Rebecca Leach, RN, BSN, MPH, CIC

Creating vaccines for coronavirus disease 2019 (COVID-19) and getting them approved by the US Food and Drug Administration (FDA) proved to be an arduous task fraught with scientific and logistical hurdles. Now comes the hard part: Getting those vaccines widely distributed to the right people. Where do infection preventionists (IPs) fit into this part of the pandemic response?

There are 2 overarching levels of vaccine implementation: regional public health mass vaccination planning and local, targeted efforts for specific populations. In both areas, IPs need to be involved in planning and implementation. IPs have both education and training in public health and outbreak response as part of their core concepts to become an IP. Also, many IPs work closely with local, regional, and state public health partners on a regular basis, so the relationships are already built.

The first wave of vaccination is focused on large-scale public health-driven efforts. These are being implemented at the state level for distribution to focus on healthcare workers and residents of long- term care facilities. These efforts clearly must be multi-disciplinary in order to have effective planning and viewpoints that can bring creativity to solve the problem of how to effectively distribute millions of doses of a vaccine that require very specific handling and storage parameters.

For example, the Pfizer-BioNTech vaccine requires ultra-cold storage and will be allocated in large dosage counts, requiring vaccination of large groups over a short time period. The teams need to include providers, pharmacists, public health, healthcare facility leadership, emergency management, and other local leaders. It is likely that members of these groups have not worked closely together before on such a large-scale task. It will be crucial to function with a hospital incident command system to keep the group moving forward with the same objectives and bring obstacles to the forefront quickly for rapid problem solving.

IPs have been working scenarios of mass vaccination for years, in preparation for pandemic flu primarily, but also with potential biological threats (anthrax, smallpox) and other outbreaks such as measles and pertussis. These skills and insights make IPs and their public health colleagues subject matter experts on the nuances of mass vaccination. For example, some hospital systems would take the opportunity to turn annual employee flu vaccination into a drill and treat it as if it were a mass vaccination event in collaboration with emergency management colleagues. These events would teach valuable lessons in the best way to reach all staff, including having multiple vaccination administration locations and the best way to handle the data collection necessary to track large scale vaccination efforts.

Infection prevention needs to be a partner in the large-scale planning that is occurring currently in most states and local healthcare facilities. These efforts are largely being led by public health on state or regional levels, but the local hospitals will also need to plan when vaccine is distributed in future tiers for local administration. Not only to help with logistics of vaccine storage, administration, documentation, and data collection and reporting, but also to focus on safety of the workers and vaccine recipients of the vaccine clinics. Staff use of personal protective equipment (PPE), workflow to ensure social distancing and decrease crowding, and cleaning and disinfection practices of the clinic site are all logistical concerns that should be addressed in the planning stage to avoid potential exposures or contamination concerns.

Another area for concern is the cold storage and transport of the vaccine. Specialized freezers and transport companies that can safely move vaccine shipments from distribution sites to clinics are necessary to maintain that cold chain delivery system. Specialized transport companies that have experience in this type of system will be in high demand and IPs can help evaluate the processes of these third-party vendors to ensure they will be able to accommodate the level of transport needed and maintain the storage parameters of the vaccines.

Data collection for the large-scale clinics will likely be mediated through health departments, but the details of tracking, knowing which employees did receive the vaccine, and communicating that to the local healthcare facilities will need to be addressed. Each state will likely have to determine the best way to communicate vaccine administration, but it will also be the responsibility of each employee to report their vaccination status back to the healthcare facility.

Hospital vaccine programs are historically a collaborative effort between infection prevention and employee health programs. As COVID-19 vaccine efforts continue, there will need to be consideration of how that will be managed within the context of the current hospital-based vaccination programs. How will a COVID-19 vaccine be handled at each facility? Will it be mandatory? Will it be given annually? Will it be a condition of employment? These are all questions that will need to be addressed. There are some unknowns at this point, including the need for annual boosters, required storage needs, and data reporting.

Infection prevention is also a key partner with employee health programs to promote vaccine uptake and educate on the mechanism of how the vaccine works and potential side effects. As these new vaccines are approved for distribution, it will be key for IPs to learn about the studies completed to date to have an understanding of these key points to help with staff education. Reviewing the articles published during the trials, as well as the recommendations from the federal programs will help IPs become knowledgeable about the vaccines. Also, key information that IPs will likely need to address will be side effects, efficacy, and recommendations of priority risk groups (such as healthcare workers, elderly, essential workers, etc). IPs can help address these questions through rounding and education opportunities, published newsletters and new employee orientation.

Planning for the logistics of how vaccine will be distributed locally will take much effort. Some items to consider are the timing of when staff will receive their dose and when they work their next shift. As virtually all healthcare facilities are screening for COVID-19 symptoms, the reactions to a vaccine may potentially meet some of those criteria, such as low-grade fever or malaise. It will be important to plan for this as an organization, to consider that with screening or plan for staff to have 24-48 hours after their dose before their next shift. The calculations will also need to include the fact that the vaccines are given in 2 doses.

Planning for this process should already be starting. As many healthcare facilities are operating under the hospital incident command system, the vaccine administration can be brought under that structure and would already have all the key departments at the table to help coordinate.

Data reporting for COVID-19 vaccination will likely be extensive. Many employee health programs may not have the reporting capabilities to handle the level of data collection and tracking that will be necessary for this initial wave of vaccination. Often employee health programs do not have electronic systems that integrate with other reporting programs or link to state health departments, therefore much of the work will be manual. Infection prevention needs to advocate for improved data systems for employee health tracking, which will not only be beneficial in the COVID-19 vaccine process but, going forward, for all other employee health activities.

One thing that IPs must remember: Vaccination is not the end of this pandemic. Most likely, the vaccination rate needed to provide sufficient population immunity to control spread is around 80%.1 It will take years to achieve that level of vaccination, if at all. So, the vigilance of basic infection control measures will need to be maintained in some fashion until such a point. This is part of the IP toolkit.

Having worked with vaccine preventable diseases for decades, IPs understand that vaccination is not the only way to prevent disease transmission.

Behavior modification, engineering controls, such as modifying traffic patterns and increasing ventilation air exchanges, and other active processes are key to a multi-focal prevention plan. Universal masking will continue in healthcare facilities and hopefully on a community level for some time, until population immunity is of a sufficient level or community spread is low to minimal.

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

1. Bartsch SM, MPH, O’Shea KJ, Ferguson MC, et al. Vaccine efficacy needed for a COVID-19 coronavirus vaccine to prevent or stop an epidemic as the sole intervention. Am J Prev Med. 2020;59(4): 493–503. doi: https://doi.org/10.1016/j.ajic.2020.10.018

Articles

How will the COVID vaccine be handled at each facility?  Wil it be mandatory? Will it be given annually? Will it be a condition of employment? These are all questions that will need to be addressed.

Infection Preventionists to Play Crucial Role in Vaccine Efforts

The monitoring and tracking of healthcare-acquired infections (HAIs) has evolved over time based on national and local guidelines and regulations. Formal standard definitions for HAIs were first developed by the Centers for Disease Control and Prevention (CDC) through the network of hospitals that participated in the National Nosocomial Infection Surveillance (NNIS) program.

 This network was a voluntary group of facilities that used the definitions to standardize the collection of HAI data and also report to a national database where analysis was completed and disseminated. This national data surveillance program provided a method for benchmarking HAI events with the advantage of having consistent definitions and data collection methodologies.

Facilities could determine what HAIs they would actively track and report, leaving it to the discretion of the infection control program, facility leadership, and assessment of specific population risk factors. Therefore, each facility could be tracking different infections, but all would be using the same definitions for data collection and determination of HAI status. Eventually, the NNIS evolved into the National Healthcare Safety Network (NHSN) and the HAI definitions transitioned over to the NHSN division of the CDC. Currently, HAI definitions in the United States are standardized to the NHSN criteria and infection prevention (IP) programs to use those definitions as their surveillance strategy.

Over time, the tracking of HAIs became more regulated. State governments were passing legislation mandating public reporting of select HAIs, thereby forcing IP programs to focus efforts on those particular HAIs that were publicly reported. Each state would have different HAIs required, however the majority focused on device associated infections, such as central line associated bloodstream infections (CLABSIs), or various surgical site infections.

 As the risk and impact of HAIs became more noticed in the public media, the federal government established the reporting requirements through the Centers for Medicare and Medicaid Services (CMS) of several HAIs, starting with CLABSI and adding more indicators.1 Currently there are 6 HAIs that are federally publicly reportable: CLABSI, catheter associated urinary tract infections (CAUTI), surgical site infections (SSI) for colon procedures, SSI for total abdominal hysterectomies, and laboratory based measures for 

 (MRSA) bacteremia infections. The public reporting of these HAIs impacted the way IP programs define their surveillance plans and tied hospital reimbursement directly to performance on these indicators.

As public reporting became a reality for IP programs, the focus of the surveillance shifted from what would be more individualized to each facility to these 6 specific HAIs. The efforts of IP programs had to meet the reporting need, and also were more visible as a financial impact to hospitals. IP programs also were pressured from hospital leadership when reviewing cases to determine if they met NHSN definitions, and would then be reported and potentially result in CMS penalties.

These aspects of the mandatory reporting were new experiences for IP programs, and the task of describing an event as hospital-associated or not, suddenly became much more at the forefront of the role performed by infection preventionists (IPs). Meanwhile, the requirement for public reporting meant that surveillance became more important and a higher priority for IP programs; therefore, other important program functions, such as rounding, education, process improvement projects, construction and biopreparedness all had to be set aside for the time to monitor and report HAI data.

Resources need to be provided for IP programs that can help ease the burden of reporting, and also free up time for IP staff to perform other tasks. Surveillance and data mining systems that can automate much of the reporting requirements would be ideal for IP programs. Also, as mandatory reporting continues, it would be essential to have input from IPs on what items should be included or added to the reporting requirements. IP staff input would allow federal and state legislators to understand the time and resource requirements of mandatory reporting and be a voice to advocate for changes in legislation that would improve reporting.

The coronavirus disease 2019 (COVID-19) pandemic has impacted HAIs across the country. Not only were IP programs stretched during the pandemic as part of the public health response, but also the HAI reporting was still being done. IP staff had to figure out how to manage all the workload of the pandemic response and continue to keep surveillance and data reporting current and active.

The work of HAI prevention was also impacted similarly, with less time for IPs to do rounding and focus on the elements that contribute to HAIs. As the national data is analyzed and released in coming months, it will be interesting to see if HAIs were impacted by COVID-19 and to understand exactly how a pandemic influences HAI prevention efforts. Anecdotally, patients with COVID-19 were seen to be high risk for HAIs, particularly CLABSI and CAUTI, due to long lengths of stay, duration of ICU admissions, proning treatments to help with respiratory function and other unique aspects of care.

As IPs work toward a future that includes COVID-19, there will continue to be a resource pull away from traditional infection prevention work to help focus continued efforts toward pandemic response, vaccination of staff and patients and public health collaboration. Compounding this work is the increased risk for HAI events with COVID patients. IP programs can work with nursing and medical staff to develop COVID-19 pathways for patients to help address concerns around HAIs and other healthcare-associated complications, such as pressure injuries and falls. These pathways can include specific interventions that are based on current best practice, such as chlorhexidine bathing, daily assessment of devices, and use of external urinary catheters, but make modifications that would further help mitigate risk for these patients who are at increased risk.

The impact of COVID-19 on HAI identification and reporting is still to be seen. Perhaps more reporting will be required of other respiratory illnesses, such as influenza or pertussis, as well as hospital onset COVID outbreaks. Perhaps COVID status will be part of routine reporting to NHSN as a risk factor. However, the regulations around reporting may change, IP programs will need to continue to incorporate pandemic response into their daily routines, while working to maintain a presence with HAI prevention. All this puts a strain on IP programs, and increased resources or new collaborations and partnering across programs will be essential for success, and ultimately for patient and staff safety.

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

Dixon RE. Control of healthcare associated infections, 1961-2001. 

. October 7, 2011. Accessed September 10, 2020. 

https://www.cdc.gov/mmwr/preview/mmwrhtml/su6004a10.htm

Infectious Disease Advisor. Mandatory public reporting of hospital acquired infections. Accessed September 12, 2020. 

https://www.infectiousdiseaseadvisor.com/home/decision-support-in-medicine/hospital-infection-control/mandatory-public-reporting-of-hospital-acquired-infections/

Bean M. How the pandemic is affecting HAI rates: 5 things to know. Becker’s Hospital Review. Published August 5, 2020. Accessed September 12, 2020. 

https://www.beckershospitalreview.com/infection-control/how-the-pandemic-is-affecting-hai-rates-5-things-to-know.html

COVID-19 possibly hindered the prevention of healthcare-acquired infections (HAIs) because infection preventionists have less time to do rounding and focus on the elements that contribute to HAIs. 

Tracking of Healthcare-Acquired Infections Continues to Evolve

As the coronavirus disease 2019 (COVID-19) pandemic has disrupted and derailed 2020, many see the promise of a vaccine as the pathway back to “normal.” As of this August writing, there are 26 vaccines in various stages of clinical trials and 139 vaccines in preclinical trials across the globe.1 Vaccine development typically takes years from design to US Food and Drug Administration (FDA) approval and readiness for mass market. Even with the increased funding and drive to create and distribute a vaccine that protects against COVID-19, it may be well into 2021 before one is available for the public. And even when it is available, the efficacy of the vaccine will be unknown until large populations have received it.2 Given this timeframe, and other factors associated with vaccination as a tool in pandemic response, the road to normalcy may not be as smooth as many hope.

Infection preventionists (IPs) are collaborators with other departments, such as occupational health, human resources, and clinical leadership, to promote and implement vaccination programs for healthcare providers (HCPs). Typically, staff vaccination programs are owned by occupational health departments and IPs work closely to monitor trends and help remove barriers and provide recommendations on special cases or accommodations. When the vaccine for COVID-19 is available, this again will be a collaborative moment to develop the plan for vaccination, tracking, and promoting.

Infection prevention will likely need to be a resource for education about the vaccine, including concerns over side effects or any booster or follow-up needed based on how the vaccine is designed.

Another role for IPs in this pandemic will be to work with local public health programs to promote vaccination of the public, including patients and residents of congregate settings, such as nursing homes, acute rehab facilities, and inpatient mental health centers.

One example of a way that IPs can collaborate with other departments to implement a vaccination program is to work with occupational health and emergency response departments to have a mass vaccination drill.

This is a way for many programs to meet requirements and also provide a vaccine to staff in a rapid and coordinated process. When having these types of drills, it’s important that the vaccine be brought to where the staff is located, so having roving carts or teams is important. Also having stations at staff entrances that are manned during shift change can capture staff members as they come into the facility.

There are many examples of vaccination programs and lessons-learned about ways to increase staff compliance; however, even with a vaccine in development, the role of infection prevention will need to be strong for COVID-19 response for the foreseeable future.

Vaccines are one weapon that is often used in outbreak response for vaccine-preventable diseases (VPD). Countries with strong emergency response and public health programs have vaccination plans in place for such diseases as cholera, polio, and Hepatitis A.3

Disaster preparedness teams in hospitals need to have plans in place for potential increases in VPD and recognize that the typical vaccine administration will be interrupted by that disaster, whether it is a natural disaster, conflict and warfare, or a pandemic.

In this case, given the lag time we have until the vaccine is developed, planning can be done to address the other issues of regulatory barriers, looking at how to store and stockpile vaccine doses and administration supplies, roles of local, national and international partners in the distribution, communication and marketing, enhanced surveillance for adverse response and for effectiveness and the general mobilization and operationalization of the vaccine to the populations of need.3

These are huge undertakings, especially within a global pandemic. However, looking at historical mass-vaccination efforts can provide some guidelines on best practices and lessons learned and can be a resource to help guide the COVID-19 vaccine response plan.In order for the vaccine response to be successful, these areas of operation need to be addressed. Also, the social aspects of vaccine administration are equally important to understand and develop plans for before the vaccine is ready. These areas include vaccine hesitancy, access to healthcare, health equity, and mistrust of government institutions.4

Many of these barriers can be addressed with similar tactics, including assessing areas of vulnerable populations where these social constructs exist and working with local community leaders to build relationships and establish trust. Build capacity in healthcare organizations to address these concerns and to engage the community to provide accurate information. Healthcare providers are the most trusted source on vaccine acceptance.4 If providers have a clear understanding of the benefits of vaccination and have the communication skills to educate their patients, then the likelihood of vaccine uptake may increase. Similarly, HCPs are a high-risk group and their opinions on the COVID-19 vaccine can sway others.

When looking at influenza vaccine compliance, in recent years the percentage of HCPs taking the vaccine has increased, with a reported 81.1% overall compliance in 2019.5 One reason this has increased is because of many organizations making a flu vaccine a requirement for employment. In HCPs who did not have a work requirement or any work-related promotion, the compliance rate was just 42.1%. If we extrapolate this data to a COVID-19 vaccine, likely without work requirements, we would see low levels of uptake within HCPs as well. Not only does this increase potential for transmission in this high-risk population, but it also sends the message to their patients and community that the vaccine is not important.

A recent survey found that less than half of Americans would get a COVID-19 vaccine right away.6 Nearly 25% of respondents would “not get the vaccine anytime soon” or “never” get the vaccine.6 African-American respondents were the least likely to want to receive a COVID-19 vaccine right away compared with other races and ethnicities. These data show that there is much pre-work to be done, in particular with minority groups who have been disproportionately impacted by the disease, to increase vaccine acceptance and address underlying issues that are influencing these responses. Interestingly, respondents who reported receiving the annual flu vaccine were nearly twice as likely to report willingness to get the COVID-19 vaccine.6 Understanding what influences people to get the annual flu vaccine may help guide programs to use similar tactics to influence COVID-19 vaccine uptake.

Even if the vaccine is widely accepted and trusted, how long will it take to establish the level of population immunity necessary to prevent transmission? It’s estimated that, for COVID-19, with the reproduction number (R0) of around 1, about 50% of the population needs to have immunity.7 This is ideally achieved through vaccination, but can also include natural disease acquisition. With COVID-19, most speculate that the vaccine will not provide 100% immunity, and liken it more so to the influenza vaccine, with 40-60% efficacy depending on the annual strains.

Certainly, in the early days of a COVID-19 vaccine roll-out, high-risk groups and vulnerable populations should be targeted first, with prioritization then expanding to general population over time. Given the complexities of such an effort, the timing to reach the 50% threshold could be months to years. Confounding this work is the concept that we may need to have annual boosters or vaccine modifications if the predominant viral strains mutate.

Based on all these challenges with vaccine development, acceptance, and administration, there will need to be a continued emphasis on the basic infection control practices we are currently employing to mitigate risks: wearing masks, social distancing, updating personal protective equipment guidelines in healthcare facilities for universal masking/eye protection, and developing surveillance programs tracking coronavirus activity to be able to adjust the vaccine to fit predominant strains.

These basic tenants are what will provide the most protection against transmission until such a time as we have an effective and widely accepted vaccine. And even after that time, as emerging infectious diseases continue to impact global health, these practices should become part of our culture and part of our national response to outbreaks of respiratory disease.

In disease prevention, it is important to remember that the science exists on a continuum and having all-or-none thinking only impedes progress and understanding. When dealing with a pandemic, multiple approaches are necessary to reach full effect. In infection prevention, we are used to working with bundles for prevention of central line infections, surgical site infections, and other hospital-associated infections. The same approach needs to be taken with COVID-19. We must not dilute the response to relying on a vaccine to “cure” the pandemic. Disease prevention requires a broad range of interventions, including vaccines, in order to be effective and truly address the risks of transmission.

World Health Organization. Draft landscape of COVID-19 candidate vaccines. World Health Organization website. Accessed August 9, 2020. 

https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines

Wilson J. Experts predict what life will be like after a COVID-19 vaccine arrives. Huffpost. Updated August 6, 2020. Accessed August 9, 2020. 

https://www.huffpost.com/entry/life-after-covid-19-vaccine_l_5f2ad9c6c5b64d7a55ed7b2c?ncid=APPLENEWS00001

Walldorf JA, Date KA, Sreenivasan N, et al. Lessons Learned from Emergency Response Vaccination Efforts for Cholera, Typhoid, Yellow Fever, and Ebola. 

. 2017;23(13). doi:10.3201/eid2313.170550.

World Health Organization. Improving vaccination demand and addressing hesitancy. World Health Organization website. Updated June 17, 2020. Accessed August 7, 2020. 

https://www.who.int/immunization/programmes_systems/vaccine_hesitancy/en/

Centers for Disease Control and Prevention. Influenza vaccination information for health care workers. Centers for Disease Control and Prevention website. Updated December 18, 2019. Accessed August 8, 2020. https://www.cdc.gov/flu/professionals/healthcareworkers.htm

Bean M. 48% of Americans would get COVID-19 vaccine right away, survey finds. Becker’s Hospital Review. Published August 5, 2020. Accessed August 9, 20202. 

https://www.beckershospitalreview.com/public-health/48-of-americans-would-get-covid-19-vaccine-right-away-survey-finds.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_source=BHRE&utm_medium=email&oly_enc_id=7243F3869212B6R

Fine P, Eames K, Heymann DL. “Herd immunity”: A rough guide. 

. 2011; 52(7); 911-916. Accessed August 9, 2020. 

https://academic.oup.com/cid/article/52/7/911/299077

Why a COVID-19 Vaccine Might Not Be the Answer We’re Hoping For

Standard precautions have a long history in healthcare, being practiced in some form since the Middle Ages. The Centers for Disease Control and Prevention (CDC) formalized these precautions into what was then called universal precautions in response to the HIV epidemic in the late 1980s. Universal precautions were focused on protecting healthcare workers from blood borne pathogens, focusing on the use of personal protective equipment (PPE) such as gowns and gloves. The concept treats all blood and body fluids as potentially infectious. Universal precautions were revised and became standard precautions in 1996 and became more inclusive of an overall infection prevention aspect when engaging in patient care. Respiratory hygiene was added to standard precautions in 2007, in recognition of the increasing risk of respiratory spread of illnesses such as pandemic influenza.

Transmission based precautions were developed in the 1970s, and were revised to be a next higher level of precautions for those infectious diseases that were spread through contact, droplet and airborne transmission. The emergence of antimicrobial resistant pathogens drove the need to update standard precautions so that healthcare environments could prevent transmission as well as keep providers safe. Just as the need for transmission-based precautions was driven by emergence of pathogen resistance, it is now time to look again at the concept of standard and transmission-based precautions and determine if additions or changes are needed in the wake of the COVID-19 pandemic.

Recent outbreaks and epidemics have shown that infection prevention needs to become more sophisticated with standard precautions, travel history and general awareness of national and international epidemiology and diseases of public health concern. Over the last two decades, the majority of the significant outbreaks was due to viral respiratory illnesses (severe acute respiratory syndrome (SARS), middle eastern respiratory syndrome (MERS), avian influenza). The SARS epidemic in part prompted the CDC to update the standard precautions to include respiratory etiquette.

In these recent outbreaks, and the current pandemic, healthcare workers (HCWs) are at increased risk for acquiring the infections purely as a result of doing their jobs. Data has shown that HCWs made up roughly 20% of cases in the SARs outbreak and 18% in the MERS outbreak.

 It is still unknown how many HCWs have become infected in the COVID-19 pandemic, but current estimates as of this writing are greater than 65,000 cases.1 Many factors can contribute to HCW infections, but often early in outbreaks and pandemics, lapses in infection control practices play a major role. Not having the appropriate type or amount of PPE, lack of isolation of infectious patients, and lack of awareness of epidemiological risk factors, such as recent travel or congregate living status, all play a part. With any type of outbreak, there is always an initial gap in awareness and understanding of the pathogen, transmission factors, and virulence. At this time is when HCWs can be most vulnerable and the outbreak has the potential to grow from a local or regional level. It is during this time when traditional application of standard precautions may not be enough.

Recent articles in the press have been debating the role of airborne transmission in COVID-19 spread.

 While there is not a clear consensus, what does appear to be clear is the need to develop more nuanced definitions of droplet and airborne transmission. The desire to have a very mutually exclusive and clear separation of the types of transmission makes it easier to educate, implement, and monitor. However, science shows that it is more of a continuum that is impacted by many variables, which leaves much up to the bedside practitioner to evaluate and assess risk levels.

Environmental factors, such as humidity level, air exchanges, pressure differentials, can all impact the amount of aerosolization that can occur with respiratory droplets.

 Patients themselves impact, with activity levels, cough etiquette and other host factors that can potentially impact communicability of the virus. The strain of the virus can be more infectious than others, which is not known at the time of admission to the healthcare facility. Manipulations and treatments that are done to the patients also impact the ability of aerosolization, such as oxygenation modalities, endotracheal intubation, bronchoscopies or nebulizing medication treatments.

 All of these factors make the isolation precautions for diseases like COVID-19 more complex than typical droplet or airborne definitions.

With the knowledge that respiratory illnesses have been the greatest international impact on recent outbreaks, it is time to again review the items included in standard and transmission-based precautions and potentially include some variation of universal masking for patient encounters. In particular, this may be most essential in frontline areas, such as emergency departments, urgent care centers, ambulances and first responders, where there is no known history for the patient and unknown exposure risks. Also, in areas where many aerosol generating procedures are occurring, such as intensive care units, procedural areas, respiratory care units and dental clinics.

Another difficult lesson learned from the COVID-19 pandemic is the inadequate supply of respirator options that are available across the healthcare continuum for staff. Traditional N95 masks that require fit testing were in short supply as the pandemic ratcheted up. In even shorter supply were other types of respirators that did not require fit testing, such as PAPRS, CAPRS and other full-face respirator options.

And with almost all of these types of respirators, there are still contraindications for use, such as facial hair, eyeglasses, severe asthma, or other health conditions of the worker. This has revealed a long feared weak link in the ability of a facility to provide adequate protection to all its healthcare workers at the most crucial time it is needed. Efforts to increase not only the availability of current respirators, but also develop new technologies that offer the same level of protection, but have more universal fit and application to a wide variety of users, should be a push from manufacturers and vendors for healthcare and other essential workers.

More research is needed in the field of disease transmission, and in particular for respiratory illnesses. Many studies are based on animal models, which have limitations with human physiology, or are lab-based, which have limitations in real-world scenarios. Understanding of how effective the airborne or aerosol spread is for various respiratory diseases would provide much needed information on how best to develop transmission-based precautions that are effective. A review of the current recommendations of airborne precautions would also elucidate which components are most effective in breaking the chain of disease spread.

And based on these types of data, precautions for specific viral illness could be more specific and also more customizable based on transmission factors. However, until that time comes, and with the continued threat of emerging viral respiratory pathogens, consideration of universal masking guidelines as part of standard precautions may be the beginning of another evolution of how we approach infection prevention practices in healthcare organizations.

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

Xiao J, Fang, M, Chen Q, He B. SARS, MERS and COVID-19 among healthcare workers: A narrative review. 

World Health Organization. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations.WHO website.https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations#.XxIWGGzGYPA.email

Klompas M, Baker MA, Rhee C. Airborne transmission of SARS-CoV-2:theoretical considerations and available evidence. JAMA Network. Published online July 13, 2020. doi:10.1001/jama.2020.12458

Shiu EYC, Leung NHL, Cowling, B. Controversy around airborne versus droplet transmission of respiratory viruses: implication for infection prevention. 

Many factors make the isolation precautions for diseases like COVID-19 more complex than typical droplet or airborne definitions. 

Rebecca Leach, RN, BSN, MPH, CIC

Articles

Infection Preventionists to Play Crucial Role in Vaccine Efforts

Tracking of Healthcare-Acquired Infections Continues to Evolve

Why a COVID-19 Vaccine Might Not Be the Answer We’re Hoping For

Revamp Standard Precautions for Infection Preventionists