Personal protective equipment (PPE) remains in short supply across the United States during the ongoing coronavirus disease 2019 (COVID-19) pandemic. During this time, the N95 respirator has emerged as a critical piece of PPE to protect health care workers during aerosol-generating procedures. What makes an N95 respirator different from standard surgical masks is that it is a particulate-filtering face piece worn to filter at least 95% of airborne particles measuring as small as 3 microns in diameter. To extend the quantity of available respirators, PPE reuse—something once done only in low-resource settings—has become necessary in resource-rich settings as well, as recommended by the Centers for Disease Control and Prevention in situations where PPE is running low.

To complement reuse strategies, PPE decontamination has become a topic of great interest and research. First, it is important to distinguish the difference between cleaning and decontaminating PPE. Cleaning is the initial step of removing organic material including microorganisms from equipment, but it does not necessarily inactivate enough microorganisms to render the equipment safe for usage. Decontamination inactivates or eliminates pathogenic microorganisms, allowing for safe usage. Therefore, in all of the following decontamination strategies, masks with visible soiling are discarded prior to decontamination during the quality assessment phase. Finally, to increase the PPE supply, a successful decontamination method must achieve adequate target organism inactivation without compromising respirator fit and filtration. Here, we will review 3 common sterilization modalities currently in use for N95 respirator decontamination, how they work, and their strengths and limitations.

Ultraviolet (UV) light has long been used for environmental disinfection in health care; UVC wavelength (as opposed to UVA or UVB) light has been studied and approved by the National Institute for Occupational Safety and Health for use in health care settings to kill organisms hardier than viruses, such as Mycobacterium tuberculosis.

 Ultraviolet germicidal irradiation (UVGI) works by exposing nonporous surfaces, water, or air to UV-light–producing lamps, usually to a peak UVC wavelength of 254 nanometers. That light breaks and creates new bonds in the organismal RNA and DNA nucleic acid, preventing replication and inactivating pathogens. No residual byproducts remain on the masks that would result in user injury once decontamination is complete. One of the earliest N95 respirator reprocessing protocols to emerge during the ongoing COVID-19 pandemic was from the University of Nebraska, utilizing UVC-based UVGI.

 Subsequent studies have further demonstrated that UVC irradiation successfully inactivates severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; the virus that causes COVID-19) while UVA and UVB irradiation do not. 

A key consideration with UVGI reprocessing is the need to ensure that both the interior and exterior surfaces of the N95 are not obscured from the lamp, which would prevent UVC from reaching and subsequently sterilizing those areas. Practically, this means personnel must be trained to properly hang masks and to include quality assurance steps prior to and after irradiation to look for shadowing. Another issue is the adequate decontamination of mask straps; this can be achieved, but only at higher wavelengths, which risks strap and mask damage.

Heat, with or without humidity, has been a decontamination strategy of significant research interest, given its easy accessibility and low cost. This involves exposing N95 respirators to heat sources such as autoclaves, which are often readily available in health care settings and are easy to adapt. Furthermore, most hospitals already use heat-based sterilization for nonporous equipment and have personnel who are familiar with the technology, eliminating the need for a training period. In one study, SARS-CoV-2 inactivation occurred when N95 respirators were exposed to 70 °C dry heat. However, quantitative fit testing found that those heat-treated N95s were able to maintain acceptable fit only for 1 to 2 rounds of decontamination, leading the authors to conclude that heat was a less practical real-world option compared with vaporous hydrogen peroxide (VHP) and UV treatments for masks. Masks treated with the latter 2 methods retained adequate filtration and fit for 3 or more rounds.

 Studies on moist heat have also been successfully applied to inactivate influenza virus on N95 respirators.

While one major obstacle to the widespread usage of heat is the aforementioned change to fit, a second is filtration retention, which diminishes with higher temperatures and multiple cycles, and a third is the need for different temperatures and humidity levels depending on the mask model.

 Studies recommend a range of temperatures between 70 °C and 80 °C and humidity percentages of 50% to 85% for decontamination.

 This can be a challenge for health care settings which use several respirator models: Some may have disparate heat and humidity needs, and others may have not yet been assessed for an ideal temperature and humidity. Finally, while other reprocessing strategies have been shown to inactivate bacteria and mold on respirators, heat/humidity sterilization has not yet been demonstrated to do so, and it has yet to be proven to inactivate SARS-CoV-2.

VHP has been used widely in health care environmental decontamination for many years. The vaporization of liquid hydrogen peroxide inactivates pathogens, including SARS-CoV-2, when the covalent bonds between oxygen and hydrogen break; this releases free oxygen radicals. These radicals then penetrate cell walls, inactivating microorganisms, and the atoms then take new form as molecules of water vapor and oxygen gas. Safety and efficacy when VHP has been applied to N95 respirators have been confirmed to a maximum of 50 cycles in 1 study and 20 in others without fit or filtration failure. Furthermore, 2 protocols were published early in the pandemic by both Duke and Yale universities that confirmed SARS-CoV-2 inactivation and feasibility with VHP.

Of the 3 reprocessing methods, VHP is the most time-consuming, requiring a decontamination period lasting 40 to 45 minutes, not including the time required for several other critical steps in the process, including the vaporization of liquid hydrogen peroxide. Depending on the manufacturer’s protocol, there can also be recommendations for a longer or shorter dwell phase to provide time for adequate amounts of gaseous hydrogen peroxide to settle on the exposed surfaces of the N95 respirators and straps. Moreover, an aeration phase of at least 2 hours is required. Aeration of the VHP room and respirators is necessary, allowing any residual hydrogen peroxide gas to break down into water vapor and oxygen; otherwise, lingering gas can cling to the mask and cause skin irritation to the end-user. The entire process from start to finish can thereby last upwards of 2 hours. VHP also requires the presence of trained personnel, who may not be available at every institution, to monitor hydrogen peroxide gas levels throughout the decontamination process. Ultimately, all 3 methods have either the potential or evidence to demonstrate SARS-CoV-2 inactivation; however, limitations of the 3 sterilization methods lie in the number of processing cycles that can be performed until fit and filtration are compromised (Table).

As the pandemic continues and PPE remains in short supply, more real-world, controlled studies are required to assess a safe duration of N95 respirator reuse until production can meet demand. To complement these efforts, innovations in N95 respirator decontamination must continue to augment the supply of available PPE. Numerous studies from environmental and occupational health, infection prevention, and other disciplines have since emerged to translate traditional environmental decontamination technologies into PPE decontamination strategies, as well as to test the safety and efficacy of these processes. Whether this innovation will be a temporary feature of the infection prevention and PPE landscape, or a permanent addition, has yet to be seen. However, it behooves the infection control community to consider the viability and longevity of these technologies and their roles in PPE stewardship, environmental waste, and ascertaining the true lifespan of N95 respirators.

CHRISTINA YEN, MD, completed her clinical infectious diseases fellowship at Beth Israel Deaconess Medical Center in June 2020 and has stayed on to be the infection control/hospital epidemiology fellow. Her interests are in diagnostic stewardship, antimicrobial stewardship, and strategies to prevent central line–associated bloodstream infections.

AHMED ABDUL AZIM, MD, is an assistant professor of medicine and infectious diseases at Rutgers University Robert Wood Johnson Medical School. He completed his clinical infectious diseases fellowship and an additional year of training in infection control/hospital epidemiology at Beth Israel Deaconess Medical Center. His interests are health care epidemiology and medical education.

PREETI MEHROTRA, MD, MPH, is a dually trained adult and pediatric infectious diseases physician. She is currently associate hospital epidemiologist at the Beth Israel Deaconess Medical Center and director of infection control at Atrius Health. She earned her MPH from the Harvard T.H. Chan School of Public Health, focusing on health policy.

Implementing filtering facepiece respirator (FFR) reuse, including reuse after decontamination, when there are known shortages of N95 respirators. Updated October 19, 2020. Accessed November 21, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

Whalen J. Environmental control for tuberculosis: basic upper-room ultraviolet germicidal irradiation guidelines for healthcare settings. CDC/National Institute for Occupational Safety and Health. March 2009. Accessed November 19, 2020. https://www.cdc.gov/niosh/docs/2009-105/pdfs/2009-105.pdf

Lowe JJ, Paladino KD, Farke JD, et al. N95 filtering facepiece respirator ultraviolet germicidal irradiation (UVGI) process for decontamination and reuse. Nebraska Medicine. Updated April 10, 2020. Accessed November 17, 2020. https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf

Silke Heilingloh C, Aufderhorst UW, Schipper L, et al. Susceptibility of SARS-CoV-2 to UV irradiation. 

Lindsley WG, Martin SB Jr, Thewlis RE, et al. Effects of ultraviolet germicidal irradiation (UVGI) on N95 respirator filtration performance and structural integrity. 

Fischer RJ, Morris DH, van Doremalen N, et al. Effectiveness of N95 respirator decontamination and reuse against SARS-CoV-2 virus. 

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Lore MB, Heimbuch BK, Brown TL, Wander JD, Hinrichs SH. Effectiveness of three decontamination treatments against influenza virus applied to filtering facepiece respirators. 

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Rodriguez-Martinez CE, Sossa-Briceño MP, Cortés JA. Decontamination and reuse of N95 filtering facemask respirators: a systematic review of the literature. 

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Rodriguez-Palacios A, Lejeune JT. Moist-heat resistance, spore aging, and superdormancy in Clostridium difficile. 

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Richter W, Hofacre K, Willenberg Z. Final report for the Bioquell hydrogen peroxide vapor (HPV) decontamination for reuse of n95 respirators. July 22, 2016. Accessed November 19, 2020. 

https://www.fda.gov/media/136386/download

Kenney PA, Chan BK, Kortright K, et al. Hydrogen peroxide vapor sterilization of N95 respirators for reuse. 

Schwartz A, Stiegel M, Greeson N, et al. Decontamination and reuse of N95 respirators with hydrogen peroxide vapor to address worldwide personal protective equipment shortages during the SARS-CoV-2 (COVID-19) pandemic. Duke Occupational & Environmental Safety Office. March 2020. Accessed November 18, 2020 https://www.safety.duke.edu/sites/www.safety.duke.edu/files/Duke-N95-VHP-Decon-Webinar-Slides.pdf

Heimbuch B, Harnish D. Research to mitigate a shortage of respiratory protection devices during public health emergencies. Applied Research Associates. 2020. Accessed November 18, 2020. https://www.ara.com/wp-content/uploads/ARAReviewN95FFRDecontamination.pdf

Liao L, Xiao W, Zhao M, et al. Can N95 respirators be reused after disinfection? how many times? 

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N95 decontamination & reuse comparison matrix. N95DECON. August 8, 2020. Accessed November 18, 2020. 

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Articles

Here, we will review 3 common sterilization modalities currently in use for N95 respirator decontamination, how they work, and their strengths and limitations.


From Single to Multiuse: A Brief Review of N95 Respirator Decontamination Strategies

Coronavirus disease 2019 (COVID-19) found many long-term care facilities (LTCFs) splashed across the front page of national newspapers, but not in the manner that they desired. The well-cultivated images associated with beautifully groomed gardens and formal dining settings were replaced by exhausted care workers wheeling hospital beds to waiting ambulances. These gloomy images captured a severe health care crisis unfolding as quarantining Americans watched and wondered about their elderly loved ones. The LTCF industry watched expectantly as well. As these events unfolded, each organization wondered how they might sidestep a similar crisis, maintain care standards, and avoid an ensuing public relations storm. The efforts of each organization would rely on the ability to manage infection control within buildings, routines, and staffing structures all foundationally not inclined to prevent disease transmission. In retrospect, which organizational response model produced the best outcomes for infection control?

President Joe Biden’s pick for United States assistant secretary of health, then Pennsylvania’s Health Secretary Rachel Levine, MD, confirmed on May 11, 2020, that the state of affairs in Pennsylvania was so compelling that it warranted the removal of her mother from a personal care home.

 As the Pennsylvania’s governor’s choice in leading the pandemic response, Levine had a bird’s eye view of the unfolding crisis. The view from above showed that although only a minority of elderly individuals receive care at LTCFs, the pandemic had disproportionate effects in these facilities. By May 2020, of the COVID-19 deaths in Pennsylvania, 70% had occurred in LTCFs, and these locations accounted for 21% of the reported cases. These staggering statistics were enough for some family members to remove loved ones from facilities.

For those in the industry, removing residents was not an option. They would have to face down the systemic risks rooted in an industry lacking any significant innovation since its inception. These risks included buildings designed for efficient congregant living, communal dining, and shared overextended staffing. In defense of the nursing home industry, these risks are largely a byproduct of decreased assistance in the form of reimbursement. Thus, LTCF providers must continue to consolidate costs to manage historic and continued underfunding. According to a 2016 American Health Care Association report, the cost to nursing homes to care for Medicaid patients exceeded their actual Medicaid reimbursement by $25.43 per day in 2015. This means the average Medicaid resident would cost in excess of $27,000 over their expected 3-year care period.

Systemic risks associated with the intersection of long-term care and infectious diseases required a successful response in the form of a combination of robust measures. Facilities placated with business as usual, the checking-off of survey boxes, and hopes that daily Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), and state health department guidelines would provide the organization protection, soon reported facility wide outbreaks of COVID-19 and accompanying deaths.

A robust response required an organizational structure with components previously in place and an ability to modify existing structures. The organization needed the ability to sustain and achieve new goals within short time frames. These included new regimes in sanitation, dining, laundry, cleaning, and supplies, among others. At the forefront was a culture of trust associated between employees and the organizations’ directors. Managers would need an established trust and support from those working within departments to maintain morale during difficult times. This trust would hopefully avoid extensive turnover and short staffing during a time when the organization needed to maintain high levels of care. Sadly, this has been a significant issue in long-term care, where a recent study in Health Affairs found that the mean annual turnover nationally for total nursing staff was roughly 128%.

The best prepared organizations had previous investments in disease prevention personnel. Outside the traditional medical team, 2 important roles include an infection preventionist nurse and a respiratory therapist. These roles, with the associated training and professional development, were required to provide competences in personal protective equipment (PPE) fitting and infection control practices. Respiratory therapists with hospital training and previous treatment experience in infectious diseases were a strong asset able to provide nursing facilities novel respiratory insight and treatment.

COVID-19 spread quickly in high-density congregant living spaces. Most residents live in shared rooms and have between 3 and 6 caretakers a day. The average resident has about 100 sq ft of living space with limited associated air supply. The entire air in this space is shared with others for 15-minute increments. Difficulties in communicating with the elderly necessitate close speaking. These circumstances present a ripe atmosphere for spreading respiratory diseases. Although residents were largely isolated from the broader population, their caretakers were not. Those organizations that could afford to decrease the interactions of infected individuals within stood the best chance of keeping the virus from spreading. Many measures attempted by organizations focused on this area of containment: screening staff and vendors, suspending or modifying visitations, freezing admissions, isolating residents in their rooms, dedicated isolation floors, masking, decreasing or prohibiting shared staffing between organizations. All of these measures had unintended consequences of isolating and depressing social interaction and thus the quality of life for residents, but they worked. They worked like a porous block of Swiss cheese (ie, James Reason’s Swiss cheese model [SCM]). Reason’s SCM model proposes multiple layers of protection like slices of Swiss cheese to manage risk. The more layers of protection (slices), the greater the likelihood of preventing the transmission of infections.

The timing of precautionary measures was an important contributing factor. Instituted too late, even the strictest of measures are bypassed by a spike in community spread. Records I collected in Lancaster County, Pennsylvania, revealed that facilities that instituted early isolation measures with extensive prohibitions faired the best at keeping the virus out of the facility. Had the pandemic been shortened, these measures might have provided significant returns. However, these early prohibitions were akin to a city under siege. They lasted for some time, but the virus ultimately seems to have “acquired” each facility.

The purpose and mission of long-term care is to provide life-affirming health care services to populations that have no other means or access to skilled care. However, hospital emergency departments and case managers relate stories of elderly individuals for whom they could find no accommodations during the pandemic. Some states had limited programs involving COVID-19–only facilities. This was an attempt to avert the commingling of hospital and nursing home populations. The low quality of the care and poor performance within these facilities has been a topic within CMS advocacy groups.

 Otherwise, skilled nursing facilities mostly closed their doors to protect internal populations. This was arguably a logical component to a broader infection control program. However, defying purpose by closing off resources to a community in urgent need of assistance and causing hospitals the additional burden of providing extended care during a health crisis is hardly a model approach. So, what could have been done?

One facility attempted a novel approach, which I hold up as a model in maintaining the essential purpose and mission of long-term care providers. The facility proactively established a negative pressure zone in its therapeutic center modeled alongside university research engineers. Nursing staff obtained training and expertise from a respiratory therapist with hospital experience in infectious diseases involving PPE and proper isolation techniques. Additionally, they consulted nursing staff at research hospitals operating COVID-19 centers. They then promptly began providing COVID-19 assistance to the elderly within their community, strictly within their designated unit.

The measure was proactive, and the facility experienced no COVID-19 cases outside of the designated unit for several months. During this time, the facility garnered experience in managing COVID-19 while keeping the virus isolated to a uniquely engineered zone. This experience in managing COVID-19 became a resource when the virus successfully “acquired” the facility after months of working through layers of isolation protections (SCM). The virus entered the facility not from the COVID-19 unit as some feared would happen, but a separate location most likely associated with staffing and community spread. The ensuing results were similar yet somewhat better than what other facilities experienced. The facility, sufficient in size with 114 beds, was one of the last in the associated area and broader state to acquire the virus outside its designated COVID-19 zone.

This novel approach is the only one I know of where a nursing facility was able to record assisting more COVID-19-positive residents within the community than it would have had original exposure to. This approach benefited community hospitals, prepared facility staff, and provided economic resources to the organization. The intent to provide this care and the labor and risk that this organization expended deserves recognition. It is to this that I commend Jerry Lile and the employees past and present at Fairmount Homes in Lancaster, Pennsylvania.

CEDRIC STEINER is a licensed nursing home administrator in Lancaster County, Pennsylvania. Contact him at steiner@gshealthcare.org to learn more about the use of negative pressure for immediate or future COVID-19 relief.

Fung, K. Pennsylvania health secretary moved mother out of nursing home as coronavirus death toll increased in state. 

. May 13, 2020. Accessed November 18, 2021. 

https://www.newsweek.com/pennsylvania-health-secretary-moved-mother-out-nursing-home-coronavirus-death-toll-increased-1503853

Long-term care trends and statistics. Pennsylvania Healthcare Association. Accessed February 25, 2021. 

https://www.phca.org/for-consumers/research-data/long-term-and-post-acute-care-trends-and-statistics

Gandhi A, Yu H, Grabowski DC. High nursing staff turnover in nursing homes offers important quality information.

. 2021;40(3):384-391. doi:10.1377/hlthaff.2020.00957

COVID-only nursing facilities: what happened to a good idea? Center for Medicare Advocacy. October 15, 2020. Accessed February 27, 2021. https://medicareadvocacy.org/covid-only-nursing-facilities-what-happened-to-a-good-idea/

Cedric Steiner is a licensed nursing home administrator in Lancaster County, Pennsylvania. Contact him at steiner@gshealthcare.org to learn more about the use of negative pressure for immediate or future COVID-19 relief.

Difficulties in communicating with the elderly necessitate close speaking. These circumstances are a ripe atmosphere for spreading respiratory diseases. While residents were largely isolated from the broader population, their caretakers were not.

How One Long-Term Care Facility Held Off COVID-19

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.”

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)

There’s been a lot of talk about things reopening. From restaurants to schools and so many places in between, it seems as if we’re moving full steam ahead. Vaccines are being deployed and cases of coronavirus disease 2019 (COVID-19) are down, which we’ve been working toward and should celebrate. Two things come to mind, though: Are we being cautiously optimistic or blindly optimistic? Also, how do we handle this challenging time where developments are trending in the right direction but there are still many unknowns and much work to be done?

First, vaccine distribution is increasing as several states have successfully administered a first dose to at least 17% of their population.

 Now is the time that we work to deploy more doses and address perhaps one of the bigger issues we knew would occur—vaccine hesitancy. This is not a new issue and with a pandemic and vaccine development process that was so politicized, it’s not surprising this would be a biproduct.

Data on vaccine distribution, specifically demographics, have been lagging and the data we do have access to have shed light on significant disparities in recipients. As a recent article in Politico points out, “Limited data continues to show that people in hard-hit minority communities are getting vaccinated at a much slower pace than people in wealthier white ones.”

 Coupled with hesitancy, we have a long road to go. Vaccine equity is a global issue, and the variants are a prime reason why we should be emphasizing this. As the United States and many industrialized countries distribute their vaccines, there is a still a huge disparity as many countries are struggling to gain access.

 These larger issues are important as we look to the future and what the next few months or even years will look like.

One of the trends I’ve noticed is that, as states reopen, they have often failed to do so in an incremental manner. We learned this in Arizona, and unfortunately, the United States has a bad habit of rushing things when the case counts start to decrease the burden on public health and health care. As more people become vaccinated, we will be navigating the aspects of a partially vaccinated public. This will be especially challenging as we learn more about prevention of infection and not just severe disease. As virologist Angela Rasmussen, PhD, noted recently in The New York Times: “Many scientists are reluctant to say with certainty that the vaccines prevent transmission of the virus from one person to another. This can be misinterpreted as an admission that the vaccines do not work. That’s not the case. The limited data available suggest the vaccines will at least partly reduce transmission, and the studies to determine this with more clarity are underway. There should be more data within the next couple of months. Until then, precautionary measures like masking and distancing in the presence of unvaccinated people will remain important.”

 While we wade through this optimistic but unknown period in COVID-19 response, it’s important to continue vigilance and patience in these reopening efforts—both within the hospital and in the public.

Huang P, Carlsen A. How is the COVID-19 vaccination campaign going in your state? National Public Radio. Accessed March 1, 2021. https://www.npr.org/sections/health-shots/2021/01/28/960901166/how-is-the-covid-19-vaccination-campaign-going-in-your-state

Kenen J, Ehley B. Urgency to ramp up vaccination clashes with Biden’s equity focus. 

. February 22, 2021. Accessed February 25, 2021. https://www.politico.com/news/2021/02/22/covid-vaccine-racial-disparities-470361

McGregor G. Is the global distribution of COVID-19 vaccines about to get more equal? 

. February 24, 2021. Accessed February 27, 2021. https://fortune.com/2021/02/24/covid-vaccine-who-covax-first-shipment-poor-country-ghana/

Rasmussen AL. Does the vaccine stop transmission? 

. February 23, 2021. Accessed February 27, 2021. https://www.nytimes.com/2021/02/23/opinion/covid-vaccines-transmission.html

For more coverage based on industry expert insights and research, subscribe to the Infection Control Today® e-Newsletter

As more people become vaccinated, we will be navigating the aspects of a partially vaccinated public. This will be especially challenging as we learn more about prevention of infection and not just severe disease.

Beware Pitfalls of Reopening Too Quickly

As Ravi Starlz, PhD, told Infection Control Today® in December,

 when it comes to humanity’s battle against bacterial infections, the bacteria have a head start. “If you’re constantly focused on trying to escalate the war of destruction, I think that the bacteria will always win that war,” said Starlz, an adjunct professor at Carnegie Mellon University. “They just have too many countermeasures available to them, and our rate of developing new antibiotics is far slower than their rate of developing countermeasures.”

Which brings to us to the problem that multidrug-resistant organisms (MDRO) pose to infection preventionists, and for that matter, to the entire health care system.

It’s a problem that investigators at Harvard Medical School and Shanghai Jiao Tong University School of Medicine hope will one day be solved, and that their work will have helped to solve it. Investigators say that surface bacteria can be illuminated using a blue light along with carvacrol, which is a phenolic monoterpenoid that can be found in oils made from oregano, thyme, pepperwort, wild bergamot, and other plants. It’s common, but also uncommon, in that it contains hydrophilic molecules and the phenol moiety. That combined with the blue light can effectively treat skin and soft tissue infections (SSTIs), according to their study in 

Investigators wanted to see how their method would fare against such MDROs as Acinetobacter baumannii and methicillin-resistant Staphylococcus aureus. The 2-step process for SSTIs can also conceivably be used to treat patients with diabetes who suffer from wounds, the sort of wounds that are not always easily treated with antibiotics.

“A growing number of patients with compromised immunity, such as cancer and diabetic patients, invasive medical procedures, and the associated surgical site infections all have contributed to the increasing incidence of SSTI over the past decade,” the study states. “It has been suggested that the ability to control the surface of the wound contamination below 10 CFU/g of tissue is crucial to prevent sepsis, which might be achievable by blue light combined with carvacrol.”

According to the Centers for Disease Control and Prevention (CDC),

 MDROs infect about 2.8 million people in the United States each year, killing about 35,000 of them. The CDC says, “Dedicated prevention and infection control efforts in the US are working to reduce the number of infections and deaths caused by antibiotic-resistant germs, but the number of people facing antibiotic resistance is still too high. More action is needed to fully protect people.”

Disinfecting bacteria on a wound would probably lessen instances of nosocomial infections, according to the authors of the study in 

. MDROs “are commonly colonized on the wound surface and openly exposed to the atmosphere, becoming one of the major sources for contaminating the health care environment and posing high risk to vulnerable patients to contract the bacteria in hospitals,” the study states. “Therefore, quick and efficacious eradication of surface wound bacteria could effectively minimize nosocomial infections.”

The blue light and carvacrol not only killed the bacteria, but also produced no adverse events to the animals used in the study. “We ascribe this safety profile to initiation of the phototoxic cascade reaction by blue light excitation of endogenous porphyrin-like molecules. These porphyrin-like molecules are primarily tetrapyrrole macrocycles—such as protoporphyrin, uroporphyrinogen III, coproporphyrinogen III, and coproporphyrin III—based on their absorbance and excitation spectra and ability to respond to blue light similarly as PPIX [protoporphyrin IX],” the study states. 

Diamond F. Q&A: ‘It’s far worse than COVID’. 

. Published online December 28, 2020. Accessed March 1, 2021. https://www.infectioncontroltoday.com/view/q-a-it-s-far-worse-than-covid-

Lu M, Wang S, Wang T, et al. Bacteria-specific phototoxic reactions triggered by blue light and phytochemical carvacrol. 

2021;13(575):eaba3571.doi:10.1126/scitranslmed.aba3571

Centers for Disease Control and Prevention. Antibiotic/antimicrobial resistance; biggest threats and data. Accessed March 1, 2021. https://www.cdc.gov/drugresistance/biggest-threats.html

Investigators wanted to see how their method would fare against Acinetobacter baumannii and methicillin-resistant Staphylococcus aureus, and results were promising.

Blue Light, Food Oils Combo Kills Superbugs, says Study

One of the most disturbing reports, which has largely gone unnoticed by the news media, was released on December 18, 2020, by the 

 analyzed England’s National Health Service (NHS) data regarding hospital-acquired SARS-CoV-2 infections. SARS-CoV-2 is the virus that causes COVID-19 (coronavirus disease 2019), and unfortunately, 

 found that hospital-acquired infections (HAIs) are not uncommon, estimated to cause nearly 1 in 4 hospital COVID-19 cases. The NHS metric considers any COVID-19 case diagnosed 8 days or more after admission an HAI. The United Kingdom also has a more infectious strain of the virus (B.1.1.7) than is commonly found in the United States.

Information has not been widely available in the US regarding COVID-19 HAIs. The metric used in the US is even more restrictive than the one used in the UK. The US metric defines COVID-19 HAIs as the: “Total current inpatients with onset of suspected or laboratory-confirmed COVID-19 14 or more days after admission for a condition other than COVID-19.”

If one considers that the average incubation period for SARS-CoV-2 is 5.1 days3 and the average hospital stay in the United States is 4.6 days,4 this metric is next to useless. It will at best detect only a small minority of cases. A more accurate metric would define cases that occur after 5 days as an HAI, which would better create a balance between false positive and negative cases. And the metric should count cases that occur for a period of 5 days after the patient leaves the facility, again, creating a balance between false positive and negative cases.

With the Centers for Disease Control and Prevention projecting that the UK variant will become the dominant strain in the US, it is imperative that we bolster our strategies to safeguard both staff and patients.5

Some have postulated the increase in infectivity of the UK strain is due to an increased ability to attach to cells or to more viruses being reproduced by the infected cells. However, I would expect that if its increased spread was based upon these mechanisms, we would see an increase in COVID-19’s case fatality rate. Many sources, including the 

,6 have stated the UK variant is not more lethal than our current variant infecting the United States, D614G.

Other possible mechanisms for the UK variant’s increased spread is either greater survivability in the environment or an increased ability to aerosolize. Thus, we need an increased commitment and enhanced strategies to prevent spread. This includes all health care workers becoming vaccinated. You owe it to yourselves, your family, and your patients to receive the vaccine. The increase in infectivity also raises concern regarding the importance of spread by fomites. Hence, environmental cleaning needs to have strict and comprehensive protocols. All segments of our society, including frontline health care workers, need better personal protective equipment and N95 masks (without exhalation valves). Facilities of all types (including schools and retail establishments) need to increase complete air exchanges and air sanitization. Testing needs to be increased for staff and patients. We also need to eliminate, whenever possible, outpatient waiting rooms, and implement strict social distancing (not having chairs next to doors and areas of traffic flow). Finally, we need “data for action.” We need to have mandatory reporting of worker and patient acquisition of SARS-CoV-2 and the development of COVID-19 with metrics to provide us the most accurate estimate of cases so we can effectively plan and allocate resources.

Diab-El Schahawi M, Zingg W, Vos, M. et al

 Ultraviolet disinfection robots to improve hospital cleaning: real promise or just a gimmick? 

 2021;10(1):33. doi:10.1186/s13756-020-00878-4

Bisht A. How to train environmental services teams. 

. Published online December 11, 2020. Accessed December 17, 2020. https://www.infectioncontroltoday.com/view/train-environmental-services-teams-in-healthcare-the-right-way

In response to COVID-19, companies manufacture robots that would complement the cleaning and disinfection work done by environmental services teams in hospitals. Might the machines also one day take their jobs?

Infection Control Today, April 2021 (Vol. 25 No.3)

From Single to Multiuse: A Brief Review of N95 Respirator Decontamination Strategies

How One Long-Term Care Facility Held Off COVID-19

The STDs Infectious Disease Experts Hate Most

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

Beware Pitfalls of Reopening Too Quickly

Blue Light, Food Oils Combo Kills Superbugs, says Study

Robots Disinfect Hospital Rooms with Ultra-Violet Light

Intense Infection Control Stops C. Auris Spread

Keep an Eye on Ventilation Standards at Clinics

Endoscope Cleaning: What Infection Preventionists Should Know