Saskia v. Popescu, PhD, MPH, MA, CIC

When the US Centers for Disease Control and Prevention (CDC) released 

 on shortened quarantine options, there was a mixture of relief and concern. What does it mean for infection prevention though?

As the coronavirus disease 2019 (COVID-19) pandemic reaches new records across all metrics—cases, hospitalizations, and deaths, we are struggling. Vaccine bottlenecks and distribution hurdles are stressing public health and healthcare resources even more and ultimately impact the public’s attitude towards the vaccine.

This pandemic has also pulled back the curtain on so many disparities across the United States, many of which we already knew about, but others that have been amplified by the stresses of the pandemic. A year into this, many of us have continued to hear accounts of people unable to quarantine after exposures. For so many, their places of work outside of healthcare have made it hard to be safe while paying bills, like having to take time off to quarantine if you have been exposed. Tough decisions like this make safety a challenging goal and if you have bills to pay and can’t take 14 days unpaid, it leaves little room but to work during quarantine.

Situations like these have challenged public health interventions to get people to quarantine for 14 days following an exposure. Late last year, the CDC released 

 on options to reduce quarantine. The goal was simple—if we can get people to quarantine for at least a minimum amount and get tested, we might have a better chance at getting them to stay home. Two options were presented—10 days of quarantine without a test, or 7 days with a negative test (test must occur on day 5 or after).

In both cases, people were still expected to monitor their symptoms until 14 days had passed since the exposure, Moreover, people still needed to mask, distance, wash their hands, avoid crowds, and other COVID-19 prevention efforts. The CDC noted that people need to follow their local public health department for quarantine requirements, but these recommendations had been made available. “CDC continues to endorse quarantine for 14 days and recognizes that any quarantine shorter than 14 days balances reduced burden against a small possibility of spreading the virus. CDC will continue to evaluate new information and update recommendations as needed.”

I think we can all agree that having some quarantine is better than none, but ultimately this really speaks to bigger issues with employers and how we financially support companies and their employees during a pandemic to encourage safety. When this guidance was released, there was a mixture of gratitude for its message, but also concern for how it would be utilized. With an average incubation period of 4-6 days, testing on day 5 or 6 for a 7-day quarantine period has the potential to miss infections.

(MMWR) evaluated a shortened quarantine period in Tennessee and Wisconsin from April to September 2020. The authors noted that “Among persons exposed to COVID-19 in the household who were asymptomatic and had negative laboratory test results through 7 days after symptom onset in the index patient, 19% experienced symptoms or received positive test results in the following week.”

The coming months will be telling in terms of how we approach quarantine and the implications of shortened quarantine periods. While it might be easier for people to adhere to, there is still concern for disease transmission and it is critical that those pieces be communicated to the public. For infection preventionists, there is likely pressure to utilize these measures, but it is important that we stick to local public health guidance and work to communicate the limitations of a shortened quarantine while promoting the need for continued infection prevention efforts.

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The coming months will be telling in terms of how we approach quarantine and the implications of shortened quarantine periods. While it might be easier for people to adhere to, there is still concern for disease transmission.

Reasons for Shorter Quarantines Need to be Explained

The United States continues to struggle with vaccine distribution for coronavirus disease 2019 (COVID-19). Despite a federal goal of 20 million first doses by the end of December 2020, 

 people have been vaccinated so far. In fact, only 151,000 have been fully vaccinated. Over 22 million doses have been delivered to states, but as we know, delivery does not translate to distribution. A population-scale vaccinate rollout is no easy feat and with each state doing things a little differently, it’s not surprising that things are slow. Moreover, as hospitals and public health departments are primarily responsible for coordinating and managing the actual rollout can we blame these already stressed systems for falling behind? The goal of vaccinating as many as possible in a quick fashion is hard though and despite some reports, the issue isn’t really about people jumping ahead in line, but rather a larger, institutional failure to adequately resource large-scale vaccine rollouts. Vaccines sitting in freezers do us no good, so as we struggle with healthcare worker vaccine hesitancy and work to combat the bottlenecking, it’s important to look at the larger roadblocks that set the stage for these issues. Considering that only 30% of the distributed doses have been given, there is a lot of work we need to do and that isn’t just education and combatting hesitancy, but also making the process more accessible and easier to understand. Transparency about the hurdles and challenges helps people understand that this isn’t reflective of the importance or efficacy of the vaccine, but that such efforts require a lot of logistics and resources.

The news of two new SARS-CoV-2 variants over the past few weeks wasn’t particularly surprising, but something that added more stress. The two variations—B.1.1.7 first identified in the United Kingdom and 501.V2 first identified in South Africa, raised the red flag for the continuing challenge that is COVID-19. Perhaps the hardest piece to this is navigating what we know and what we don’t know, while there is continued and often sensational press coverage. This can make it hard to answer questions we’re getting in infection prevention—whether it be about the impact to testing or vaccination or even isolation precautions. The term “mutation” often triggers images of scary gain of function in the virus that concurs images of super strains. It’s important that we communicate to healthcare workers (and the public) that genomic changes in a virus are exceedingly normal. Moreover, we should be supporting more genomic surveillance to identify these more swiftly. What we do know is that the new strain B.1.1.7 is likely more transmissible, but does not appear to be causing more severe disease. The good news is that it 

. As we learn more information about 501.V2, more information will be released, which is why communication to frontline staff is so important. This doesn’t change the routes of transmission, but with a new strain that is more adept at spreading between people, it’s critical we are vigilant in infection prevention measures in the healthcare setting, but also outside of it. If nothing else, these new variants should serve as reminders of just how important these infection prevention measures are and our need to truly follow them.

For vaccines: Delivery doesn’t mean distribution. For variants: Their appearance underscores the importance of infection prevention methods.

Hot COVID-19 Topics: Vaccine Rollouts, Variants

I’ve tried to mull over what 2020 has been like and what 2021 will likely mean. For most people, and especially those working in healthcare and public health, coronavirus disease 2019 (COVID-19) has made this one of the longest and most challenging years ever. Some people have said to me: “Pandemics and high-consequence diseases are your specialty. Isn’t this like your Super Bowl?”

In some ways yes—this is a time where years of experience and study get to be utilized, but in a more painful way—no. This is not an exciting time for those of us working in infectious disease. Mostly because we always plan for the worst and hope we never get there. If nothing else, 2020 has taught us a lot about perseverance and building sustainable efforts, both in the healthcare setting but also personally.

The bigger question is though—what will 2021 look like for infection prevention efforts? As vaccine distribution is underway, albeit it slowly, this will be perhaps one of the more 

 Healthcare workers are being vaccinated as I type this, but vaccine hesitancy is very real. Moreover, the politicization of public health and challenges with transparency and disinformation have compounded not only the pandemic but the largest vaccine distribution we’ve performed.

2021 will likely mean a mixture of things for infection preventionists (IPs). First, a focused effort on vaccine education. While this is a larger effort, IPs have always played a significant role in education and answering questions while rounding on the units and clinics. Vaccine distribution will involve information for those acquiring it, but it’s also important we continue to address concerns, questions, and reiterate that even with the two doses, staff will still need to follow infection prevention measures at work and at home.

Second, realistic discussions that a vaccine is not a panacea. Elimination of SARS-CoV-2/COVID-19 is a wonderful goal, but the United States is a large country and vaccine hesitancy is deeply rooted here. Moreover, we are still learning about the efficacy of the vaccines in not only avoidance of severe diseases, but overall infection. Ensuring isolation precautions are adhered to, even if all staff are vaccinated, is critical. Despite having our vaccinations, we still wear personal protective equipment (PPE) into the room of patients with measles, no? Continued vigilance is critical.

Third and perhaps the most important—this will take time and attention. Vaccine distribution will be a long road and not an easy one. Beyond this though, it will take time to realize that COVID-19 could be around longer than we realized and is not the only emerging infectious disease we will encounter. The investment in sustained preparedness for infectious diseases (biopreparedness) takes time and resources.

Even if COVID-19 subsides, maintaining readiness for it will be important. If COVID-19 is truly eliminated, it will need to stay a memory fresh in our minds for just how vulnerable healthcare and public health are to these events, but also that a boom-and-bust approach to response helps no one. 2021 will hopefully mean looking more at healthcare-associated infections (HAIs) and returning to a sense of normality, but it’s important that we don’t return to a pre-COVID “normal” as that’s what got us into much of this mess. Instead of preparing for new threats with old ideas, 2021 I hope will be the year that IPs shine by not only showcasing our skills and dedication, but ability to respond to new challenges with innovative approaches.

2021 will likely mean a mixture of things for infection preventionists (IPs). First, a focused effort on vaccine education. While this is a larger effort, IPs have always played a significant role in education and answering questions while rounding on the units and clinics.

What Infection Preventionists Can Expect in 2021

The United States is experiencing the worst coronavirus disease 2019 (COVID-19) surge since the beginning of the pandemic. We’re seeing a 

 of 209,000 new daily cases, over 119,000 people hospitalized, and over 2600 people a day dying from the disease. The past week has been busy with news of 

. Not only is the Pfizer vaccine in distribution, but Moderna’s vaccine recently got approval for emergency use authorization (EUA).

Now though, comes the most challenging piece for many in infection prevention and healthcare—distribution of the vaccine. Most of the healthcare workers on the frontlines will be included in the first stages of. While the US Centers for Disease Control and Prevention has released interim recommendations for the use of COVID-19 vaccines through the 

Advisory Committee on Immunization Practices (ACIP)

, it’s ultimately up to local (state) authorities to determine roll-out. In addition to these recommendations, the National Academies of Sciences, Engineering, and Medicine has released 

. This allocation proposal includes four phases, which starts with those working in high-risk health settings and first responders, followed by those with underlying conditions and older adults living in congregate or overcrowded settings.

In Phase 2, the direction shifts to teachers and school staff, high-risk industrial settings, and people in prisons and jails. The authors also noted that “Current evidence shows that COVID-19 disproportionately affects particular racial and ethnic minority groups, including Black, Hispanic or Latinx, American Indian and Alaska Native, and Native Hawaiian and Pacific Islander communities. Many of these groups experience increased social risks and are impacted by structural inequalities that contribute to health inequities, along with pre-existing conditions that put them at higher risk of severe illness and death from COVID-19.”

Currently, US states and hospitals are working to identify their 

. For many in healthcare though, the question will be—who goes first? Part of this will involve infection prevention efforts and insights—who are those most at risk and involved in exposures? One piece will be to involve those working on designated COVID-19 units and high-risk areas, like emergency departments and urgent care clinics.

For those in intensive care units and even oncology centers, this will be also be a critical decision regarding allocation for those working with vulnerable patient populations. In addition to those most at risk and working with at-risk patients, it’s important to consider ancillary staff. Employees in environmental services, lab, respiratory therapy, physical therapy, and food services, are all people who have been working in these high-risk areas as well.

This also includes infection preventionists, which means we must be advocates for not only those ancillary staff, but also our programs and people who have been educating and rounding in those high-risk units and areas. Fundamentally though, it will be critical that vaccine allocation efforts in hospitals not only integrate public health strategies, but also make the vaccine rollout accessible and efficient. Moreover, these efforts will need to counter vaccine misinformation and proactively focus on how to educate healthcare workers, and the public, regarding the vaccines, their side effects, and efficacy. This will be a critical time in US history, healthcare, and infection prevention, but through strategy and continued information sharing, we can start to rollout in an equitable and effective manner.

When it comes to COVID-19 vaccinations, it’s important to consider ancillary staff. Employees in environmental services, lab, respiratory therapy, physical therapy, and food services who have been working in high-risk areas.

Saskia v. Popescu, PhD, MPH, MA, CIC

Articles

Reasons for Shorter Quarantines Need to be Explained

Hot COVID-19 Topics: Vaccine Rollouts, Variants

What Infection Preventionists Can Expect in 2021

How COVID-19 Vaccination Effort Should Proceed