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.

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Articles

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

Bug of the Month: I Can Be Deadly for Cystic Fibrosis Patients

A vascular access consultation order is placed, and the process begins. What is the patient’s admission diagnosis? Ordered medications? Expected length of stay? What is their vascular access history and what might they need in the future? Are there any physical, psychological, or perceptual barriers in regard to the placement of a vascular access device (VAD)? What is the patient, nursing staff, and physician preference in VAD? All these questions are addressed by the vascular access specialist working in today’s healthcare environment.

As healthcare has evolved, so too has the role of those working in the vascular access specialty. At my 117-bed community hospital, I have been a part of much of this evolution. When I started placing peripherally inserted central catheters (PICC) 7 years ago, I knew very little about vascular access as a specialty. PICC placement was a skill I had wanted to learn since I witnessed my first placement while still in nursing school and, once I became part of the “PICC Team,” I worked hard to improve my skill.

I did not look at vascular access in a holistic way, and I did little in the way of assessment prior to placing an ordered PICC. As my knowledge grew, I joined national professional organizations, attended local chapter meetings, and read professional journals, and it became clear that the PICC nurse was evolving into the vascular access nurse. I realized the next step would be forming a vascular access team.

The vascular access team at my facility was created 2 years ago with the goal of improving patient outcomes and increasing staff and patient satisfaction. Although we have never had a large number of central line-associated bloodstream infections (CLABSIs), one of our biggest goals was to prevent CLABSI by ensuring that only the most skilled inserters place PICC and midlines and that daily rounding by specialists is performed on all central lines. Although our infection preventionist is not an official member of the vascular access team, we do work closely with her to update and create new policies and interventions pertaining to vascular access. We also work together to stay current on best practices and to trial any products we feel might benefit our patients in reducing infection rates.

Our close working relationship with the infection preventionist stems from the fact that we trust each other to keep what is best for patients at the center of everything we do. We also have great respect for each other’s expertise and recognize that our specialties intersect in many areas.

Although both vascular access and infection prevention have their own focus, our commonality is in ensuring patients get the care they need while minimizing their chances of nosocomial infections. Infection preventionists have a wide scope, as infections can be caused by many factors while in the hospital, from medical devices to the hands of the healthcare workers caring for them. Vascular access specialists focus on the devices placed into the bloodstream of patients in order to deliver needed medications, allow access for dialysis, or accurately monitor blood pressure. It is because we know that these devices can be a conduit for life-threatening infectious agents that infection preventionists are vital to our specialty.

Since we are a smaller facility with a team of 2 vascular access nurses, we only officially round on central lines; however, we are called daily to assess VADs of all types, intervene when necessary, and replace VADs when required. Our objective is to get the patient through their hospital stay with the least invasive vascular access device that is appropriate for their condition while experiencing as few needle sticks as possible. Not only do fewer vascular access devices and needle sticks decrease cost and increase patient satisfaction, but each time the skin is broken there is an increased risk for infection. As we continue to grow our team, our goal is to provide care for all VADs as they each provide an entry into the same circulatory system and are therefore capable of serving as a source of serious (even deadly) infection. We were working toward this goal when COVID hit and both delayed our plans and helped justify our team.

My community hospital of 117 licensed beds received our first possible case of coronavirus disease 2019 (COVID-19) on a Sunday afternoon in March. The patient was in a negative pressure room in our intensive care unit (ICU), and a vascular access consult was ordered. Due to the patient’s condition and multiple ordered medications, a PICC line was selected as the most appropriate device. I had personally never placed a vascular access device while wearing airborne precautions personal protective equipment (PPE), but I did remember our infection control nurse teaching me how to don the powered air-purifying respirators (PAPR), gown, gloves, and shoe covers in the correct order. As the ICU staff assisted me into the PPE, I wondered about the feasibility of performing a sterile procedure while covered almost head to toe in PPE, but I knew the patient needed vascular access.

Because of my experience as a vascular access specialist and my collaboration with infection preventionists both at my facility and through professional organizations and journals, I was able to place a PICC that successfully delivered the needed medications. That patient ended up being discharged home at the completion of their stay while only undergoing 1 needle stick for vascular access during their stay at my facility.

Less than 24 hours after placing that PICC line I met with our infection control nurse to discuss how the COVID-19 team was going to interact with the vascular access team. We collaborated to create a plan for best protecting our team of 2 from exposure while also ensuring that our patients were protected from further infection caused by a vascular access device. In addition, the infection control nurse and I met with the directors of the lab, the medical floor, and the intensive care unit to discuss ways to minimize exposure of their staff to the patients with confirmed COVID-19 infection.

We also spoke with the emergency department and the hospitalists to plan for the vascular access needs of these patients. When it became clear we would have to change some of our normal practice to work within the national PPE shortage while still protecting staff, we worked together with our materials department to ensure we would have the needed supplies.

One concern we had was maintaining ideal positioning of vascular access devices once they were placed; to this end, we ordered a subcutaneous securement device we had been trialing. Although there were many areas of the country where PPE shortages did negatively impact healthcare systems, the incident command center at our facility was able to maintain an adequate supply for our staff. Through teamwork we were all able to navigate the unknown waters of COVID-19 while providing the highest level of care for all of our patients and protecting our staff.

The healthcare team is composed of different specialists from widely varied backgrounds. Although we each have our own focus, we all work together to care for our patients in an effective and efficient manner. Collaboration between specialties is vital to maximizing patient outcomes while minimizing complications. Although complications with vascular access devices are sometimes dismissed as a necessary evil associated with hospitalization, through the collaboration of vascular access specialists and infection preventionists we can decrease complications, decrease costs, and increase positive outcomes for our patients.

Maya Gossman, RN, is a vascular access nurse at Stillwater Medical Center in Stillwater, Oklahoma.

Although both vascular access and infection prevention have their own focus, our commonality is in ensuring patients get the care they need while minimizing their chances of nosocomial infections.

How This Vascular Access Nurse Relies on an Infection Preventionist

Healthcare professionals across the nation have been battling coronavirus disease 2019 (COVID-19) for months. They’re tired. They’re worried. They’re always in a rush. That’s when the proper use of personal protective equipment (PPE) might fall by the wayside, warns infection control consultant Sharon Ward-Fore, MS, MT(ASCP), CIC. Ward-Fore, a member of Infection Control Today’s Editorial Advisory Board says that there’s an art to encouraging the proper use of PPE and she gives fellow infection preventionists some tips on how it can be done. “Some people receive things well—criticism or compliments—and others don’t,” says Ward-Fore. “It’s not a one-size-fits-all.”

We’re going to talk a little about PPE and where we are with that thanks to the COVID-19 pandemic. Proper donning and doffing has to be a part of that conversation, correct?

It does, it does. I think one of the things we need to talk about with PPE is as we’re continuing to go through this COVID-19 pandemic, the level of infections waxed and waned in certain areas. And now we’re seeing quite a surge in the South. So those hospitals that are able to inventory their PPE and figure out how to ration it should be doing so right now. IPs should continue to audit PPE usage on their units—including donning and doffing—and then they also should be speaking to how to reuse or encourage staff how to do extended reuse of PPE if that becomes necessary. And the problem with reuse and extended reuse is the probability of contamination from reusing something you’ve already used. So IPs, the burden would be to teach staff how to safely don and doff equipment that’s been stored and then reused.

Is that a constant problem during this pandemic?

It is. It is in areas like the South where they’re just pretty much on fire. Staff have been told that they need to reuse PPE, especially things that are in short supply in those areas. Apparently, it’s still N95s. So, the caution is that manufacturers say N95s can be reused up to five times. But what that really means depends on what that N95 looks like when you’re going to reuse it. So, areas to pay attention to when you’re reusing any piece of equipment like an N95 is make sure the straps are still intact. Make sure the metal nose clip where you kind of fold the mask around your nose is intact, and make sure the mask itself isn’t showing any kind of wear and tear. That’s really important for those areas that have to reuse that kind of equipment. I think with reuse, sometimes staff tend to forget to not touch the outside of the mask, which is the most contaminated part. Or when they’re putting it on, they’ll touch the inside of the mask, which then puts them at risk, and they need to discard that mask. So careful attention to detail. And maybe in the areas that are hotspots now that maybe weren’t, just a refresh on how you put on and take off PPE that’s been reused would be a nice thing for IPs to focus on.

Careful attention to detail. Do you think that that’s going to be easier now? Since COVID-19, do you think people are paying attention more to detail?

I think you’re going to find a spectrum of that because people are fatigued. Our healthcare workers have been at this since—in Illinois, March 21—is when the lockdown came down and we saw a surge. They’ve been at this for a long time. Fatigue. Practices drift. You can become complacent and maybe your level of awareness has decreased. I think you’ll see people who are really, really attentive to detail. And those that have maybe thought, “Well, I haven’t gotten it yet. Maybe I won’t get it and I don’t need to adjust my practices.” So, infection preventionists need to be really aware of what’s happening in the areas they cover as far as PPE usage is concerned.

Do IPS work with anybody else as far as monitoring PPE usage? Are there nurse managers or even doctors who are involved in overseeing PPE usage and how it’s done? Or does the buck stop with the IP?

It doesn’t, but typically it’s under our purview. But nurse managers, even nurses, working with each other, should be aware of what their colleague is doing as far as their PPE usage. And healthcare workers, they look out for each other. I think we can hopefully rely on a level of awareness where someone else will mention to somebody, “Oh, you didn’t put that on right. Or, “You didn’t do hand hygiene.” Hopefully it’ll be taken in a way that will help prevent contamination as opposed to being critical of someone.

That sounds like an art more than a science. How do you do that?

t is an art. It’s being proactive, but showing concern instead of criticism. It’s saying, “You know, I want you to stay healthy. So maybe you should discard that mask because I think you touched the inside which may contaminate you.” It is an art and you need to tread lightly. Some people receive things well—criticism or compliments—and others don’t. It’s not a one-size-fits-all.

Do you recall any kind of pushback that was particularly forceful? And how did you manage to finesse that?

Way back in the day, I had a physician who refused to wear the PPE for contact precautions. And he went from patient to patient to patient. And I just asked him, “Do you mind if I asked you why you’re not wearing that PPE?” And he pretty much said it was stupid, and there was no science behind it. So, in situations like that, it’s just like with kids, you have to know how to pick your battles. I sort of stepped away from that and mentioned that my medical director might be contacting him because, with some folks, it’s not about the science, it’s about how it feels. He felt it was not a science-based approach.

Now everybody wants to know if it stopped there? Did you actually have to contact the medical director?

I did and then this person then became one of our PPE champions.

Well, at the request of the medical director, it all worked out. Sometimes maybe from a peer, things are better received than from someone who’s lower on the pecking chain as I was. I was merely an IP, as opposed to this pretty well-renowned physician.

Any final words of advice for you fellow IPs about PPE?

Just remind everyone to not become complacent. And the importance of hand hygiene cannot be understated in every instance of handling any kind of PPE, donning and doffing.

This interview has been edited for clarity and length.

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Sharon Ward-Fore, MS, MT(ASCP), CIC: “Practices drift. You can become complacent and maybe your level of awareness has decreased…. So, infection preventionists need to be really aware of what’s happening in the areas they cover as far as PPE usage is concerned.”

Infection Preventionists Need to Monitor PPE Use

Even today, as of this writing and very likely as of your reading, many healthcare facilities in the United States—whether acute care, assisted living, or long-term care—are not equipped to handle a surge in coronavirus disease 2019 (COVID-19) cases, even though the world has wrestled with this history-altering pandemic since last year, and even though systemic problems should be fixed by now, but are not.

Some facilities continue to refine policies, procedures, and protocols for COVID-19. In some instances, healthcare is not succeeding with staff social distancing and proper use of personal protective equipment (PPE) (note: fabric and cloth masks ARE NOT considered PPE and should not be used within a healthcare setting) and proper cleaning of 

. There is still a lack of testing for COVID-19 as well as a lack of PPE and hand sanitizer—the basic items needed to protect healthcare workers and patients.

And just when many healthcare facilities thought it couldn’t get any worse, here comes influenza. Flu season on top of COVID-19 will make many hospitals and other healthcare facilities feel as if they’ve been caught in a whirlwind.

No one can really predict what is going to happen, but take heart, because seasoned infection preventionists (IPs) will be ready to accept and take on the challenge of the flu/COVID season. Novice IPs should use all the resources available to them to help them develop strong infection prevention and control programs within their facilities. Seasoned and novice IPs should reach out to websites such as:

https://www.cdc.gov/coronavirus/2019-nCoV/index.html

These organizations will keep IPs up to date on what is happening across the United States and the world so IPs can adjust practices as needed in their facilities.

The wearing of masks and face shields or goggles have become part of healthcare workers’ uniforms. The responsibility of IPs and management continues to be reminding 

 disciplines within the healthcare facility to wear their PPE appropriately and to social distance. All disciplines must work as a cohesive group to remind and protect each other. If you see something, say something. Let coworkers know when they may have breached infection control practices such as forgetting to wash their hands, not wearing PPE properly, or missed opportunities to clean high-touch surfaces. Whether dealing with influenza or COVID-19, practices are the same. The only difference is that COVID-19 is more 

infectious and transmittable and more deadly

As of August 15, the United States has seen a total of 5,285,546 cases of COVID-19, with 167,546 deaths. Data have been collected for 3,924,574 people, but healthcare personnel status was only available for 879,436 (22.4%) individuals. For the 134,397 cases of COVID-19 among healthcare personnel, death status was only available for 93,236 (69.4%). Among the data available for healthcare workers, there have been 

The 2019-2020 US flu season data reported on April 17, 2020, showed that the number of flu illnesses reported were between 39,000,000 and 56,000,000, with between 24,000 and 62,000 flu deaths occurring from October 1, 2019, to 

. This was a total of 7 months. When deaths from influenza are compared with deaths from COVID-19, there have been fewer cases of COVID-19 than influenza, but there have been more than double the number of deaths from COVID-19 than from influenza.

So, what do we know for sure about influenza and COVID-19?

Key to balancing safety and success during influenza season in the middle of a global pandemic:

Educate staff and management about new information that is published by professional organizations and associations. We cannot anticipate what will happen if patients are co-infected with influenza and COVID-19. Monitor reputable sites for guidance.

Utilize other IPs in other facilities for advice if an unusual situation arises.

Utilize local department of health epidemiology branch.

Rounding in all patient care areas and monitor use of PPE/hand hygiene and surface cleaning and disinfecting.

Encourage the buddy system for donning and doffing of PPE.

Hold listening sessions with staff and management to let them express what they see as needs or problems.

Monitoring staff and visitors for symptoms of influenza/COVID-19.

Contract tracing once COVID-19 is identified is a must for COVID-19. US Centers for Disease Control and Prevention (CDC) has good online contact tracing education.

Vaccination to protect against influenza is extremely important. And when the flu is here, there are also a lot of other respiratory viruses circulating. It’s not just influenza A and influenza B that’re seen during flu season. Healthcare professionals only test for the virus that they suspect is going to cause the most deaths for that year. That’s how the government decides what the flu vaccine is going to be. There is still respiratory syncytial virus (RSV) among young kids, and even the elderly.

Infection control personnel really have to monitor closely all respiratory viruses that are out there and be sure to work with management to put in place whatever needs to be put in place. Communicate well with the nursing staff and communicate well with all departments because if environmental services teams see nurses wearing a particular PPE, but they’re not being given it to wear, they’re going to be scared and wondering “why do they get better protection than me?”

IPs need to have all lines of communication open and really work hard at it. This can get very complicated.

LINDA SPAULDING, RN, CIC, BC, CHEC, CHOP, is an infection prevention consultant and founder of InCo and Associates International.

If you see something, say something. Let coworkers know when they may have breached infection control practices such as forgetting to wash their hands, not wearing PPE properly, or missed opportunities to clean a high-touch surfaces.

Infection Preventionist Guide for Dealing With Flu and COVID-19

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When the first tentacles of the coronavirus disease 2019 (COVID-19) pandemic reached Navajo Nation—the Native American territory occupying more than 17 million acres in Arizona, Utah, and New Mexico—leaders President Jonathan Nez and Vice President Myron Lizer responded quickly. They instituted strict curfews, issued stay-home orders, and shut casinos down—even though those are central to the local economy.

They also ramped up testing and contact tracing. They had the highest test rate per capita in the country: As of August 15, more than 40%, or about 80,000 individuals of a 200,000 service population.1 By comparison, on August 13, the United States as a whole had a testing rate of 2.14 tests per thousand.2

President Nez and Vice President Lizer were proactive in every way they could think of. In fact, Nez declared COVID-19 a public health emergency on March 11, 2 days before President Donald Trump did. Nez and Lizer were urging people to wear masks in public even before the US Centers for Disease Control and Prevention (CDC) did, and they issued a public health emergency order to do so in mid-April.

Nonetheless, the Navajo Nation was hit devastatingly hard by the virus. In May, the Nation had the highest infection rate per capita in the country, surpassing the epicenter of New York: 2344 cases per 100,000 residents.3

On August 13, though, the population reported 48 consecutive days of fewer than 100 daily cases of COVID-19 reported and 13 consecutive days with under 50 daily cases.4 Last week the Navajo Health Command and Operations Center declared the Nation to be in Orange status, or “moderate-high restrictions”, in which most businesses are allowed to reopen with 25% maximum occupancy, and restaurants and banks are allowed to operate drive-through business (casinos and other places where groups gather are still closed).5

The Navajo leadership achieved this despite the fact that many Navajo live far from hospitals and clinics, about one third don’t have access to running water, and many live with extended families in small homes. Add to this a seriously debilitated infrastructure in the form of miles of dirt or gravel roads (70% of roads are in “poor or failing condition,” according to the 2016 Navajo Nation long-range transportation plan).6 There is also no electricity in many areas.7 In 2012, only about 60% of Navajo natives had landline phones; many now have cellphones but live miles from a tower8 (access has been improving since 2014, and has been accelerated due to the COVID-19 crisis).9

How do you handle infection prevention and control under extreme conditions—exacerbated by a nightmarish virus that has claimed hundreds of thousands of lives worldwide? Jonathan Iralu, MD, FACP, Indian Health Service (IHS) Chief Clinical Consultant for Infectious Diseases, Gallup Indian Medical Center (GIMC), and his staff are exemplars of tackling it promptly and effectively.

GIMC, located on the border of the Navajo Reservation, has one of the largest workloads in the IHS—250,000 outpatient encounters and 5800 inpatient admissions annually—and the largest staff of all Navajo Area IHS facilities. Its catchment area is roughly a 50-mile radius, but if patients need to contact an infectious disease specialist, they may need to travel up to 150 miles one way, often on those bad roads. Telehealth is difficult because of the technological obstacles.

Given those parameters, GIMC personnel had to be deliberate and practical—and they had to make dramatic shifts in the way they delivered care. Early on, they shut down the clinics to focus on the influx of people coming in with COVID-19. They also set up drive-up testing, including rapid testing, “really early,” Iralu says, in part to take the potential pressure off the “aging facility” (the hospital is about 60 years old). Patients go through a screening and triage is handled outside the hospital.

Staff also prepared to focus on patients who would require hospitalization—at 99 beds, GIMC is small (“but large for the IHS”). They had only 2 medical-surgical wards and a small intensive care unit. To get ready, they repurposed rooms that were formerly used for tuberculosis (TB) patients, plus some pre-op and office space. In early March they were short on supplies, like most of the country. So, they created a personal protective equipment committee to order, track, and project what the hospital’s needs would be.

Meanwhile, they had to factor in their regular patient responsibilities for a population rife with chronic health issues including diabetes, alcoholism, and cardiovascular disease. GIMC transferred staff into the inpatient and emergency departments and left a skeleton crew back in the clinics to handle emergencies and routine primary care.

Unlike many rural hospitals, GIMC delivers not only direct patient care, but it is also responsible for public health. Where another hospital might make referrals to the county Department of Health to do contact tracing investigations, for instance, Gallup staff members have to do that themselves.

Patient education—a critical part of managing the public health crisis throughout the country—is not always easy in an area on the wrong side of the “digital divide,” where fewer than half of the residents have access to high-speed Internet service.10 So GIMC healthcare providers have to make the most of every opportunity. In addition to public service information and social media posts, they do their educating at the drive-up testing sites, for instance, and have a follow-up system in which public health nurses do more education.

Iralu has worked at GIMC since 1994, with special interest in HIV, TB, and sexually transmitted disease (STD) care in rural communities. His research has focused on undifferentiated febrile illness in the American Southwest and on rural HIV care delivery. In the 1970s, the tribe, along with the IHS, created a TB treatment program using Navajo-speaking community health workers who made home visits to manage care and medications. About 14 years ago, Iralu says, he and his staff started doing the same with HIV care. Now they’re taking lessons learned from the established TB, HIV, and STD programs and translating those for this latest health challenge.

Necessarily, much of the care for the spread-out and isolated patient population is home care. The hospital has a 3-person HIV team and about 6 public health nurses who visit patients in their homes. They all speak Navajo (COVID-19 is 

Diko Ntsaaígíí-Náhást’éíts’áadah

The home-care teams emphasize the importance of handwashing, of course. Although water may be in short supply in some places, Iralu says it hasn’t been an insurmountable problem. For one thing, “it’s been easy to get alcohol wipes.” He also points to volunteer groups that take water out into the isolated rural areas. Contrary to reports of lack of water being a major issue, he says, “it’s a bit of an exaggeration” to say so.

Another thing that they’ve done “beautifully,” he says, is to create “alternate facilities” to care for patients with COVID-19—albeit in a kind of counterintuitive way. When a member of a multigenerational family is diagnosed with COVID-19, the first idea might be to isolate that person in a different room from the rest of the family. “That’s really impractical,” Iralu says. So they do the opposite. They quarantine the healthy members in a hotel.

GIMC physicians Jennie Wei, MD, MPH, and Mia Lozada, MD, run the program, working in a federal/nonprofit/volunteer consortium to take care of people who have been exposed to the virus and have no other place to stay. More than 800 patients have been isolated in hotels since March.11 Lozada credits the program with helping to drive down the case numbers in Gallup.

Those kinds of culturally sensitive care solutions are important for all their patients, but particularly for Native American elders, who are vulnerable to the SARS-CoV-2 virus. Older people are highly valued in Native American culture, and protecting them is a high priority. “Elders carry tradition,” Iralu says. “We have to keep them safe.”

President Nez has also made this plain in his overall pandemic plans. “I challenge the Navajo people: Let’s protect [our elders] by staying home,” he said during a virtual town hall on June 9.12 “It’s our responsibility as family members.” Vice President Lizer echoed that, saying supporting elders benefits everyone. “Love for our elders means we all win.”

In the early days of what became a pandemic, Iralu and his colleagues were reassuring people that there were few cases. Then, as things worsened, they began advising extreme caution. They’re still advising caution. In an interview in July, Iralu expressed “cautious optimism” about managing the COVID-19 case numbers. He’s now concerned about what might happen as winter brings influenza, and how a combination of the 2 viruses might affect his hospital. There’s also the issue of neighboring states with conflicting rules and surges in cases. But overall, he says, he remains cautiously optimistic.

The pandemic has been good for something, too. “It has been really beautiful to see the staff rally together with single-minded purpose,” Iralu says. “We’re working better as a team now than ever in my 26 years here.”

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

Navajo Department of Health. Dikos Ntsaaígíí-19 (COVID-19). Available at: 

Our World in Data. Statistics and Research. Coronavirus (COVID-19) Testing. Available at: 

https://ourworldindata.org/coronavirus-testing#the-scale-of-testing-compared-to-the-scale-of-the-outbreak

Stoney A. Navajo Nation surpasses New York for highest infection rate in the US. 

https://www.azcentral.com/story/news/local/arizona-breaking/2020/05/19/navajo-nation-passes-new-york-highest-coronavirus-infection-rate/5218748002/

The Navajo Nation. Office of the President and Vice President. Nez-Lizer Administration issues guidelines and plan to carefully reopen the Navajo Nation with phased-in approach. Press release. Aug. 13, 2020. Available at: 

https://www.navajo-nsn.gov/News%20Releases/OPVP/2020/Aug/FOR%20IMMEDIATE%20RELEASE%20-%20Nez-Lizer%20Administration%20issues%20guidelines%20and%20plan%20to%20carefully%20reopen%20the%20Navajo%20Nation%20with%20phased-in%20approach%20w%20health%20order.pdf

Navajo Department of Health. Public Health Emergency Order No. 2020-020. Public Health Emergency Order Implementing the Navajo Nation Reopening Plan and Declaring “Orange Status.” Aug. 13, 2020. Available at: 

https://www.navajo-nsn.gov/News%20Releases/NNDOH/2020/Aug/NDOH%20Public%20Health%20Emergency%20Order%202020-020%20Dikos%20Ntsaaigii-19.pdf

Wilson & Co. 2016 Navajo Nation Long Range Transportation Plan. Final Plan. April 2016.Available at: 

https://www.wilsonco.com/sites/default/files/images/LRTP%20The%20Plan.pdf

Morales L. For many Navajos, getting hooked up to the power grid can be life-changing. National Public Radio. May 29, 2019. Available at: 

https://www.npr.org/sections/health-shots/2019/05/29/726615238/for-many-navajos-getting-hooked-up-to-the-power-grid-can-be-life-changing

Smithson S. 4G network creates opportunities on Navajo Nation. National Public Radio. Available at: 

https://www.knau.org/post/4g-network-creates-opportunities-navajo-nation

Globe Newswire. Choice NTUA Wireless provides greater speed & bandwidth to the Navajo Nation. Press release. May 13, 2020. Available at: 

https://www.globenewswire.com/news-release/2020/05/13/2033022/0/en/Choice-NTUA-Wireless-Provides-Greater-Speed-Bandwidth-to-the-Navajo-Nation.html

Groetzinger K. Navajo families without internet struggle to home-school during COVID-19 pandemic. April 22, 2020. Available at: 

https://www.kunc.org/npr-news/2020-04-22/navajo-families-without-internet-struggle-to-home-school-during-covid-19-pandemic

@PIH. Dr. Jennie Wei discusses the plan to begin providing safe spaces for COVID-19 positive people in Gallup, NM to isolate safely, which led to organizing to turn hotel rooms into isolation shelters for COVID-19 in March. This plan expanded to multiple hotels in April. 

https://twitter.com/PIH/status/1283482283375243271

Reinhart K. ‘It just feels like they’re forgotten’: Navajo women mobilize to protect elders from COVID-19. Cronkite News. Arizona PBS. Aug. 13, 2020. Available at: 

https://cronkitenews.azpbs.org/2020/08/13/covid-indian-country-navajo-women-elders/

Much of the care for the spread-out and isolated patient population is home care. The hospital has a 3-person HIV team and about 6 public health nurses who visit patients in their homes. They all speak Navajo. (COVID-19 is Diko Ntsaaígíí-Náhást’éíts’áadah.)

Practicing Infection Prevention in Isolated Populations: How the Navajo Nation Took on  COVID-19

The myriad of the widely different strategies emerging throughout our nation when it comes to the reopening of schools (as of, it must be stressed, this August writing) can be called nothing other than a Great American Experiment, and our children are the subjects with little safeguards in place. We know that school-aged children are less likely to develop severe coronavirus disease 2019 (COVID-19) illnesses. In a recent study, the US Centers for Disease Control and Prevention’s COVID-19 Response Team reported that only 1.6% to 2.5% of children below the age of 20 who acquired COVID-19 required hospitalization. And intensive care unit (ICU) admissions and deaths were not observed in 123 patients.1

When Europe opened its schools this summer, it did so during an exceptionally low nadir of community spread. Even then, viral outbreaks occurred, and some schools had to be closed in France and Germany.2,3 In one country, Israel, public health guidance was reported to be thrown to the wind, allowing older students to attend early on and, because of the hot desert, without masks.4 This was associated with spiking cases and the closure of 130 schools.5 South Korea also had to reclose more than 800 schools.6

Infection preventionists are a critical asset that school systems should lean on to provide the safest strategies and environmental modifications to suppress the transmission of the SARS-CoV-2 virus.

That’s because deaths can rarely occur, and severe disease in children can manifest 2 to 4 weeks later in the form of multisystem inflammatory syndrome in children (MIS-C). MIS-C can cause shock, cardiac, respiratory, renal, gastrointestinal, and neurological disorders. MIS-C occurs in less than 1% of children diagnosed with the SARS-CoV-2 virus.7 As of the end of July, more than 300 cases have been reported in the United States. In one study, 80% of children with MIS-C required ICU admission, 80% had cardiovascular involvement, 20% required mechanical ventilation, and 2% died.8 Finally, infants less than 12 months of age appear to be at high risk for severe COVID-19, possibly due to their underdeveloped immune systems.

However, 2 possibilities exist: That children are not as likely to get infected by the SARS-CoV-2 virus, or that they contract the infection, but the vast majority of children are asymptomatic.

Studies are indicating that both may be a factor. Davies et al, writing in 

, reported that almost 80% of the children who acquire the SARS-CoV-2 virus are asymptomatic as compared with only 31% of the elderly.9 They also estimated that children were half as susceptible to infection as adults.

In addition, infected children shed the virus similar to adults and that “pre- or mildly symptomatic children carry viral loads likely to represent infectivity.” There was “little evidence in the present study to support the suggestion that children may not be as infectious as adults.”10

A report from South Korea studied the chances of spreading the virus based upon age of those infected11. Ten to 19-year-olds were found to spread the virus to 18.6% of family members, higher than any other age group, including adults. Young children, from age 0 to 9, spread the virus between 0.29 to 0.76 times less than adults. But against a backdrop of a raging epidemic, even this level of spread is too much. Before opening schools, many experts advise that the SARS-CoV-2 diagnostic test positivity rate needs to be less than 5% and there should be less than 5 cases per 100,000 residents per day.

These children also pose a risk of spreading SARS-CoV-2 to their parents, grandparents and very young siblings, all of whom are at risk of developing severe COVID-19 infection. Finally, 24% of the teachers are also at a higher risk for severe COVID-19 disease, having co-morbidities, such as diabetes, COPD, BMI over 40 or being older than 65.12

There are unknowns. One is whether the virus can aerosolize. Another is whether the high-pitched, often loud vocalization of our children will promote such aerosolization? At least one study has shown loud talking can produce small viral droplets,13 and studies of various settings such as churches,14 restaurants,15 and hospitals16 strongly suggest aerosolization of this virus. If so, the virus may linger in the air, surviving for up to 3 hours17 and spread widely via heating and air conditioning units.

Our schools are anything but healthy buildings.18 Concerns have existed for decades regarding both the air quality and the crowded conditions our children are exposed to, but no one has been watching, with the last US Government Accountability Office report conducted in 1995.19

We need to upgrade our schools with extensive infrastructure investments to prevent the spread of infectious diseases, with larger rooms to allow at least 6 feet of social distancing between desks20 and with windows that open to allow in fresh air. We need to upgrade substandard and dilapidated HVAC systems to increase airflow and to filter and serialize the air. Common areas need to be made safer; and cafeterias, restrooms, and hallways redesigned with attention to student flow and contact. School districts should even consider switching to classroom models that can easily be changed from indoor to outdoor environments. We do this for sports stadiums, why can’t we do the same for our schools?

There is no doubt that the COVID-19 pandemic may be on its way to resolution before all of this can be accomplished, but schools are also a nidus for other infectious diseases, such as influenza. After Middle East Respiratory Syndrome (MERS), SARS and Ebola, let’s not delude ourselves into thinking this epidemic will be our last.

School bubbling, or keeping a small number of children and teachers together and not exposed to others, needs to be implemented. Students may need to eat in their classrooms with intermittent bubble privileges for the cafeteria. Initially, schools should scale back to basic core activities. Pool testing will become extremely important for the testing of students in the bubble and their families. Testing is key to safely opening schools. If professional sports teams are employing bubbling strategies, along with extensive and frequent testing, the same should be true for our children.

We need ample hand sanitizer stations, bathroom soap dispensers that work, and pristine cleaning of fixtures and contact surfaces. This should be standard, but in the COVID-19 pandemic, availability of janitorial supplies is of utmost concern.21 Masks need to be worn by all.

Mounting evidence has found that children become infected and shed the virus, that the virus aerosolizes, that school buildings are crowded with poor air circulation and quality, and finally that 24% of teachers are high risk for COVID-19. What could possibly go wrong?

Similar to our healthcare system as a whole, COVID-19 is shedding a light on deficiencies and the dearth of personal safeguards in our schools. Let us not forget, schools are a nidus for spreading the flu and other diseases. Opening schools should depend upon low rates of viral spread in the community, widespread testing, rigorous following of public health guidelines, and upgrading the physical infrastructure of our buildings. COVID-19 should be viewed as an opportunity for transformation, allowing us to build a better school system with smaller class sizes for better education and implement strategies to prevent the spread of all infectious diseases.

KEVIN KAVANAGH, MD, is the founder of the patient advocacy group Health Watch USAsm and a frequent contributor to 

The CDC COVID-19 Response Team.Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020.MMWR Morb Mortal Wkly Rep. 2020 Mar 27;69(12):343-346. doi: 10.15585/mmwr.mm6912e2.


https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm

Coronavirus flare-ups force France to re-close some schools. May 18, 2020. CBS News. Accessed on Aug. 12, 2020 from 

https://www.cbsnews.com/news/coronavirus-france-close-some-reopened-schools-covid-cases-flare-up-today-2020-05-18/

Ellyatt H. German district sees lockdown return as country tries to suppress regional outbreaks. CNBC. June 23, 2020. Accessed on Aug. 12, 2020 from 

https://www.cnbc.com/2020/06/23/germany-is-struggling-with-more-coronavirus-outbreaks.html

Nicholson E. Lessons On Reopening Schools The U.S. Could Learn From Germany, Israel And Thailand. NPR. July 10, 2020. Accessed on Aug. 12, 2020 from 

https://www.npr.org/2020/07/10/889842725/lessons-on-reopening-schools-the-u-s-could-learn-from-germany-israel-and-thailan

Estrin D. After Reopening Schools, Israel Orders Them To Shut If COVID-19 Cases Are Discovered. NPR. June 3, 2020. Accessed on Aug. 12, 2020 from 

https://www.npr.org/sections/coronavirus-live-updates/2020/06/03/868507524/israel-orders-schools-to-close-when-covid-19-cases-are-discovered

Strauss V. South Korea closes schools again amid coronavirus spike, days after reopening. Wash. Post. May 30, 2020. Accessed on Aug. 12, 2020 from 

https://www.washingtonpost.com/education/2020/05/30/south-korea-closes-schools-again-amid-covid-19-spike-days-after-reopening/

Levin M. Childhood Multisystem Inflammatory Syndrome — A New Challenge in the Pandemic. N Engl J Med. 2020;383(4):393-395.doi: 10.1056/NEJMe2023158.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346677/

Feldstein LR, Rose EB, Horwitz SM, et al., Multisystem Inflammatory Syndrome in U.S. Children and Adolescents N Engl J Med. ;383(4):334-346.doi: 10.1056/NEJMoa2021680.

https://www.nejm.org/doi/full/10.1056/NEJMoa2021680

Davies NG, Klepac P, Liu Y, et al. Age-dependent effects in the transmission and control of COVID-19 epidemics. Nat Med. 2020;26(8):1205-1211. doi: 10.1038/s41591-020-0962-9. 

https://www.nature.com/articles/s41591-020-0962-9

Jones TC, et al. An analysis of SARS-CoV-2 viral load by patient age. MedRxiv. June 9, 2020. Accessed on Aug. 12, 2020 from 

https://www.medrxiv.org/content/10.1101/2020.06.08.20125484v1

Park YJ, et al. Contact Tracing during Coronavirus Disease Outbreak, South Korea, 2020. Emerg Infect Dis. 2020 Jul 16;26(10).doi: 10.3201/eid2610.201315.


https://wwwnc.cdc.gov/eid/article/26/10/20-1315_article

Claxton G. et al. How Many Teachers Are at Risk of Serious Illness If Infected with Coronavirus? Kaiser Family Fund. July 10, 2020. Accessed on Aug. 12, 2020 from 

https://www.kff.org/coronavirus-covid-19/issue-brief/how-many-teachers-are-at-risk-of-serious-illness-if-infected-with-coronavirus/

Anfinrud P, Stadnytskyi V, Bax, CE, Bax A. Visualizing Speech-Generated Oral Fluid Droplets with Laser Light Scattering. N Engl J Med. 2020 May 21;382(21):2061-2063. doi: 10.1056/NEJMc2007800. 

https://www.nejm.org/doi/full/10.1056/NEJMc2007800

Infection preventionists are of utmost importance to work with school systems and provide the safest strategies and environmental modifications which can suppress the transmission of the SARS-CoV-2 virus. 

Infection Control Today, October 2020 (Vol. 24 No. 08)

Bug of the Month: I Can Be Deadly for Cystic Fibrosis Patients

How This Vascular Access Nurse Relies on an Infection Preventionist

Infection Preventionists Need to Monitor PPE Use

Infection Preventionist Guide for Dealing With Flu and COVID-19

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

Practicing Infection Prevention in Isolated Populations: How the Navajo Nation Took on COVID-19

Infection Preventionists Might be Needed in Schools