Making getting vaccinated against influenza has become a requirement for employees in many hospitals and other healthcare institutions. Christopher Blank, CIC, MPH, an infection preventionist with BJC Healthcare, a large healthcare system in the Midwest in which workers are required to get vaccinated, recently sat down with 

 to discuss some of the hurdles involved in flu vaccination campaigns during the coronavirus disease 2019 (COVID-19) pandemic. “Rather than opening up a mass vaccination campaign in the cafeteria and having staff come when they’re able, we’ve tried to focus very heavily on using staff that are working on, for example, a nursing unit to vaccinate coworkers because they’re working together, they have PPE that they’re using,” Blank tells 

. He also says that leadership and various departments at BJC Healthcare have been meeting to discuss exactly how to deal with the COVID-19 vaccine when it arrives. Should it be mandatory for healthcare workers, too?

 are really eye-popping. Before they had to get the flu shot, healthcare workers [at BJC Healthcare] had something like a 70% compliance rate for flu shot, and it after became mandatory it shot up to 98.4%. Were you surprised by the findings?

I don’t know if surprised would be the word I would use. I think when you look at the literature, we know that employer policies make a big difference in this area. The last year of our study, if you look at the overall flu vaccination rate in the United States among healthcare workers, it was around 75% or 80%. But when you break that down, based upon how that healthcare worker’s employer treated flu, you see big differences. It’s less than 50%, or was less than 50%, when employers didn’t require, promote, or offer flu vaccine in that workplace. And it exceeded 90%, nearly 95%, when employers required it and offered it. And so, we know that employer policies matter a great deal. I think this study really is another example and further evidence of just how important employer policies are when we start looking at flu vaccination for healthcare workers.

And if memory serves, you also found that the number of people who asked for exemptions because of religious or health reasons also decreased after the flu shot became mandatory as well?

 Yes. In the year before the mandatory policy, there were about 3400 people. In the 10th year—so after 10 years of a mandatory policy—there were about 400 people in the organization who received a medical exemption, or religious accommodation to flu vaccination. Obviously, a big shift there in terms of people not only getting vaccinated, but actually receiving the flu shot. Not just complying with the policy, but actually getting vaccinated, which is why the policy exists.

I have to ask: Did you get your flu vaccination this year?

Not yet. You know, it just started. Spent a lot of work getting the campaign going. And that’s on my list for either tomorrow or later this week. I want to make sure that we are providing access to all of our staff before I jump in and get in line, but it will be essential, particularly this year. [Note: Blank has since gotten the flu vaccine.]

I have to admit that I haven’t gotten my flu vaccination yet, but I usually do try to get it. I think it’s a good idea. Now, what’s also interesting is that even though you’re talking about the flu vaccine, we know everybody is talking about the coming COVID vaccine when that arrives. Do you think that some of what you found out will carry over to that COVID vaccine? In other words, will hospital leaders make it mandatory for healthcare workers to take the COVID vaccine, or will they wait a while to see how it works in the community and if there might be any side effects?

I think we have to be careful about drawing direct connections from what we know about flu vaccines and how we would approach COVID vaccines. The diseases are different. There are a lot of differences in the vaccine. I think there’s a lot more information that we need to gather and think through and understand before we can take the evidence base that has been developed for flu and how we encourage and promote flu vaccinations and try and directly apply that to a COVID vaccine going forward here. But, that said, just like everything else with COVID, there’s just a lot that we don’t know yet that we really need to understand so that we’re applying things in a way that’s going to work well in that scenario.

You are a practicing infection preventionist. What is your role in the healthcare workers getting flu vaccine where you work?

I’m fortunate in that I am an IP, but I work directly with occupational health and emergency preparedness. We have been fortunate enough to be able to assign an IP to assist with those two departments. I’m heavily involved with flu vaccinations from a data management perspective, from a program management perspective. Although we heavily rely upon our occupational health nurses to actually administer the vaccine, I help support that effort in terms of how we structure our campaigns, as well as how we maintain the data and track compliance with the requirement. And also, this year with everything that’s been going on with COVID, I’ve been heavily involved in ensuring that the design of how we are approaching vaccinations this year is in a way that’s safe and in alignment with the precautions that we put in place to prevent COVID transmission within our workplaces and our facilities.

I think it’s a lot of the strategies that we that we have tended to use, although to the degree that we can, we’ve tried to decentralize. Rather than opening up a mass vaccination campaign in the cafeteria and having staff come when they’re able, we’ve tried to focus very heavily on using staff that are working on, for example, a nursing unit to vaccinate coworkers because they’re working together, they have PPE that they’re using. But we’re not drawing from all of the departments and all of the areas of the hospital into one spot. So, we’ve tried to decentralize where we can. That obviously works in some areas, it doesn’t work in others. We have used and are using appointments. We’re vaccinating by appointment in 10-minute blocks. And then where we have staff from throughout our facility coming to one location to be vaccinated, we’re promoting very heavily some of the social distancing measures that are so important. And then also screening at that vaccination site, which is a requirement already to get to work each day, but just to validate that screening has been done and that the employee is not symptomatic, which is important, both from a safety perspective, but also from a vaccine effectiveness perspective.

How effective is the flu vaccine? I know there might be a range of how effective it is through the years?

Yes, you know, so that varies every year and part of it is the match between the vaccine and what’s circulating. Part of that is what is the predominant subtype of flu that’s circulating. But we know that it is effective. And that even if it doesn’t prevent someone from getting the flu, it decreases the duration and the severity of symptoms. There’s a benefit from a direct prevention perspective, but also from an overall health perspective, even if there is a vaccine breakthrough.

And keeping with social distancing, and masking and decentralizing how the flu vaccine is given out, does that make it harder to keep track of how many employees actually get the flu vaccine?

We’ve been very fortunate. We have a pretty strong data management system in place where we are able to track pretty effectively who is vaccinated, what they’re vaccinated with, the date that they were vaccinated. Information that’s essential from an employee health record perspective, and also essential from a policy compliance perspective. And so that hasn’t been as much of a challenge as some of the other pieces when you think about social distancing steps and other precautions that have the downside of decreasing your throughput a little bit. It requires a little more staff and a little more intensive of an effort in order to reach everyone that that we’ve been able to reach every year. But we’re well on track to be able to accomplish that.

Is there usually a deadline for when staff needs to get the flu vaccination? And has that deadline been adjusted this year in light of everything else that’s happening?

For us, it has historically been before mid-December. And this year, we decided to push that up to before November 25. And the logic for that decision, which wasn’t made lightly, is that we want to encourage earlier season flu vaccination. We also wanted to increase the likelihood that our staff have had time to be vaccinated, develop immunity, before we get to what has historically been our peak flu season, so that it maximizes the effectiveness of vaccination. And from our research, we observed that the dates of vaccination were heavily correlated to when we made concerted efforts to promote vaccination and made it the vaccine most available. And so recognizing that we had a degree of influence at least over when staff got vaccinated, it made it a little easier to stomach trying to do everything that we do in a typical flu season with the precautions that we need to take for COVID. And also do that on a little bit tighter timeline.

What about patients and visitors? Are they reminded about the flu vaccine when they come to your hospitals? Are they getting more encouragement this year?

In our region in St. Louis, we partnered with other healthcare providers in our area to promote flu vaccination broadly to the public. For patients there is a separate essentially protocol for vaccinating patients for flu, who may not be in the hospital for flu and often are not. But as long they’re our patients, we’re able to promote and encourage flu vaccinations.

A lot of my readership, as you know, our comprises infection preventionists. Any words of advice for them about how to go about flu vaccination? Well, let’s back up a little bit. Any words of advice for those [working at hospitals] who have not made it mandatory yet?

So obviously, that’s an organization by organization decision. And there’s a lot that goes into it. I think the evidence base is pretty clear at this point, certainly from our study, and from other organizations that have published their experience with flu vaccination and flu vaccination requirements, that it is effective. And that we’ve been able to sustain that effectiveness over 10 years. One of the key steps as you’re approaching this is truly leadership support and buy in from some of your key groups in the organization. We’ve been very fortunate that we’ve had strong leadership support for when it was a promotion and an encouragement phase for doing that. And then when it became a requirement, that support which is so important, has been sustained. Because if not…. There are resources that are required in order to do this. We’re vaccinating around 30,000 employees every year. And BJC Healthcare leadership supports that effort and the resources that are required to reach all of those employees. They support the requirement to do it. And they’ve also supported us as we’ve administered this program and move forward. Building that leadership support has been really important for us.

You used the phrase keep key groups in the organization. Now, aside from leadership—and I think by leadership, you mean hospital administrators or the hospital administration team—what are the key groups as far as the vaccination program in hospitals are concerned?

I think if you look at your big employee groups. So nursing, obviously in a hospital, that’s a major staff population and ensuring that nursing is aware of the discussion, participating in that discussion and ultimately, ideally supportive of the requirement is important. Obviously, there’s going to be a medical provider component to it as well. But also thinking through what will this mean for occupational health. And who is going to be—to the extent you need—the person who’s going to enforce the requirement. HR as a partner is particularly important. Human resources as a partner has been a key partner for us. In occupational health going forward from your other requirements, because there is being a condition of employment, we needed human resources to be supportive of that. And then also assisting in some of the religious accommodation components of the requirement. That’s really not an occupational health issue so much as a human resources issue. Human resources has been a key partner on that as well.

Are you meeting now or making plans now with either hospital administrators or anybody else in hospital for when the COVID-19 vaccine does arrive and how you’re going to deal with that?

We have a planning team that is multidisciplinary that has been meeting. It includes infection prevention, it includes emergency preparedness, occupational health, human resources, pharmacy supply chain. I’m sure I’m missing a few others that are part of our group that’s actively trying to develop what our strategy is going to be. There are a number of things that we don’t know, that make developing that strategy a little more difficult. But we’ve been meeting now for probably about a month, just trying to understand what is the current landscape and trying to stay current on that, which is its own almost full-time job. And then trying to think through what that will look like for our organization, particularly where our organization is in two different states, which adds its own layer of complexity.

Anything I neglected to ask you that you think might be pertinent?

I don’t think so. I think you covered … just looking at my notes to see if I didn’t cover anything. And I think the only point I would make that was another interesting finding that we had very specifically around the medical exemption is that with the advent of the egg-free flu vaccine, that really made a big difference on the number of employees that needed a medical exemption. And we didn’t necessarily see a mass migration from “I need a medical exemption because I have an egg allergy” to “I need a medical exemption for another reason.” And so, we were able to—and do—provide an egg-free flu vaccine that reached a notable number of our employees that were exempted from the from flu vaccination for that reason.

This interview has been editor for clarity and length.

Videos

Christopher Blank, CIC, MPH, an infection preventionist with BJC Healthcare, sits down with Infection Control Today® to discuss the benefits of making employment for healthcare workers contingent on getting the flu vaccination. 

Infection Preventionist Leads Flu Vaccination Effort

In a study of 596 patients with coronavirus disease 2019 (COVID-19) who were admitted to an intensive care unit (ICU) in New Delhi earlier this year, 15 (2.5%) had bloodstream infections caused by the drug-resistant “superbug” 

.1In 10 patients the predominant agent was 

. Two of the patients had hospital-acquired COVID-19.

Eight of the patients with candidemia died. That’s a death rate of 53%. Among those with 

, the death rate was 60%. “Of note,” the researchers say: 4patients who died experienced persistent fungemia and despite 5days of micafungin therapy, 

Data like those are why the US Centers for Disease Control and Prevention (CDC) calls 

 a “serious global health threat.” In a 2017 interview with 

, Anne Schuchat, MD, then acting director of the CDC, called 

 a “catastrophic threat” to society.2 At that point at least 61 patients had been diagnosed with 

 infection; the count was soon to rise to 98.

’s Editorial Advisory Board, says that drug resistant 

 is a dangerous pathogen, it first came to attention back in 2015. “Presently, it is known to be highly infectious and can cause dangerous co-infections,” says Kavanagh.”

 co-infections do occur in COVID-19 patients and if present the case-fatality-rate is 60%.3

 is a fungus not a bacteria and unfortunately there are few treatment options, with some strains becoming resistant to all of them.1

 has been diagnosed in 40 countries since the first report about it in 2009, when clinicians found a single isolate from the discharge of the external ear canal of a 70-year-old inpatient at Tokyo Metropolitan Geriatric Hospital. By 2016, 13 cases had been identified in the United States, leading the CDC to issue interim recommendations, as well as a clinical alert, requesting laboratories to report cases and send samples to state and local health departments and the CDC.3

The CDC cites 3main reasons for concern about 

First is that it’s difficult to identify it with standard laboratory methods. It can be misidentified in labs without specific technology, which can lead to mismanagement.

 is often resistant to antifungal drugs used to treat 

Third, importantly, it can cause outbreaks in hospital settings. 

 outbreaks have resulted in mortality rates as high as 72%.4 Although 

 is the main agent of hospital-acquired fungal infections, 

 in particular attacks patients with weakened immune systems, making it an even more serious concern when 8% to 9% of roughly 530,000 ICU patients in the United States have COVID-19.5

The CDC updates case counts monthly; the count as of this writing is 1272 clinical cases,5 based on cultures or culture-independent diagnostic testing from specimens collected during the course of clinical care. A targeted screening conducted as part of an effort to control the spread of 

 turned up another 2493 patients found to be colonized with 

 (patients may be carrying the fungus but not necessarily be sick with the infection).6

The problem has been on the rise and is complicated by the coincident pandemic. The California Department of Public Health (CDPH), for instance, issued a health advisory in August alerting healthcare providers to the increasing number of 

 cases reported in southern California: The number of newly identified 

 cases more than doubled from May to June. July cases (73) exceeded the combined total for April, May and June (59). According to the CDPH, personal protective equipment (PPE) conservation strategies and other containment practices on the basis of COVID-19 status alone “might be contributing to this resurgence.”7

In a study published in June, Chowdhary and Sharma3 point out that COVID-19 patients who are pre-colonized with 

 and who require indwelling catheters have higher risks of 

–related bloodstream and urinary tract infections. It’s also important to emphasize, they say, that COVID-19 patients in the ICU tend to share risk factors, medications, and underlying comorbidities with 

 infections, such as diabetes, chronic kidney disease, intubation, and administration of broad-spectrum antibiotics.4

 in the United States have been linked to other parts of the world, the CDC says, “a result of inadvertent introduction.” Limited diagnostic capabilities in developing countries may mean under-recognition of fungal coinfections in patients with COVID-19. Chowdhary and Sharma called 

 a “lurking scourge.” They warned the global medical community about the potential of 

 as a confounding factor in COVID-19. They suggested that COVID-19 patient mortality might already have contributions from 

 or other coinfections. A follow-up study, published in October, bore out their prediction.

Chowdhary et al1 say the patients in that study were probably infected while hospitalized, highlighting the fact that 

 can be transmitted in healthcare settings just like other multidrug-resistant organisms (MDROs), such as methicillin-resistant 

 (4patients also had bacteremia caused by 

Despite upgraded infection control measures, they say, the pandemic may provide “ideal conditions” for outbreaks of 

 in hospital ICUs. They point out that both 

 and SARS-CoV-2 have been found on hospital surfaces, including air conditioner ducts, windows, and hospital floors. 

 can survive on a wide range of surfaces, both dry and moist, for up to 14 days. Disinfectants with sporicidal activity and hydrogen peroxide-based products are the most successful, so far, at reducing 

 colony-forming units, and chlorine-based detergents, ultraviolet light, and hydrogen peroxide vapor have been effective in environmental decontamination. But Coriegiani et al say the persistence of 

 in the hospital environment despite disinfection procedures suggests “an involvement of the interaction between the pathogen and surfaces and the length of exposure to disinfectants.”8

Those researchers also cite evidence that 

 is spread through exposure to contaminated facilities and transmission from healthcare personnel. Persistent outbreaks, they note, have been associated with hand transmission and contamination of surfaces. Positive samples have been collected even from surfaces with little to no patient contact and infrequent healthcare workers contact, such as door handles and alcohol gel dispensers. Thus, these researchers say, once 

 is introduced in the hospital setting, environmental contamination “evolves well beyond the patient bedside.”

 is not only a health threat—it’s an economic one. Each case of candidemia results in an additional 3 to 13 days of hospitalization and costs between $6,000 and$29,000, according to the CDC.9 So until a more effective treatment for multidrug-resistant 

 can be found, the best offense is a good defense.

 is its sheer tough persistence. Patients and residents in healthcare facilities often remain colonized with 

 for many months—“perhaps indefinitely,” the CDC says bleakly—even after acute infection has been treated and resolves. It can be shed into the environment and linger there for weeks, which makes infection control both an immediate and an ongoing issue.

To try to corral the fungus before it reaches vulnerable patients; the CDC recommends placing high-risk patients on preemptive contact precautions while awaiting screening results. The CDC says healthcare providers don’t need to be tested for 

 unless they’re identified as a possible source of transmission to patients.

With regard to PPE, the CDC advises against reusing or extending use of gloves or gowns between patients with different or unknown 

 or other MDROs and COVID-19. If PPE is in short supply, prioritize gown use for high-contact care activities and extend use of gowns only when patients are known to have the same infectious status and when those patients are housed in the same room. Healthcare providers should not continue to wear their gloves and gowns in the same hallway or other common areas—even in the designated COVID-19 unit.

Other means for keeping the counts down include putting patients in single rooms if possible; if not possible, a patient with both COVID-19 and 

 should only be placed in the same room as another patient with COVID-19 and 

Multiple patients with the same conditions can be placed together in 1wing or unit to reduce the direct movement of healthcare personnel and equipment from those colonized or infected with 

 from turning into a nosocomial nightmare, stringent measures are called for, but sometimes even those aren’t enough. Infection control specialists at London’s Royal Brompton Hospital were thwarted by 

which was on the rampage for 16 months in the ICU. Enhanced cleaning didn’t stop the spread, nor did segregating infected patients. In a last-ditch effort, the hospital temporarily shut the ICU. The outbreak finally ended—after 22 of 50 patients developed possible or proven 

 was detected in <1% of healthcare personnel.

Colonization was transient on the hands and in the nostrils. However, the researchers learned some hard lessons about the fungus’ “innate resilience” during the outbreak. Despite the recommended daily chlorhexidine washes, they say, “patients continue to be colonized.” They cite other studies showing that hands can be key vectors in the transmission of 

 species via direct contact with patients or indirect contact with contaminated environment or equipment.

The Royal Brompton Hospital outbreak, in 2015-2016, was the first experience with the baffling “globally emerging” 

 in a European hospital. Since then, epidemiologists and infection preventionists have learned more but, all in all, still don’t know enough about what promotes 

 transmission to stop it. A variety of treatments are being posited, such as antimicrobial peptides. Until those candidates get past the first research stages, though, 

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

Chowdhary A, Tarai B, Singh A, Sharma A. Multidrug-resistant 

 infections in critically ill coronavirus disease patients, India, April–July 2020. 

https://doi.org/10.3201/eid2611.203504. Accessed 10-12-20

Branswell H. A ‘perfect storm superbug: How an invasive fungus got health officials’ attention. 

https://www.statnews.com/2017/04/21/superbug-cdc-fungus-candida-auris/

Vallabhaneni S, Kallen A, Tsay S, et al. Investigation of the first seven reported cases of 

 a globally emerging invasive, multidrug-resistant fungus — United States, May 2013–August 2016. 

 A. The lurking scourge of multidrug resistant 

. 2020 Sep; 22: 175–176. Published online 2020 Jun 12. doi: 

Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN). Current hospital capacity estimates – Snapshot. 

https://www.cdc.gov/nhsn/covid19/report-patient-impact.html

Centers for Disease Control and Prevention. Tracking 

https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html

California Department of Public Health. Health advisory: resurgence of 

 in healthcare facilities in the setting of COVID-19. August 2020. 

https://www.smchealth.org/sites/main/files/file-attachments/2020-08-19_mdroandcovid-19containmentcahan081920.pdf?1597881499

egiani A, Misseri G, Fasciana T, et al. Epidemiology, clinical characteristics, resistance, and treatment of infections by 

. 2018; 6: 69. Published online 2018 Oct 29. doi: 

Centers for Disease Control and Prevention. Invasive candidiasis statistics. 

https://www.cdc.gov/fungal/diseases/candidiasis/invasive/statistics.html

 First hospital outbreak of the globally emerging 

https://doi.org/10.1186/s13756-016-0132-5

Articles

Candida auris is difficult to identify with standard laboratory methods. It can be misidentified in labs without specific technology, which can lead to mismanagement.

COVID Unleashes the ‘Lurking Scourge’ Candida Auris 

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today.

Bug of the Month: I’m Mostly a Non-Entity Until I Turn Deadly

The first case of coronavirus disease 2019 (COVID-19) in the United States was reported on January 21, 2020.

 A lot has changed since then. People outside of healthcare have become all too familiar with terms usually reserved for epidemiologists and public health professionals such as pandemic, social distancing, hand hygiene, masking, family pods, antibody tests, and quarantine. Healthcare personnel have also learned a thing or two about all of these terms and much more. Infection prevention and control (IPC) teams have been thrust to the forefront to guide staff through these challenging times, sharing their knowledge of personal protective equipment(PPE), disinfection of medical equipment and patient care spaces, and communicating the ever-evolving changes as more information is gained about SARS- CoV-2, just to name a few.Articles about “lessons learned” and what healthcare providers and hospital systems can expect in the coming months are plentiful, but no one really knows what lies ahead. Healthcare and the world have been turned on its head. Outside of healthcare, everyday items like toilet paper and paper towels became scarce. In healthcare, things that we took for granted, such as performing our daily tasks of providing patient care and keeping an eye on PPE, disinfectants and cleaners, hospital bed availability, critical medications and equipment, and especially staff, became problematic as supplies proved to be in short supply and infection preventionists (IPs) had to hit the ground running. COVID-19 demonstrated huge gaps in preparedness worldwide. So, the key “takeaway” is the need for preparation for the upcoming months and into the future. The COVID-19 pandemic is here to stay so we had better learn from it to prepare for the next one because there will be another.

During the beginning of the pandemic, the importance of ongoing communication was highlighted. IPC staff learned they needed to find ways to stay on top of all of the information that was being disseminated by the various media sources. Although social media platforms like 

Facebook and Twitter seem to be the “go- to” source for information these days, IPs had to keep up-to-date on information provided by reliable sources such as the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC), and the Association for Professionals in Infection Control and Epidemiology (APIC), and redirect healthcare personnel to these “sources of truth.” Communication via in-person in-services and huddles, real-time education, and handouts became absolutely vital for providing accurate information and guiding practice. The ability to answer questions and explain why just yesterday we were doing something differently than today occurred fairly frequently because of the evolving nature of the pandemic. Communication had to be winnowed down to succinct bullet points with the disclaimer that we still don’t know very much, and things could change. And change they did!Another key lesson IPC staff learned was how important it was to keep a rolling supply of PPE on hand.

 Most hospitals maintain adequate supplies of PPE on patient care units and in supply rooms, but none anticipated the amount of PPE that would be needed for the volume of patients ill from the virus. PPE shortages caused serious problems for some hospitals necessitating the need to reuse, or reprocess for reuse, PPE, especially N95 masks. This was uncharted territory for IPC professionals and healthcare workers. Healthcare workers faced possible risks from reusing PPE previously designated as one time or single-patient use. Donning and doffing used PPE posed risks of self-contamination and possible PPE failure. IPC staff had to step in and train staff on how to safely reuse PPE.

Looking back, IPCs learned they needed to audit not only when PPE should be used but also how staff don and doff. They also learned that retraining staff to reuse PPE, no matter how well they messaged it, was a difficult task at best because of staff safety concerns. To counteract the justifiable staff safety issues, some hospital systems are stockpiling PPE. In order to not waste the stockpiled supplies by letting them expire, more frequent drills are planned to keep the supplies fresh. To help prevent shortages of PPE from happening in the future, hospitals in some states, California for example, have recently passed a law that requires hospitals, nursing homes, large medical groups and dialysis clinics to have a 45-day supply of pandemic-level PPE on hand. IPCs learned you can never have enough PPE on hand and staff work better when they know they are being kept safe.IPCs learned how to think outside the box to help create safe, flexible spaces to accommodate large volumes of patients, both COVID-19 positive and non-COVID-19 patients. They learned about the importance of ventilation and barriers. Fatigue and the emotional toll on the frontline staff was something no one saw coming. IPCs and healthcare staff learned to lean on each other for emotional support. They learned the importance of flexibility in planning and thinking, re-evaluating how processes and practices can be safely continued with many different variables. As states begin to re-open their economies and healthcare facilities continue to be financially and physically exhausted, fears of a second wave of the coronavirus are a growing concern. According to the director of the CDC, Robert Redfield, MD, “a second wave of the novel coronavirus will be far more dire because it is likely to coincide with the start of flu season. Hav- ing 2 simultaneous respiratory outbreaks will put significant strains on healthcare systems.”

 These factors heighten the importance of remaining prepared for what lies ahead. The pandemic mitigation tactics for the public of frequently washing hands, wearing face masks, and physically distancing and avoiding gatherings, especially indoors, remain important measures to enforce. Increasing and sustained public buy-in on these measures, as well as ramping up flu vaccination, would help prevent further strain on health systems and staff in the months ahead.

Health systems and healthcare workers should have evaluated what worked and what didn’t during the pandemic onset. They should be stocking up on equipment like ventilators, medications, and personal protective supplies, including gowns, eye protection, and masks. Cleaners, disinfectants, and hand sanitizers should have been purchased in sufficient quantities, if available. Alternative products should be investigated and validated. IPCs should be rounding, auditing, and training on all aspects of PPE, cleaners and disinfectants, especially if new products have been introduced. Examination of patient surge capabilities and patient throughput should be performed, refined and tested, running drills for worst-case scenarios. Processes and protocols should be in place to support staff mentally and emotionally. COVID-19 has already taken over 1 million lives worldwide, more than 200,000 of them American lives, as of October 8, 2020. COVID-19 is here to stay. Some believe the future course of the pandemic will play out as different scenarios such as low-grade continuing infectivity, gradually infecting more younger people, or local and multiple outbreaks on a small scale. Worse yet, disastrous uncontrollable second waves may occur in the United States as well as in many other countries. Best advice—plan for the worst, hope for the best. The devil is in the details.

SHARON WARD-FORE, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago. She is also a member of 

Johns Hopkins University & Medicine Coronavirus Resource Center. Accessed October 4, 2020. https://coronavirus.jhu.edu/data/cumulative-cases

LagasseJ. California passes nation's first bill requiring hospitals to keep a 45-day supply of PPE.Healthcare Finance News. September 2, 2020. Accessed October 4, 2020. https://www.healthcarefinancenews.com/news/california-passes-nations-first-bill-requiring-hospitals-keep-45-day-supply-ppe.

Washington Post. CDC Director warns second wave of Coronavirus is likely to be even more devastating. Washington Post website. Accessed October 5, 2020. https://www.washingtonpost.com/health/2020/04/21/coronavirus-secondwave-cdcdirector/

The ability to answer questions and explain why just yesterday we were doing something differently than today occurred fairly frequently because of the evolving nature of the pandemic. 

The Year Infection Preventionists Showed the World Their Worth

Despite a clear requirement of water vapor during the human breathing process, the presence of water in the gaseous state, or humidity, in buildings has acquired a bad reputation. Even hospitals prefer to turn humidification systems off in patient-occupied spaces. The reasons for a dislike of humidification are complex, but the lack of understanding about health problems associated with low humidity has resulted in harmfully dry indoor environments. In fact, we now know that low humidity strengthens infectious microbes and weakens the human immune system.

This is especially problematic in regions with cold winter months when outdoor air is heated to comfortable indoor temperatures and the indoor relative humidity plummets to values of less than 30%. Are our prejudices about indoor humidity correct? Turning to scientific data is essential when trying to differentiate between subjective opinions and best-practice actions based on objective data.

Where can we gather relevant data on water vapor and occupant health? One great place for such research is the hospital. The reason for this is that we collect reams of data from the most relevant occupant—the patient. From vital sign measurements, blood cell and chemistry analysis, microbiology culturing of every imaginable fluid to imaging and other diagnostic procedures, we gather tremendous amounts of data from the patient. This wealth of data on humans can be correlated with indoor air metrics to understand whether our views on best indoor air quality is truly beneficial to people.

Currently, clinicians caring for in-patients focus on medical and surgical interventions that will hopefully heal the patient. Meanwhile, hospital facility managers follow building standards that are not necessarily based on medical data. Caught in the middle are infection preventionists (IPs), the team that strives to protect the patient from encountering infectious microbes during their inpatient treatment that could result in a healthcare-associated infection (HAI). By having an understanding of how the built environment influences clinical outcomes, the infection control team can utilize a whole new set of tools for reducing HAIs. We are now learning just how impactful these measures are.

A 2014 landmark study in a tertiary care hospital analyzed patient room metrics in conjunction with HAIs in the patients occupying those rooms. Data on clinician and visitor activity, indoor air metrics, and new infections in the patients inhabiting those rooms was logged for 1 year. Rigorous statistical testing using multivariable regression analysis was applied to the data to look for independent correlations between the indoor environment and patient HAIs. To the surprise of the author, the most significant correlation with which infection rates was room relative humidity (RH) less than 40%.1 When the patient room RH was above 40%, the infection rate was close to 0.

Another study following this protocol was done in a nursing home in 2015. Once again, when the indoor RH fell below 40% the infection rate was high.2 The ideal zone of indoor humidity for best patient outcomes was found to be RH 40%-60%. Although these 2 studies reveal powerful correlations between dry indoor air and poor patient health, they do not prove causation because of the lack of data from a simultaneous control group.

In 2016, researchers at the Mayo Clinic published a study that showed a causal relationship between low indoor humidity and increased infectivity of the influenza virus in preschool children.3 This study compared indoor RH of 20% or 45% with the number and infectivity of influenza virus in classrooms and with the number of school days missed by the children in each area. The humidified rooms had fewer and less infectious viral particles as well as significantly fewer children absent from influenza illness.

The infectivity of airborne viruses and bacteria depends on the transmission and infectivity of pathogens and on the vulnerability of the secondary human host.

When a person with a respiratory infection breathes, talks, or coughs, their airways expel thousands of droplets containing saliva, mucus, and embedded microbes into the ambient air. Moisture levels in the expelled droplets quickly equilibrate with ambient air water vapor through condensation and evaporation. Thus, vapor equilibrium, or RH, of room air determines the resulting droplet size, concentration of salts and the viability of the infectious microbe.

When expelled droplets encounter dry room air with RH less than 40%, they instantly shrink by roughly 90%. The resulting tiny droplet nuclei with diameters less than 0.5 microns can remain airborne for extended periods of time and be carried over great distances.

Prior to the use of genetic analysis tools, microbiologists determined the infectivity of these tiny droplet nuclei through the ability to grow the organisms on incubated petri dishes, known as tissue culture. This technique vastly undercounted the number of potentially infectious particles. We now supplement tissue culture with techniques that identify the genetic material of particles. This has revolutionized our thinking about microbes, human health and the indoor environment. For example, we have learned that infectious microbes in dry airborne aerosols are often temporarily in a dormant state, yet highly infectious when rehydrated.

When desiccated droplet nuclei suspended in low RH ambient air are inhaled by a secondary host, the droplet rehydrates in moist airways and many pathogens are able to begin a new infectious cycle (Figure 1).

Conversely, when ambient RH is above 40%, the respiratorydroplets maintain larger diameters of approximately 50 microns. Becausethe droplet diameter dictates the settling distance and rate,these larger droplets land on surfaces within 4 to 6 feet oftheir source where they can be efficiently removed with surface cleaning. Clearly, as transmission through room air or mechanical systems is decreased, the possibility of a secondary host being exposed is proportionately decreased (Figure 2).

Air sampling that mistakenly excludes the dormant pathogens in droplet nuclei underestimates the infectious load of indoor air particles. In fact, microbiologists now conclude that most infectious microbes that can transmit disease through contact also move through the air at some point between the initial host and a secondary host. Because of this airborne component of disease transmission, even the strictest adherence to hand, surface and short-range droplet hygiene will not reduce the incidence of infectious diseases as much as when the airborne route is also managed.

Not only does low indoor RH increase pathogen infectivity and transmission, it also diminishes the integrity of the human immune system. When RH is maintained between 40%–60%, the natural human skin and respiratory tract defenses and immune cell functioning are optimized.

In summary, the hospital’s physical environment has a significant impact on the health and healing of patients. Unfortunately, avoidable HAIs harm too many patients and cause significant waste of healthcare dollars.

By maintaining RH in patient care spaces between 40% to 60%, the transmission and infectivity of airborne pathogens will be reduced, surface cleaning will be more effective and patient immunity will be optimized.

Current indoor air guidelines for hospitals do not specifya lower limit RH in patient care areas and are evenpromoting lowering the minimum acceptable RH level inoperating rooms from the current 35% down to 20%.This is a mistake! Management of healthcare facilities mustfocus on the number one priority— patient healing.

Managing the indoor physical environment of hospitals and out-patient centers to optimize patient care is neglected. This may be because awareness of the powerful impact of indoor air quality, and specifically the value of proper humidification, on human health is lost between the silos of clinical medicine and facility management. The infection control team, once again, must come to the rescue of patients.

Stephanie Taylor, MD, M. Arch, is an infection prevention consultant at Harvard Medical School. She is also the CEO of Taylor Healthcare Consulting, a member of ASHRAE Epidemic Task Force, Environmental Health Committee and a Distinguished Lecturer.

Where can we find data on whether or not water vapor is necessary for humans residing in buildings? One great place for such research is the hospital. There is a tremendous amount of data that is collected from one type of hospital building occupant—the patient.

Why Water Vapor in Hospitals Matters

Preventing surgical site infections has long been the goal of hospitals across the United States. Important components for preventing SSIs are:

Implementation of the US Centers for Disease Control and Prevention’s (CDC) 2017 updated guidelines for the prevention of SSIs.

Compliance with recommendations for proper prophylactic antimicrobial use for its efficacy against pathogens causing SSIs for specific procedures.

Self-monitoring of procedure and processes with the surgical suites.

Rounding by the hospital’s infection preventionist.

Following guidelines from credible organizations.

These are the key components to limiting or decreasing SSIs to 0 or as close to 0 as possible. This article will concentrate on surgical rounding by the hospital’s infection preventionist (IP). There are 4 key areas that the IP should focus on: the environment throughout the surgical 

suites, the surgical attire of staff, decontamination and the sterilization processes. New IPs can use this checklist to perform IP rounds in the surgical suite, decontamination areas, and sterile processing area. Included with each question is a rationale that can be used as training for the new IP.Developing well-run, infection-free surgery and post-surgical practices is important in today’s market of reimbursement that rewards good performance.

SSI rates are one of the key safety measures tied to value-based purchasing programs as well as the Afford- able Care Act Hospital Readmissions Reduction Program, in which the Centers for Medicare and Medicaid Services (CMS) will penalize hospitals for readmissions in some situations. To be successful, there must be a multidisciplinary effort that includes the surgical team, decontamination and sterile processing, infection prevention techniques, and training as to the post-op care of the patient and surgical site, as well as environmental services and plant operations.

The provided checklist is only a small sample of items that beginner IPs can utilize when making rounds in the OR, decontamination, and sterilization areas.

It is important for IPs to continue their education around this topic so they can continuously improve on their skills in identifying issues within the OR, decontamination, and sterile processing areas to ensure safety for patients. To learn more, a good resource is the 

1 published by the Inter- national Association of Healthcare Central Service Materiel Management (IAHCSMM) (page numbers in the tables refer to the manual).

Patel SN, Murray-Leonard J, Wilson AP. Laundering of hospital staff uniforms at home. 

Munk S, Johansen C, Stahnke LH, Adler-Nissen J. Microbial survival and odor in laundry. 

Nordstrom JM, Reynolds KA, Gerba CP. Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs. 

New infection preventionists can use this checklist to perform IP rounds in the surgical suite, decontamination areas, and sterile processing area.

Checklists for Infection Preventionists Working in ORs 

Along with it brought the generosity of many to help others in a variety of ways. As hospitals and healthcare facilities quickly began to run out of regular supplies such as personal protective equipment (PPE) and hand sanitizer, numerous companies and individuals quickly offered their support in the form of donations of supplies or production of much-needed items. However, with the abundance of donations and new products that have come to market, it is important to still validate the effectiveness and authenticity prior to use in the healthcare setting.

As COVID-19 spread through the United States, inventory of PPE rapidly declined and, as respiratory season continues, the potential for PPE shortages remains. When purchasing or accepting PPE or other medical supplies from new manufacturers, the following criteria are important to consider.

Obtaining Samples Prior to Purchase or Donation

COVID-19 has offered the opportunity for new manufacturers and inventors to come to the market, especially when it comes to healthcare supplies. If it is possible to obtain samples of products that are available for purchase or donation before they are bought or delivered, multidisciplinary teams can have the opportunity to review items to determine whether the items will be useful and where they can be best used. For inventors who are hoping to donate products, this can also be a way to offer feedback so that changes can be made before products are donated.

Gowns, gloves, facemasks, and eye protection worn in clinical settings all have standards to prove compliance in how products are made and used. Common standards organizations are ASTM Inter- national (indicated by the symbol ASTM on products, formerly the abbreviation for the American Society for Testing and Materials)

, American National Standards Institute (ANSI)

, the National Institute for Occupational Safety and Health (NIOSH)

, and the US Food and Drug Administration (FDA)

. Many of these standards have been made readily available during the pandemic. Supplies which do not meet these standards, should be carefully assessed on whether clinical use is appropriate.

Although proof of standards on packaging and PPE are often good indicators that products have been validated, throughout the pandemic, many have seen the use of counterfeit products which are falsely marketed and sold. One of the most common imitated PPE items hospitals have seen have been respirators. NIOSH regularly updates its website

 to show non-NIOSH- approved respirators and common signs to indicate that respirators may be counterfeit.

Lastly, when evaluating new PPE, consideration in how the PPE may affect donning and doffing should be reviewed. When new PPE is brought into a facility, additional training may also need to be feedback so that changes can be made before products are donated.

Two items which many infection preventionists (IPs) are infamous for always having with them are hand sanitizer and disinfectant wipes. These products have not only vanished from stores and hospital shelves, but have significantly increased in price. As many common brands of hand sanitizer and disinfectant wipes ran out of stock, manufacturers of other products have come to the market with their own versions of these highly sought after items. When accepting or purchasing hand sanitizer, the US Centers for Disease Control Prevention (CDC) recommends the use of an alcohol-based hand sanitizer that contains at least 60% alcohol.

 Hand sanitizer that contains higher amounts of alcohol is not necessarily better as it can lead to skin drying or adverse reactions. In addition to the amount of alcohol, scent should also be considered, as fragrances in the healthcare setting can affect both patients and healthcare staff.

Prior to purchasing new wipes to use in facilities, it is important to make sure that they are not only effective, but that the con- tact wet time to be effective is a reasonable time. Because SARS-CoV-2 is a novel virus, the US Environmental Protection Agency (EPA), developed a database, known as List N

, which is updated frequently to document products which are effective against SARS-CoV-2 along with the contact time required. After ensuring wipes are appropriate for use, it is also vital to check that they are compatible with equipment that will need to be disinfected.

Generosity during the pandemic has not only been seen with medical supplies. Many businesses, including restaurants, have wanted to show support to frontline providers through the donation of food. In accepting food donations on units, requesting individually packaged meals over buffet trays is preferred. If food is brought to a unit, remembering to place it in the refrigerator if it is not consumed in a timely manner is also important to avoid spoilage. When eating, remembering to stagger meals in common spaces is also a priority to reduce the number of individuals to maintain physical distancing.

As time goes on, the hope is that the supply chain for much needed products will be restored. In the interim, it is important to maintain standards in bringing in new items and donations to protect not only healthcare providers, but anyone who enters the health system as well.

If you are an infection preventionist and are not currently involved in product review, now may be a great time to reach out to your supply chain team to explain the perspective you can bring to the table and ask to be involved.