphus, doomed to push a massive rock uphill, whereupon it would roll back down again…and again, eternally. But there are successes, both in treatments and encouraging behavior change. As intractable as gonorrhea and syphilis can be, targeted public health campaigns can help.

In Alaska, for instance, cases of early syphilis had spiked from 24 to 97 between 2017 and 2018—a 300% increase. The Alaska Division of Public Health (ADHP) teamed up with the CDC’s Division of STD Prevention to build a relationship with the community, in particular with MSM. ADPH organized testing and community outreach events, and by January 2019, more than 300 people had been screened for syphilis.5

And Hawaii is taking a layered approach. The state is a critical site for monitoring antibiotic-resistant gonorrhea (resistance historically emerges in the East and moves into the mainland United States through Hawaii). Participating in the Gonococcal Isolate Surveillance Project to collect samples of N gonorrhoeae, Hawaii’s STD clinics collect a higher percentage of samples for monitoring resistance than in any other state. When test results from 7 patients at the Hawaii State Department of Health’s STD clinic showed possible resistance to both drugs in the last recommended treatment, local public health professionals acted quickly, handing off the information to the “next link in the chain,” disease intervention specialists (DIS). The DIS made sure the 7 patients were cured by the treatment they received, and also began contact tracing to prevent spread of the potentially resistant strain. Within a matter of weeks, all but 1 of the patients were tested (and retreated in 1 case).4

The Sisyphus tale is usually considered a metaphor for futility. Still, one theory holds that it’s a metaphor for the sun rising and setting. And rising again. Certainly STIs can be relentless. But so is science. By winning battle after battle, we may win the war.

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

Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2018. Accessed February 28, 2021. https://www.cdc.gov/std/stats18/default.htm

Centers for Disease Control and Prevention. STD awareness month; CDC digital toolkit. Accessed March 2, 2021. https://www.cdc.gov/std/sam/STDAwarenessMonthToolkit.pdf

Durvasula M, Pan SW, Ong JJ, et al. Enhancing public health messaging: Discrete-choice experiment evidence on the design of HIV testing messages in China. 

. 2019;39(5):568-582. doi: 10.1177/0272989X19859344

Centers for Disease Control and Prevention. Shedding light on disease in the US: how STD prevention programs benefit from strong data. Accessed February 28, 2021. https://www.cdc.gov/std/products/success/SSuN-Success-Story_FINAL.pdf

Centers for Disease Control and Prevention. Sexually transmitted diseases; STD prevention success stories. Accessed February 28, 2021. 

https://www.cdc.gov/std/products/success/default.htm

Even with effective screening, treatment, and education, STIs can be like movie villains who just won’t die, who change form, and who keep coming back to wreak havoc. They’re relentless, but so is science.

The STDs Infectious Disease Experts Hate Most

In a way, SARS-CoV-2 resembled science fiction’s hypothetical dark matter: Its existence could be inferred but couldn’t be clearly defined—until it appeared. In other words, coronavirus disease 2019 (COVID-19) may have taken a lot of people by surprise, but its possibility wasn’t in doubt. As Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), and David Morens, MD, NIAID’s senior scientific adviser, write, this has been “but the latest example of an unexpected, novel, and devastating pandemic disease…[w]e have entered a pandemic era.”1

But while coronaviruses aren’t new to us, COVID-19 shifted our recent experiences with SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) into hyperspeed. “We weren’t prepared for it. It put us on our heels,” David Aronoff, MD, tells Infection Control Today®. He speaks to the way infectious disease experts live now—always on the qui vive for the next pathogenic threat. “We’re constantly concerned that something will be around the corner. And we’re living on a street that’s all corners.”

Aronoff is director of the Division of Infectious Diseases, Department of Medicine, and professor and Addison B. Scoville Jr. Chair in Medicine at Vanderbilt University Medical Center. He has a lot to do in his regular jobs, but like his colleagues in infectious disease, he pretty much dropped everything else to concentrate on COVID-19—“to just lean into it,” he says. That includes, for instance, giving 2 lectures on COVID-19 one day, and 3 the next.

But that doesn’t mean that he, or others in the field, have abandoned preparations for other pathogenic threats. There’s always something else on the radar. In fact, “we haven’t gone a generation without emerging threats,” Aronoff says. “It characterizes the profession that we’re confronted by them on a regular basis.”

With the current pandemic running everyone in health care ragged, this may not be the best time to ask, “What’s next?” But…what’s next? What pathogen(s) not called COVID-19 should we be most concerned about? And where will it (they) be coming from?

On Aronoff’s list of concerns: Diseases that might not cause pandemics, but cause small epidemics. “I get particularly nervous about antibiotic-resistant infections that we thought we had control over, but then lost control of. Gonorrhea is a good example. It’s increasingly hard to treat with antibiotics, and increasingly easy to spread.”

Priya Nori, MD, also puts antibiotic-resistant infections at the top of her list. Nori is associate professor of medicine (infectious diseases) and of orthopedics at Albert Einstein College of Medicine and medical director of the Antimicrobial Stewardship Program at Montefiore Health System. She also co-developed the Infectious Diseases Society of America and the Centers for Disease Control and Prevention (CDC)’s COVID-19 Real-Time Learning Network2 resource page for stewardship during COVID-19. This includes up-to-date information from infectious diseases physicians, pharmacists, and infection preventionists (IPs) on personal protective equipment, vaccines, therapeutics, stewardship—“anything you can think of related to the pandemic,” she says.

As she speaks on a Zoom call, enormous COVID-19 molecules loom over her shoulders, a sad metaphor for these days (“I put the background up for a med student lecture weeks ago, and now I don’t know how to take it down,” she says).

“If we think of it in the immediate COVID-19 aftermath, we’re greatly concerned that we’ll see emergence of lots of multidrug-resistant bacteria and fungi,” Nori says. “And these are not novel pathogens necessarily, these are things we had before but that were starting to get lots of attention the past few years before COVID-19 because they had become so widespread. These are the most concerning things, I think, to the folks [who] practice infection prevention and ID [infectious disease]. As soon as COVID-19 starts calming down because of control measures and vaccinations, I think we’re going to unmask all these other things that COVID-19 left in its wake.”

One reason, she says, is that there was a lot of excess antibiotic use, especially in the early stages of the pandemic, which has probably abated now that people are more aware of how the disease works and its long-term effects. “But we’re worried because lots of patients, if they’re fortunate enough to survive COVID-19, unfortunately end up in a sort of chronically medicalized state. There’s a whole new population of long-term-care residents who are now bedbound, plugged in to lots of devices, meaning catheters, tracheostomy tubes, PEG [percutaneous endoscopic gastrostomy] tubes, urinary catheters. This is exactly the type of host who becomes colonized with multidrug-resistant pathogens, which can spread within health care facilities, like long-term care and acute care.”

One of the things that CDC infectious disease experts have found to be a problem, possibly re-emergent due to the COVID-19 pandemic, is carbapenem-resistant Acinetobacter, Nori says. “Any kind of carbapenem-resistant Enterobacteriaceae, especially the extensively drug-resistant ones, like New Delhi metallo-beta-lactamase–producing Enterobacteriaceae, these are definitely the things to watch for.”

Moreover, people who have been hospitalized with COVID-19 are particularly vulnerable to all the “old” hospital-acquired infections. They may have survived COVID-19, but they survive with substantial damage, immunologically and to organs, and then pick up other infections along the way.

However, in some interesting ways, COVID-19 may actually have contributed to the benefits side of the ratio in hospitals. Nori says, “Because of the really heightened control measures for COVID-19 in hospitals, somehow Clostridioides difficile has not played a role in this as we initially thought. Part of that is that we were not testing as much for C diff, but even if you correct for that, it seems like C diff has maybe not been as much of an issue as some of these other pathogens.”

Does that good thing balance out some of the bad things? “Potentially,” Nori says. “But then you worry that you’re just sort of squeezing the balloon, and that one thing gets better but at the expense of another thing. So, it’s probably a little too early to celebrate. Maybe 3 years down the road, if it seems this really mitigated that issue, then I think it is definitely a win.”

In addition to home-grown pathogens, we have to worry about others that come from far-flung regions. Both Aronoff and Nori point to what some of our deadliest contagions have had in common: The viruses were transferred via air. “If you look back over the history of the world,” Nori says, “it’s really respiratory viral pandemics that have been the ones that have infected and killed people across borders and have gone on and on for many years and sometimes revisit.

“As far as long-term concerns,” she adds, “definitely what’s likely to lead to a pandemic state is another respiratory viral pathogen, without a doubt, because these are the things that spread most quickly, that are most transmissible between human beings, and have extensively high viral loads that make it very easy to spread between individuals.”

What’s more, it’s very likely, she predicts, that the next pandemic could be due to a respiratory viral pathogen that hasn’t been seen before, because of some kind of mixing of genetic elements from different species. The species-mixing element concerns Aronoff as well: As we’ve discovered, many viruses that live in animals can jump to humans.

However, the next big threat could also very well be an old one. In many ways, the world has been becoming more hospitable to pathogens we thought we’d seen the end of. And it’s hard to fight the 2 main things that drive the threat, Aronoff says: evolution and opportunism. Pathogens like cholera, diphtheria, tuberculosis (TB), and malaria take advantage of people gathering or living in crowded spaces, people with already poor health.

“Infectious disease is a kind of barometer for other causes, geopolitical, social disturbances or inequities, even political,” says Aronoff. “TB is a great example. It hits on all cylinders: crowding, lack of effective vaccines, malnutrition, poverty. It’s a disease that’s been around forever, but scares us in ID as a newly forming threat. It’s both a looming and perennial threat.”

On the other hand, Nori says, “That’s what makes this whole area of study so fascinating. It’s the convergence of the climate crisis, politics, conflicts…. Infectious diseases that we previously eradicated, or things that really should be under control in the year 2021, like cholera, diphtheria, those are reemerging because of regional conflicts.”

Another factor, climate change, is also driving changes in infectious disease. As animals and people migrate, searching for a more livable environment, we see vector-borne or insect-borne diseases shift with them. “There may not be emerging or entirely new diseases, but arrival in new areas,” Aronoff says.

Now add in human mobility (as in global travel), and it’s a recipe for another worldwide catastrophe. The reality is that plagues have been a part of human life since hunter-gatherer days—it’s just that nowadays the diseases get around the world much faster. It took the Black Plague roughly 2 years to travel from Italy to Scandinavia. It took SARS-CoV-2 about 4 months to travel from China to Seattle, Washington, to New York, New York. Dengue, chikungunya, Zika—they’re all on the move. Zika, for one, started out in a relatively small area of the world, and is now found in 86 countries and territories.3

It all sounds ominous, but Aronoff is reassuring, in a restrained sort of way. We might not have been prepared for COVID-19, he says, “but we’ve learned lessons about how to deal with other pathogens. It’s possible to be frozen in anxiety and fear about what’s next, but this is what we’re trained to do. We’re trained to look for emerging threats and figure out how to deal with them.”

What can be done to make the next pandemic—and there will be one—less traumatic? “We need more,” Nori says. “We need more advocacy, we need more resources diverted toward really bolstering very strong IP programs in hospitals and long-term care. The decisions we make, the policies we put into place, they’re impacting the entire system, and not just the one patient at a time. I hope that resources are allocated accordingly after all this, whereby it’s a more proactive approach, rather than trying to fix a problem after it’s too late. If you really invest in that workforce, the ones leading prevention and patient safety, then collateral damage to the system won’t be nearly as bad.

“Health leaders recognize it, definitely, now. They see where the holes are. Unfortunately, where hospitals find themselves now in terms of the bottom line, that type of resources investment is probably not going to be possible for a long time. What’s awesome, though, is that the new CDC director [Rochelle Walensky, MD, MPH,] is an infectious disease physician who practiced medicine. She gets it. She gets what we all do, and I think once the dust settles on all this, she’s going to be a tremendous advocate for IPs.”

As we scrounge for silver linings to the COVID-19 cloud, one might be the growing recognition of how crucial the IP job is. “It’s certainly been a really interesting year for our discipline,” Nori says. “Finally, I think people understand what we try to do on a day-to-day basis. Infection prevention has really come into the forefront.”

In fact, given all that’s been going on, and all that could be going on, Nori thinks it’s time for a loud shout-out to IPs. “I want to advocate for our people. They’re holding this whole thing together. And by extension, infectious disease physicians. We hold the fort. We’re the glue. We keep the hospital running, make sure elective surgeries can still happen. We continue to think about these things when everybody else goes to sleep at night.

“If this country, the world, successfully emerge from this whole crisis…thank your neighborhood IP, basically.” She chuckles. “Give ’em a hug and kiss. Well, maybe not a kiss.”

When the world gets back to some kind of normal, maybe it will include some positive change coming out of this health crisis. In the meantime, to avoid turning the world into one huge disaster movie, Aronoff warns, “It’s really important that we keep our head in the game.”

“We remain at risk for the foreseeable future,” say both Fauci and Morens. “COVID-19 is among the most vivid wake-up calls in over a century. It should force us to begin to think in earnest and collectively about living in more thoughtful and creative harmony with nature, even as we plan for nature’s inevitable, and always unexpected, surprises.”

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

Morens DM, Fauci AS. Emerging pandemic diseases: How we got to COVID-19. 

 2020;182(5):1077-1092. doi:10.1016/j.cell.2020.08.021

COVID-19 real-time learning network. Infectious Diseases Society of America and Centers for Disease Control and Prevention. Accessed February 4, 2021. https://www.idsociety.org/covid-19-real-time-learning-network/

Zika Virus. World Health Organization. July 20, 2018. Accessed February 24, 2021. https://www.who.int/news-room/fact-sheets/detail/zika-virus

This may not be the best time to ask, “What’s next?” But…what’s next? What pathogen(s) not called COVID-19 should we be most concerned about? And where will it (they) be coming from?

Ready for the Next Pandemic? (Spoiler Alert: It’s Coming)

A clinician walks out of a patient’s room. Seconds tick by. The clinician takes a bit too long to clean his hands. “Please sanitize,” a calm voice says. It’s coming from his belt, apparently.

Actually, it’s coming from the badge attached to the belt. The badge reel contains Bluetooth technology, which communicates with sensors affixed to soap and sanitizer dispensers parked in various places around the patient care area.

If hospital administrators could have 1 wish, it might be to have 100% adherence with hand hygiene protocols. So, they are doing everything they can to encourage adherence, which is particularly critical now when people (including 3142 health care workers as of January 7, 2021) are still dying of coronavirus disease 2019 (COVID-19).

Electronic monitoring, sensors, and voice prompts aren’t new, and the technology keeps evolving. The Clean Hands–Safe Hands system allows users to customize the audio file reminder with their preferred voice and content, such as an infection preventionist (IP) or a child.

Personalized touches like that are born of experience. Hospital experts know that monitoring alone doesn’t change behavior. In fact, technology alone isn’t always the answer either. Some of the most effective systems are a hybrid of the latest technology and traditional methods such as rewards and recognition.

Take the solutions they came up with at Sentara Healthcare, a not-for-profit integrated health care system based in Norfolk, Virginia. With 12 hospitals, 4 medical groups, and more than 30,000 employees, it’s Virginia’s largest health care system. Nearly 10 years ago, after a large group of health care professionals there did some brainstorming about best hand hygiene practices, Sentara hired QualPro, a quality control consultancy, to test and analyze 21 interventions. Eventually, Sentara decided on interventions that included computer screen savers encouraging hand hygiene and awarding Hero of the Month titles to employees with high adherence rates. Other low-tech interventions included red stop signs to remind staff to wash their hands and random quizzes.

They didn’t stop there. Sentara’s adherence rates “are generally in the 90s, but ‘secret shopper’ audits show lower adherence that varies,” says Linda Estep, manager of infection prevention and control. “This is driving the push for electronic auditing that captures all opportunities we set up, and measures adherence more widely and accurately. Our manual audits are time-consuming and may not cover all shifts consistently. Currently, we’re reviewing electronic hand hygiene monitoring to expand our ability to capture a wider picture of adherence across all shifts.”

In fact, methods such as secret shoppers have underscored the need for more advanced methods of monitoring adherence. Study findings have shown that direct observation captures only a small percentage of all events. What’s more, it can massively overstate actual adherence.

Sentara’s ongoing hand hygiene campaigns are very successful, Estep says. “We update our approach regularly and we pay careful attention to our rates, as well as what we see when rounding on patient care units.” Keeping the message fresh is important, she notes.

Sentara not only has a top-down approach led by divisional leaders, but also peer-coaching efforts that address and overcome the “authority” gradient. “Sentara has a solid, long-standing culture that infection prevention is everyone’s job,” Estep says.

That means getting everyone on board. One of Sentara’s most successful campaigns is All Hands On Deck (AHOD). AHOD is Sentara’s code word to remind staff they forgot to clean their hands when required. “It’s a fun way to deliver the reminder,” Estep remarks. Leaders also model the correct response: Thank the person for the reminder and immediately sanitize hands. “Negative responses prevent our more shy staff from stepping up to coach,” Estep says. “We’re all responsible for creating a culture that promotes coaching.”

The Johns Hopkins Hospital in Baltimore, Maryland, has also found that the personal touch helps keep an adherence program from running out of steam. The hospital doubled rates of adherence with hand hygiene protocols between 2007 and 2008, and increased adherence again by 27% between 2008 and 2009.

 How? With a hospital-wide communication and education campaign called WIPES:

Precautions use (eg, gowns, gloves, and masks)

Hanan J. Aboumatar, MD, MPH, a family practitioner focusing on behavior change and an assistant professor at Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, and Polly Trexler, MS, CIC, director of operations for the Department of Hospital Epidemiology and Infection Control at The Johns Hopkins Hospital, started the program “because there was a lot of work to do.” They spent about a year planning, looking at behavior, and researching how to change it. They used focus groups with hospital staff and leaders to understand the issues and which behavior models to support.

The WIPES project included the usual steps of putting up posters and hosting sessions about the importance of using sanitizers. “The program helped increase adherence significantly,” says Trexler. “Then we stalled for a while. People were lagging behind. So, about 5 years into the project we added [the component of] direct feedback. We hired someone in addition to secret shoppers to address those employees who were a little more resistant to change.”

A successful program includes accountability, she believes, referring to “a new buzzword: Just Culture.” That is, applying discipline in a fair way to be sure staff understand expectations. But it’s also important to make it possible for them to adhere easily, for example, by having dispensers everywhere. “We set expectations to clean hands on entry and exit, changing the behavior of only cleaning on entry and then thinking ‘I didn’t touch anything’ so not cleaning on exit,” Trexler says. “We did it on purpose to create habits, and to make it simple to keep the new habits.”

The accountability model also includes escalating consequences for nonadherence, beginning with a note to the employee, a note to the supervisor, then a talk with the supervisor, and up the chain of command. Nonadherence after 6 observations in the year means termination. But “we never go over 3 observations,” Trexler says.

The traditional methods—positive reinforcement, educational posters, reminders, rewards, recognition, secret shoppers—help keep the day-to-day level of adherence up, but technological innovations can make it easier for administrators to spot and calibrate for weak areas. An online reporting tool allows managers to collect data entered into a phone or iPad. “It’s real-time data that can be pulled up by hospital, service, unit, health care worker type, and timeframe,” Trexler says.

At Johns Hopkins, adherence is rewarded with the old-fashioned kind of positive reinforcement—compliments and congratulations—but also with data-based reinforcement. Taylor McIlquham, MPH, an infection control epidemiologist at The Johns Hopkins Hospital, says, “We present data to the IC [infection control] committee every month about which units are doing well, and which aren’t, and which ones have reached more than 92% adherence in the previous 3 months.” High performers are treated to individually wrapped cookies (pre–COVID-19, they had pizza parties). Leadership comes to the meeting to thank them (the personal touch again).

COVID-19 has intensified just about everything to do with infection control, including the need to find the right tools for the right situations. According to McIlquham, Johns Hopkins has spent the past 2 years looking into electronic monitoring systems, made by everyone from GE to smaller startups. Time constraints make it hard to rely on secret shoppers, she says. “We have over 50 clinical units to observe each month. Also, it can create bias [in the data] if staff begin to recognize the secret shopper.” Badges and digital monitors take out the human element, she adds. “We’re interested in technology primarily to reduce bias and understand what the numbers actually are, to be as accurate as possible. And to use data to target which interventions improve outcomes.”

It’s a big undertaking. “Even just doing studies, it’s a huge, huge infrastructure,” says McIlquham. “Think about thousands and thousands of people on our campus who would need the badges and monitoring tools. But we’ll continue exploring. We were doing short-term trials. Right before COVID-19 we were just about to do another but put it on the back burner for now.”

Hand hygiene is always important, but during this pandemic it’s crucial to preventing transmission. Now technology is making it possible for hospitals not only to monitor adherence, but also potential viral exposure.

SwipeSense, which initially was intended to track whether staff were washing their hands correctly, has a new application: contact tracing. Via sensors added to staff badges, managers can create a virtual “historical” map of staff whereabouts. If someone has received a COVID-19 diagnosis, administrators can better identify where the person was and who might have been in contact with them.

SwipeSense CEO Mert Iseri is fully aware of the implications of the monitoring, but in a recent interview with CNBC insists the company is “taking steps to alleviate the ‘creep’ factor.” For example, the system doesn’t track people throughout their day. Acknowledging the potential for misuse, he said, “We have to be really thoughtful about the technology we’re building.”

Used wisely, the technology is a benefit in fighting COVID-19 spread. At Edward-Elmhurst Health in Illinois, where more than 3000 workers agreed to wear the SwipeSense badge, the data populated a dashboard that, by the end of March 2020, could help administrators monitor exposures. In 1 case, they determined that 75 employees had been in the room of a patient who tested positive, so they tested those workers and isolated them for 72 hours. One tested positive and was further isolated, and the virus was contained.

Hazard Appalachian Regional Healthcare (ARH) in Kentucky is also using the SwipeSense technology for contact tracing. “We are 1 of only 3 hospitals in the nation who are currently utilizing this technology for contact tracing,” James J. Hensley, MLS (ASCP), CIC, system director of infection prevention for ARH, wrote in a blog on the hospital’s website.

 In addition to contact tracing for staff, ARH attaches radio-frequency identification asset tags to mobile equipment such as ventilators. Through the SwipeSense Asset Tracking app, the hospital can virtually map and track equipment throughout the facility.

“This helps us identify equipment that may need [to be] assessed, cleaned, and even quarantined,” Hensley said. “The facility has location hubs connected all over, including in common areas, which ‘talk’ to staff badges and asset tags to log data for asset tracking and also for contact tracing.”

Sentara’s Estep says, “The pandemic has reaffirmed our focus on correct, consistent use of [personal protective equipment] and hand hygiene to prevent exposures. We’re compliant with the Virginia Emergency Temporary Standard for the prevention of SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2], which has a high focus on staff training, including correct hand hygiene technique. We created a training video, Safe at Sentara, that covers all aspects of COVID-19 prevention, and we plan for it to become an annual educational requirement.”

Sentara also continues to explore adherence-enhancing technology. “This will not only emphasize our commitment to 100% hand hygiene adherence,” Estep says, “but also our willingness to identify gaps and opportunities and commit to the technology cost of such a project. We’re also using the more stringent Leapfrog requirements to justify electronic monitoring, since receiving additional points involves a much higher volume of audits than we can achieve manually.” (The Leapfrog Group is a national watchdog organization focused on health care safety.)

The original WIPES program at Johns Hopkins increased adherence in hand hygiene to more than 80%; the enhancements have boosted it to the 90% range, and COVID-19 has made it critical. “Adherence is higher this year than ever before,” Trexler says. “People are more conscientious. We’re hoping this habit will bleed over after the pandemic.” She sees reason for optimism. “COVID-19 will have one benefit: changing behavior.”

Hospitals might get their wish for 100% adherence granted after all.

. August 11, 2020. Accessed January 7, 2021. 

https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database

Aboumatar H, Ristaino P, Davis RO. Infection prevention promotion program based on the PRECEDE model: improving hand hygiene behaviors among healthcare personnel. 

Farr C. Some hospitals are tracking Covid-19 by adding sensors to employees’ badges. CNBC. August 2, 2020. Accessed January 7, 2021. 

https://www.cnbc.com/2020/08/02/hospitals-tracking-covid-19-with-badge-sensors-swipesense-technology.html

Hazard ARH uses SwipeSense technology to speed up contact tracing for COVID-19. Appalachian Regional Healthcare blog. Accessed January 7, 2021. 

https://www.arh.org/portfolio_page/hazard-arh-uses-swipesense-technology-to-speed-up-contact-tracing-for-covid-19/

In 1999, Kevin Ashton, of Procter & Gamble, coined the term “Internet of Things” to describe that universe of computers communicating with each other almost independently of humans.

In 2015, in an interview with Smithsonian Magazine, he said, “In the 20th century, computers were brains without senses—they only knew what we told them. That was a huge limitation: There is many billion times more information in the world than people could possibly type in through a keyboard or scan with a barcode. In the 21st century, because of the Internet of Things, computers can sense things for themselves.”1

Consequently, we now have GPS; smart phones, TVs, and refrigerators; and devices that know when we’re home and when we aren’t.

We also have systems that can tell when health care personnel are washing their hands and when they aren’t—and reminds them when they don’t. The data those systems provide also help hospital managers understand transmission risk. In this coronavirus disease 2019 (COVID-19) pandemic, knowing where hotspots might be lurking is critical.

Here’s a brief look at some of the technological tools available:

 (CHSH) technology helps hospitals identify the most efficient path to improving hand hygiene. Its patented process, which includes gamification, “nurtures a culture of proactive HAI [health care–associated infection] prevention.” According to CHSH, hospitals that have used its technology and followed its process for at least 6 months have seen a decrease in HAIs of between 45% and 81%.


https://cleanhands-safehands.com/technology/

 has been named a “Best Infection Prevention Product” by Newsweek, in association with the Leapfrog Group. Its 55-second disinfection “UV Box,” used throughout more than 700 hospitals and hospital groups, provides up to 99.999% disinfection. According to AUVS, the surface disinfection technology in its products is similar to the technology used in the air systems at the US Pentagon to protect against bioterrorism.


, with a configurable dashboard, provides on-demand intelligence and actionable insights about adherence and clinical workflows. The insights are color coded and available in easy-to-read graphs, making it simple to track adherence history. The company says study results have found its use reduces HAIs and staff absenteeism due to illness.


Hand hygiene is always important, but during this pandemic it’s crucial to preventing transmission. Now technology is making it possible for hospitals not only to monitor compliance, but also potential viral exposure.

Jan Dyer

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