Studies show that the potential for moral injury to health care workers working with COVID-19 is relatively high, leading to burnout and impairing mental health. I asked my clients at a nursing home in Hawaii to tell me how the pandemic had affected them. They wrote this article.

March 2020 is a date that is forever imprinted on our minds, hearts, and the history books. Those of us who dedicate our lives to the world of long-term care and caring for our 

 [elders], we all shared a heightened sense of fear and anxiety, as we watched the introduction of SARS-CoV-2 (COVID-19) to long-term nursing facilities. A virus that changed the landscape of what we do. COVID-19 continued its relentless spread throughout the world, nation, and facilities, infecting millions and killing hundreds of thousands more. The long-term care industry was facing its fiercest challenge yet: to protect a population burdened by frailty.

For all of us in long-term care, work increased exponentially, with expanded regulatory compliance, health care staffing shortages, personal protective equipment shortages, and an unknown coronavirus. We found ourselves immersed in the stresses and fears of working in a crowded facility, asking ourselves and each other, "How do we survive each day, each shift, each hour, and keep our residents and ourselves safe?” It is difficult to put into words the hardships we faced and the relentless burden we endured. Only those who were, and are, in it, can understand the painstaking tasks we accomplished to battle this historic pandemic.

Two years later, we continue to fight COVID-19. We still face the challenge to protect our residents and staff. We still endure stress, fear, and surges of new variants among our population. All of this has become part of our daily routines and changed the way we view our work and our lives. Recently, our team took a step back to reflect. A common thought: “I can’t believe it’s been 2 years already.” A common question: “How did we get through this?” There is no simple answer, but to put it simply, teamwork and revising the way we view and approach the work we do.

It difficult to say that there is a silver lining, especially when hundreds of thousands 

 lost their lives. But it is this silver lining that will save many more. As our team reflected, many positives surfaced to realization. First, we truly learned the meaning of teamwork. We broke down walls, silos, and the division of duties among departments to become 1 team, 1 facility. As Pam Calilao, medical records manager, put it, “During the outbreak, you’re not just 'medical records' anymore. You quickly learn how to do patient care, test your fellow co-workers for COVID-19, correctly wear your PPE. You become a member of the COVID-buster team to promote cleanliness in the facility.” Rachel McKean, Admissions Coordinator, added: “Our team worked so well together and put in so much work to get COVID-19 out of the building. Teamwork literally makes the dream work.”

Secondly, we all felt an increased responsibility about the work we do, and had a different perspective with how we approach it. Lindsey Oroku, a registered dietitian, shared her thoughts: “COVID-19 was a rude reminder to be grateful—grateful to have a job, grateful to have a job that helps others, grateful for health. Many people lost their jobs and the ability to live carefree, lost loved ones, and went through—and continue to go through—tough times. I feel like it’s better to go through tough days than tough times.”

Christina Seto-Mook, another registered dietitian, noted, “We knew so little about this virus and how much chaos it would create in our professional and personal lives. We learned how to be more flexible. It was great to see everyone working as a team and really putting in the effort to keep our residents safe. It wasn’t just about getting our own work done but about helping each other and taking that extra mile. Adaptability was another crucial aspect of managing COVID-19, as we were all experiencing and learning how to get through this unforgettable time together.”

Two years of this pandemic has developed strength, belief, and courage within all of us. We carry ourselves, our team—our 

 [family]—with pride, owning the hand we’ve been dealt, and conquering the adversity we have faced. Our accomplishments have strengthened our bond, cemented our goals, and taught us the true meaning of 

. COVID-19 has forever changed the landscape of what we do. But the bond we have built during this pandemic— the team, the support, and empathy, will last forever. It has guided us through an adversity, unlike any other, and we believe that we can continue to conquer any challenge before us.

The words of Leina’ala Pilares, registered nurse and staff educator, sums up our pride, “Two years of unknowingness. I look into their [patients’] eyes, and I see hope. I go on for another day. Why? To protect the things I love. I have no fear when I choose to love and protect. I kept myself safe, isolated, and clean to protect my people and the residents I care for. Why do I work so hard? Because when I go to work, the next day I want to see the same faces I saw the day before. And then I tell myself, 'COVID-19, you will never be welcome in my home. I have no 

 [love] for you. I stand proud to have kept you out of my homes for another day. 

We have struggled, endured, battled, and wept. But we have also empathized, bonded, rejoiced, and overcame. We found courage and strength within ourselves that we did not know existed. We continue to grow, to be grateful, and to be committed to health care, long-term care, and our 

. The lessons we learned hardened our foundation to overcome any adversity to provide the best care for them, and we look forward to doing this for many years to come.

Articles

COVID-19, and the emotional and physical toll it caused, reached all corners of the globe.  At a nursing home in Hawaii, the staff describes how the pandemic has affected them.   

In Their Own Words: How COVID-19 Changed the Nursing staff at a Hawaiian Nursing Home

Ion AmpliSeq SARS-CoV-2 Insight Research Assay GX on the Genexus Integrated Sequencer

The Ion AmpliSeq SARS-CoV-2 Insight Research Assay GX is a next-generation sequencing (NGS) assay that is quick, accurate, and comprehensive, enabling research and surveillance of the SARS-CoV-2 virus and variants through complete genome sequencing. The intelligent assay design includes new primers that broaden the coverage for variants of concern and increase the sensitivity of the assay for improved detection from lower viral titer samples.

Features include greater than 99% coverage of the SARS‑CoV‑2 genome, covering all potential serotypes; samples with cycle threshold values greater than 28 can be used for preparing libraries, SARS‑CoV‑2 variant announcing, lineage identification, and reporting with Genexus software. 

The assay helps broaden NGS epidemiological surveillance to cover emerging SARS-CoV-2 variants through panel design improvements. It also has an improved limit of detection from various sample types due to increased sensitivity. It enables greater access to NGS to rapidly obtain epidemiological insights with quick turnaround time, workflow automation, smooth informatics, lineage identification, and data uploading to public SARS-CoV-2 data sources for viral surveillance.

The Ion AmpliSeq SARS-CoV-2 Insight Research Assay GX should be stored in the freezer (–5 °C to –30 °C) and is compatible with Genexus Software 6.2 and later.

Purell CS4 All-Weather Dispensing System is a hand hygiene dispenser that performs in extreme weather and high-traffic settings. Traditional dispensing solutions are commonly designed for indoor settings, but this innovative dispenser enables commercial and municipal buyers to offer hand sanitizer and hand soap in outdoor or high-traffic areas. 

The Purell CS4 All-Weather Dispensing System is made of engineered resin that is more than 3 times stronger than materials used in most other dispensers. Its advanced design is water resistant to help keep the rain out and prevent vandalism or refill theft, and its special graphite paint makes the dispenser resistant to UV fading to preserve its performance and appearance in a wide range of extreme conditions and temperatures—from –40 °F to 122 °F.

“With more than 80% of the public now expecting hand sanitizer to be offered in public places, access to hand hygiene is more important than ever before, so we must offer reliable Purell dispensing options suitable for any environment,” said Jessica McCoy, chief solutions officer at GOJO Industries, in a news release. “The addition of this groundbreaking dispenser means Purell hand sanitizer or soap can now be offered in any location. The Purell CS4 All-Weather Dispensing System underwent over 5400 hours of internal, third-party, and live field testing.”

Sereneview Custom Curtains feature striking landscape photography printed directly on the curtain facing the patient, drawing the viewer into the photograph to encourage a tranquil state of mind, which, according to the company, releases serotonin and reduces blood pressure and stress without having to medicate a patient during observation or painful procedures. Patients remember remote details when asked about their recent visit. In addition, studies have shown that staff is more engaged and efficient working in a clean and nurturing environment.

Medical team also appreciate the Armor finish that includes AEGIS Shield antimicrobial, which has been tested and proven to repel methicillin-resistant 

, severe acute respiratory syndrome, bacteria, mold, and most microorganisms within 1 hour of contact. Armor finish also has a stain guard that resists bodily fluids, betadine, oil, grease, dirt, and ink pen marks from becoming permanent stains. A stain guard combined with AEGIS Microbe Shield system provides antibacterial properties, an additional level of protection for patients and staff. Even after the stains have dried, they will wipe clean with a typical nonbleach cleaner without having to remove the curtains, reducing laundering frequency, saving time, reducing laundry costs, and extending the functional life of the curtain.

Sereneview Custom Curtains are available as hospital curtains, overheads, and wall treatments.

Infection Control Today's® Product Locator is a monthly column highlighting some of the latest advanced technology in the infection prevention field. 

Infection Control Today's® Product Locator

The hospital is a busy place, full of myriad devices and complex situations. Preventing hospital-associated infections feels like it requires an encyclopedic knowledge of every new and complicated health care intervention. Potential sources of transmission in the hospital include a remarkable array of specialized risks, but there are mundane, everyday risks like health care laundry too.

Which textiles are reused and laundered varies from health care facility to health care facility. Typical health care linens include patient and staff bedding, towels, clothing (scrubs, coats, uniforms, patient pajamas, and gowns), surgical drapes, curtains, and reusable mop heads. Hospital linens can harbor a significant density of pathogenic organisms, from 106 to 108 colony-forming units/100 cm2. Those most commonly isolated include gram-negative organisms (

Despite this noteworthy pathogenic burden, the significance of linens in health care transmission is unclear. When an infection occurs, it may not be possible to identify the exact environmental source of transmission because multiple potential environmental reservoirs exist in parallel. Although health care linens are not often implicated, it makes intuitive sense that they are a potential reservoir for transmissible organisms.

Workers who handle laundry are at increased risk of transmission, including gastrointestinal pathogens.

 Definitive associations between linen contamination and patient infections are harder to parse. Nevertheless, there is a need for meticulous attention to maintaining linen cleanliness.

It may be simplest to separate hospital linen–associated risks into 3 distinct sections: 1) removal; 2) cleaning; and 3) storage.

Ensure linens are removed, stored (if necessary), and transported safely to the cleaning facility. Soiled linen poses a danger to health care staff and possibly to patients. All used linen should be considered potentially infectious. Linen should not be shaken or disturbed in a way that could aerosolize infectious particles. Personal protective equipment that would be worn around the patient should also be worn when removing and packaging soiled linen for transport. If there is gross contamination without transmission-based precautions, standard precautions will necessitate the use of additional personal protective equipment.

 Some infections, including orthopoxviruses, are transmitted by contaminated linen.

 Linen should be contained before removal from a patient’s room, taking care not to disturb or aerosolize any infectious particles. Note should be made that the exterior of bagged linens may become contaminated, even with double bagging.

 In many health care settings, soiled linen must be gathered and transported to an off-site location.

Adequate cleaning and disinfection is essential. The 2003 Guidelines for Environmental Infection Control in Health-Care Facilities from the CDC and the Healthcare Infection Control Practices Advisory Committee provides detailed standards for health care laundering, including achieving minimum temperatures and disinfection concentrations that ensure pathogens will be inactivated.

 In most cases, processing according to these standards should be effective, even with 

 A few organisms may resist disinfection in the laundry. A study looking at the relative thermotolerance of 

 showed that they were inactivated during the washing cycle, despite tolerance to the high temperatures alone.

 spores inoculated into cotton sheets and run through a simulated hospital linen washing cycle were noted to remain viable after cleaning.

 An obvious potential pitfall during cleaning is failure to achieve intended time, temperature, or disinfectant concentration minimums. Excursions may be difficult to detect if laundry is managed off site or by a contractor. A busy infection prevention service may not have the bandwidth to survey off-site or contracted linen services more than once or twice a year. Trust and communication with those responsible for linen processing are critical to ensuring prompt notification and resolution if an issue is discovered.

Clean, processed linen should make it to the patient’s bedside clean. The quintessential infection prevention standard—separation of clean and dirty—must be baked into the management of clean linen. A unidirectional flow at the laundry processing facility will help prevent pathogens from soiled linen coming into contact with the clean linen, even indirectly from the hands or clothing of workers. Laundry surfaces should be routinely disinfected, and hand hygiene should be monitored for compliance.

 Laundering requires both heat and water—prerequisites for the growth of pathogenic mold. Health care outbreaks of mucormycosis have been linked to linens.

 In a vulnerable patient population, mold exposure is associated with severe or life-threatening infections. If linen must be transported from an off-site facility, it should be covered during transport to prevent contamination. Linens still warm from processing should be allowed to reach ambient temperature before covering, lest condensation and reduced airflow promote mold growth. Once linen arrives in the hospital, it should be unloaded promptly and stored in a manner that prevents contamination.

Within the clean linen supply, contamination may occur from hands of health care workers accessing clean linens without first performing hand hygiene. Clean storage rooms should be protected and monitored for excursions of temperature, humidity, and damage associated with floods. Costorage with soiled items or devices like refrigerators that include fans, condensation, or generate heat should also be avoided. Prevent contamination by ensuring covers or cabinets are kept closed. Methods of storing and using linens may vary. The astute infection preventionist may need to use shoe-leather epidemiology to identify how linens make it “the final mile” if there is a concern for potential transmission.

If there is a delay from when a bed is made to when a patient occupies the room, how long before linens would be replaced? Is there a mechanism to identify if a bed is used surreptitiously? This may not be a concern for busy facilities with high occupancy, rapid turnover, and adequate call room space, but with the change in elective procedures during the COVID-19 pandemic, there may have been changes to patient and employee flow. A process to ensure linens are freshly made immediately before patient arrival would reduce the risk of contamination.

There are many ways for pathogens to hitch a ride in the hospital environment. Linen is only one of many potential fomites that could be implicated in environmental transmission of hospital pathogens. Ensuring soiled linen is appropriately contained, transported, cleaned, and stored is essential to preventing transmission from this easy-to-overlook aspect of the health care environment.

1. Blaser MJ, Smith PF, Cody HJ, Wang WL, LaForce FM. Killing of fabric-associated bacteria in hospital laundry by low-temperature washing. 

1984;149(1):48-57. doi:10.1093/infdis/149.1.48

2. Ellsbury E, Owosekun O, Mackey K, Ten Eyck D, Mahoney LE. Outbreak of viral hepatitis in the staff of a pediatric ward — California. 

3. Borg MA, Portelli A. Hospital laundry workers--an at-risk group for hepatitis A? 

1999;49(7):448-450. doi:10.1093/occmed/49.7.448

4. Standaert SM, Hutcheson RH, Schaffner W. Nosocomial transmission of Salmonella gastroenteritis to laundry workers in a nursing home. 

5. Fijan S, Steyer A, Poljsak-Prijatelj M, Cencic A, Ostar-Turk S, Koren S. Rotaviral RNA found on various surfaces in a hospital laundry. 

2008;148(1-2):66-73. doi:10.1016/j.jviromet.2007.10.011

6. US Department of Health and Human Services, Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-Care Facilities. 

Recommendations of CDC and the Health Care Infection Control Practices Advisory Committee (HICPAC) 

2003. Published 2003. Updated July 2019. Accessed June 27, 2022. https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf

7. Pauli G, Blümel J, Burger R, et al. Orthopox viruses: infections in humans. 

2010;37(6):351-364. doi:10.1159/000322101

8. Maki DG, Alvarado C, Hassemer C. Double-bagging of items from isolation rooms is unnecessary as an infection control measure - a comparative-study of surface contamination with single-bagging and double-bagging. 

1986;7(11):535-537. doi:10.1017/s0195941700065279

9. Infection prevention and control of monkeypox in health care settings. CDC. Updated May 22, 2022. Accessed June 29, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-health care.html

10. Orr KE, Holliday MG, Jones AL, Robson I, Perry JD. Survival of enterococci during hospital laundry processing. 

2002;50(2):133-139. doi:10.1053/jhin.2001.1137

11. Tarrant J, Jenkins RO, Laird KT. From ward to washer: the survival of Clostridium difficile spores on hospital bed sheets through a commercial UK NHS health care laundry process. 

2018;39(12):1406-1411. doi:10.1017/ice.2018.255

12. Fijan S, Sostar-Turk S, Cencic A. Implementing hygiene monitoring systems in hospital laundries in order to reduce microbial contamination of hospital textiles. 

2005;61(1):30-38. doi:10.1016/j.jhin.2005.02.005

13. Cheng VCC, Chen JHK, Wong SCY, et al. Hospital outbreak of pulmonary and cutaneous zygomycosis due to contaminated linen items from substandard laundry. 

2016;62(6):714-721. doi:10.1093/cid/civ1006

14. Sundermann AJ, Clancy CJ, Pasculle AW, et al. Remediation of mucorales-contaminated health care linens at a laundry facility following an investigation of a case cluster of hospital-acquired mucormycosis. 

2022;74(8):1401-1407. doi:10.1093/cid/ciab638

Environmental sources of pathogen organisms can sometimes be difficult to narrow down in a health care facility. One possible source of transmission is the laundry used, and not maintaining strict cleanliness attention can put both patients and workers at risk.

The Role of Health Care Laundry in Infection Prevention

I’d like to tell you a story about a lady with white hair. At least I think she had white hair. It’s certainly one of the attributes I remember most about her. She was short, she had white hair, and she always had a scowl on her face that seemed to say, “Stay away, I bite.” She carried a clipboard with her everywhere, and her eyes would follow you like a hawk circling prey. She’d scribble furiously on the sheet of paper on the clipboard. And I remember always wondering what she was writing.

I was 20 years old at the time and, somehow, had landed myself a job in the emergency department as an ER and trauma nurse. ER nursing had been my first love, so I was surprised when I found a career that I loved even more. I sometimes wonder what my 13-year-old self would have thought if someone had told her that she would grow up to prevent and control infectious diseases. I don’t know that I would have believed them at the time; I was still convinced that I was going to be a musician. But I digress.

I had no idea what the lady with white hair did at our hospital, but she was absolutely adamant that I wash my hands every time I entered or exited a patient’s room. And that’s another thing—I couldn’t figure out whether she wanted me to wash my hands or use the hand sanitizer. Sometimes I would use the sanitizer, and she’d get mad that I hadn’t washed my hands. Other times I would wash my hands, and she’d remind me that I could have used the hand sanitizer. Because we didn’t know her name, we all endearingly referred to her as “the handwashing lady.” When she arrived on the unit, the charge nurse would send a message to everyone’s phone that read, “The handwashing lady has arrived.” This would cue all of us to make sure we paid attention to washing our hands as we went about our work.

It wasn’t until years later that I would understand exactly what the handwashing lady was doing during her visits to the ER. It dawned on me one day during my first year as an infection preventionist that I was now the handwashing lady. However, the issue is not so much 

 the handwashing lady was doing and the science behind it, but 

 she was doing it. What a shame that I didn’t know her name, the importance of her job, or the reason for her visiting the ER. Friends, if I’ve learned anything in my career, it’s that infection prevention is 20% science and 80% implementation of that science. If you want to succeed at preventing and controlling infections, you must master the art of implementation. I know that I washed my hands more because of the lady with the white hair, but my compliance was driven far more by fear than by recognition of the importance of hygiene.

I continue to see this scenario play out as a research nurse and consultant in infection prevention and control. We are trying to help people prevent infections who don’t even know we’re there to help them prevent infections. All they see is a man or a woman with a clipboard, telling them to wash their hands. Obviously, there is a huge disconnect here; something is missing, and that something is in our approach. We’re missing a fundamental understanding of human nature. I’m sure the lady with the white hair meant well, but we didn’t know that. I think she knew 

she needed us to do to prevent infections, but she didn’t know 

 to get us to do it. She didn’t take complicated, messy humanity into account.

Take a moment to think about one of your habits and what drives it. Would it be helpful if someone said to you, “Stop doing that. It’s bad for you.” Not really. But why? Because they are not addressing the underlying reason or reasons for that behavior. In health care, we must understand what drives compliance and noncompliance. Is it fear? Convenience? Money? Discomfort? A knowledge gap? Is it politics? Are past experiences influencing current actions? If we want to change behavior, we must recognize that people are complex. We cannot simply tell someone to do or not do something and expect immediate compliance. Instead, we must first understand the human factors that affect the behavior we’re seeking to influence.

My friends, this is why we need a revolution. We know 

we need to do to prevent infections, but we need to change 

 we do it. We’re forgetting that to prevent infections we must change the habits, perceptions, and knowledge ingrained in people and institutions. And people are so incredibly complex. I’ve already mentioned this, but I want to emphasize it. People are messy and complicated and confusing. We are filled with fear, insecurities, opinions, and habits. If we want to prevent infections, we must get to know and understand people, not just the science of infection prevention. On the surface, infection prevention and control is just science, but it’s really an art more than a science. The science of preventing infections is merely the tip of the iceberg. Underneath are people—complicated, messy people—and our approach to helping them prevent infections is key.

We need to change that approach. We talk a lot about what people must do: wash the hands, take the medicine, clean the hub, wear the mask. But we need to better understand 

 to get them to do those things. This is what I like to call “the art of prevention.” In this series of articles, art will meet science. Learning to practice this art requires us to continue learning about science because, regardless of how well one understands people, one must first understand the discipline of infection prevention. We’ll also explore human factors, psychology, and finally—possibly most importantly—personal growth. I know what you’re thinking: “What does personal growth have to do with preventing and controlling infections?” Quite frankly, everything. Infection prevention is not an easy job. To be successful in this career, we must have strong interpersonal skills and be able to handle conflict and defeat, competencies everyone can develop with time and guidance.

I’m eager for you to join me as we explore the complexities of being human in the context of infection prevention and control. My hope is that you’ll grow as a person and as a professional. This month, I want to challenge you to become known. Get out there and introduce yourself as the infection preventionist. Strike up a conversation with the environmental services worker. Tell them your name, make small talk, and share with them why you love what you do. Commit to not being known as “the handwashing person.”

Read about a lady with white hair, being human, and how infection prevention needs to transform. 

We Need a Revolution

Infection prevention has never been a “one-person show,” even if it often feels that way. Many of us who work in infection prevention and control (IPC) look at things not only through the lens of an infection preventionist (IP), but also through those of family members, friends, and even patients. This vantage point helps us to better implement prevention efforts and to see things from perspectives that often are not incorporated into traditional IPC protocols.

Collaboration is key. It’s that simple—and yet not that simple. Full transparency requires I disclose that I’ve also been an infection patient and a relative of such patients. But as someone who utterly loves what she does, I have seen the worst and the best parts of the job, particularly during the COVID-19 outbreak. Before delving into the topic of collaboration, it’s important to address what is palpable in our community right now: fatigue and a feeling of disconnect and discontent.

After more than 2 years, the pandemic has shed light on how ill-prepared hospitals are for such events, let alone our capacity to handle the fatigue that comes with the marathon that a public health crisis entails. I also want to say what generally goes unsaid: IPs have been wildly overlooked during this pandemic. We are the first advocates for health care workers (HCWs), but we often feel that our role is seen as that of an adversary rather than an ally. IPs are the ones doing the training on personal protective equipment (PPE), translating new guidance into practice, working with families and patients, in short, implementing COVID-19 IP measures on top of our daily work.

I share this because it can be isolating to feel as though your role is ignored even though it supports the response to a global event. This sentiment and our experiences during COVID-19 will likely impact the face of IPC in the future. We’re in uncharted territory; we’re not out of the pandemic, but everyone seems to have decided it’s over. The changes in public perception and sentiment toward COVID-19 are telling in terms of how we handle health, infection prevention, and nonpharmaceutical interventions.

It is obvious that IPC cannot be accomplished by any one group, but too often we forget the critical nature of collaboration. There is a triad, which is made up of the health care worker, the family/support system, and IP, and the patient sits within that triad. From prevention to response to follow-up, one of IP’s most important partnerships is perhaps with the patient. Outside of rounding, I often felt that my time with patients wasn’t really the main focus of my work. The truth is that taking the time to discuss isolation status, strategies for discharge, and safety once at home can go a long way to prevent the spread of any infection. It’s very important to talk to patients about why they’re in isolation and how they can keep their loved ones safe.

IPC has a unique role to play in that we not only liaise with community-based infection prevention but also advise on alternative hospital practices. For instance, we work with patient, child life, and social services to ensure that a patient who is feeling lonely owing to isolation can video chat with family or have window-based visits and sometimes to teach the family to properly don PPE for special visits. Helping patients understand the importance of proper infection prevention habits for the invasive devices they may be discharged with is also a way to prevent both health care–associated infections and community-associated infections. Although IPC may not be directly involved in patient care, we can give them the tools to stop the spread of germs, even if it’s only by handing out masks or sanitizer. In the case of younger patients, we have a great opportunity to collaborate with their family members.

Having relatives or caregivers on the IPC team can keep the patient safe, but that person can also serve as a good resource to remind patients or to ask important questions. Engaging with children is necessary, of course, but much pediatric care and support is achieved by interacting with their family or guardians, who are often the first to know when something is “off” with a child. Working with them to incorporate IPC strategies in the hospital—and at home—is vital. From line care to surgical wound cleanliness, and even hand hygiene, having a comprehensive approach that involves family and caregivers ensures that there is a team rallying around the patient. IPC can help discuss immunizations, at-home measures like chlorhexidine gluconate baths if needed, and infection prevention.

As Koutlakis-Barron and Hayden note, there must be awareness outside the health care setting: “Minimizing exposure to infectious organisms in the home, childcare/daycare/school settings or recreational centers will help reduce risk. Supervisory rules include the type/number of visitors with associated restrictions as applicable, preventing exposure to children with childhood illnesses being brought into the home or childcare setting. Ensuring sufficient supervision is provided by the handling of pets or animal-assisted interventions/therapy.”

 Personally, I liked rounding with pet therapy services and using that time to chat with patients and families while handing out hand sanitizer and discussing infection prevention. You’d be surprised how many people don’t realize IPC is a discipline in itself and are eager to ask us questions.

The HCW side of the triad is so essential that it feels almost comical to discuss it. Chapters could be written on the importance of their role in IPC, from perioperative care to PPE use to hand hygiene and antimicrobial stewardship. Did I mention proper cleaning and disinfection? Those are also obvious requirements, so I want to highlight another equally indispensable factor: sustainable IPC. Nearly 30 months into the pandemic, the appetite for PPE and for dealing with infectious diseases has waned. But the diseases haven’t gone away. In fact, we’re now facing the largest global spread of monkeypox ever seen, continued COVID-19 transmission alongside a diminishing interest in vaccines and nonpharmaceutical interventions, and an exhausted health care and public health workforce. So I want to spend time talking with health care workers, not at them, asking them what their concerns are and where they feel we can improve or have excelled.

Donning PPE before entering a room or waiting for a disinfectant wipe will never be the most fun thing in the world, but COVID-19 has shown us that sustaining these interventions will be our biggest hurdle. How do we get HCWs to continue caring while managing all their other work? I’ve asked them this very question. Building trust and empathetic relationships is critical for IPC-HCW collaboration and success. We depend upon them to remember the importance of infection prevention, and it’s OK to remind them of it, but without placing yet another burden on them. This is also why I like taking time to talk to patients and families, as it often lightens the health team’s duties. After all, if one side of the triad is weak or fails, the rest collapses. It takes all of us to protect patients.

Collaboration in this area calls for continuous work, not just interaction with teammates in health care, but also with patients and their families/support system. It is not easy, and it often requires us to adjust our communication strategies. Although communication, conflict resolution, and discussion of the science are vital components of IPC, we rarely talk about them. When considering collaboration as a means to prevent infections, we must look at every side of the triad and the bond between them. This quote by Epictetus should resonate with us all as we work to build these crucial relationships: “We have 2 ears and 1 mouth so that we listen twice as much as we speak.”

Koutlakis-Barron I, Hayden TA. Essentials of infection prevention in the pediatric population. 

. 2016;3(4):143-152. doi:10.1016/j.ijpam.2016.10.002

Infection preventionists are not alone, despite how the COVID-19 pandemic has often made them feel. They are one point of the patient's triad--and the bonds within the triad are vital for the patient's outcome. 

Infection Prevention: A Collaborative Effort Among Patients, HCPs, and Family Members

Because health care-associated infections (HAIs) are associated with significant mortality and cost, extensive emphasis has been placed on hand hygiene; however, stethoscope hygiene has had little emphasis. Previous studies have demonstrated 

 by infectious pathogens, including methicillin-resistant 

 that the same level of contamination as a HCP’s 

, and those pathogens on the stethoscope 

, “Assessing changes in stethoscope hygiene during COVID-19: A multicentre cross-sectional study” published in 

investigated this topic to improve stethoscope hygiene and to see how it changed—or did not change—during the COVID-19 pandemic.

Investigators from 3 major medical centers, University of California (UC) medical centers: UC San Diego, UC Davis, and UC Irvine, developed a 33-question survey asking health care providers (HCPs) about frequency of stethoscope use, perceptions of safety, and pathogen transmission associated with stethoscopes.The survey questions had 2 parts: “Before COVID-19" and “During COVID-19." Investigators also obtained demographics data, including age, sex, provider type, and years in practice. Survey questions contained a combination of 5-point Likert scale (Strongly Disagree to Strongly Agree), binary (Yes/No), categorical frequency, and free-response questions.

“In this study, we aimed to assess how HCPs’ knowledge, attitudes, and practices surrounding stethoscope hygiene have changed during the COVID-19 pandemic,” the investigators wrote in the study. “Additionally, we aimed to identify provider groups that might be deficient in stethoscope hygiene to identify potential targets for future intervention.”

The investigators discovered that, despite a positive shift in stethoscope hygiene during COVID-19, best hygiene practices were still only performed by around half of HCPs. Therefore, the investigators encouraged instruction, especially for providers early in their careers.

Of the invited 5022 participants, 515 (10.3%) completed the survey, and 55 participants (1.1%) were excluded for reporting no stethoscope usage both before and during COVID-19, leaving 460 (9.2%) included in the investigators’ analysis cohort. Interestingly, the physician respondents (75.9%), 65% were in general internal medicine, family medicine, or pediatrics, with 11% in medicine/pediatric subspecialties. 8% were in emergency medicine, 5% in surgical specialties, 4% in critical care, 3% in obstetrics-gynecology, and 5% other specialties.

Optimal hygiene increased from 27.4% to 55.0% (

 < .001). There were significant increases in Likert scores for all questions pertaining to knowledge of stethoscope contamination (

 < .001). Interestingly, the respondents’ belief in stethoscope contamination increased (

 < .001) despite no change in received hygiene education. Overall, resident physicians were less likely compared to attending physicians and nurses to have adopted optimal hygiene during COVID-19 (

“Prior studies on hand hygiene interventions have found that social pressures and increased perception of hygiene risk promote lasting improvements in hygiene behavior This phenomenon might explain the improvement in stethoscope hygiene observed in this study as well as increases in hand hygiene during COVID-19,” the investigators wrote in the study. “Amidst the greater infection control vigilance and social pressure catalyzed by the pandemic, interventions to improve stethoscope hygiene might be more effective.”

However, the investigators clearly did not hold out hope for HCPs to improve their practices. “Prior interventions for stethoscope hygiene that have been met with mixed success, including notable studies from Holleck et al, demonstrating no change in hygiene rates after implementing robust educational interventions.”

Despite the emphasis on more improved infection prevention practices, stethoscope hygiene continually falls short, possibly leading to more health care-acquired infections. 


Did Stethoscope Hygiene Improve Before and After COVID-19?

Health care environmental hygiene (HCEH) is vital to the safety and positive outcomes for patients regardless of where the facility is in the world. However, few, if any, major surveys have been done on the global stage. Recently, 50 health care facilities from 35 countries participated in a quantified review to find out what their practices are to figure out a baseline and to figure out what needs to be done to be done at all income levels.

This is the second part of a 2-part interview with Alexandra Peters, scientific lead for Clean Hospitals, Infection Control Program & World Health Organization Collaborating Centre on Patient Safety, The University of Geneva Hospitals and Faculty of Medicine in Geneva, Switzerland, and a lead author of the study, 

“Results of an international pilot survey on health care environmental hygiene at the facility level,”

The first part of the interview can be found 

“There are a lot of issues to access to products and supplies, like we know that that's not anything new. But I think what our survey showed was that there's a lot of things that are institutionally malfunctioning, and that are able to be changed without using a lot of additional resources,” Peters told 

 in the interview. “But that the environmental hygiene programs are looked at more like hotel housekeeping, and they're not being addressed holistically, and they're not being addressed scientifically. And that's where I think we can make the most headway by developing a tool like this.”

This survey was only the first step in improving the HCEH throughout the world, but Peters is optimistic: “We've seen how a similar tool for hand hygiene has improved levels worldwide. I'd like to do the same thing for environmental hygiene.”

Videos

From language barriers to lack of equipment, environmental hygiene is suffering throughout the world.  


Environmental Hygiene Shows Severe Issues in Global Survey

. However, other biosafety reviews and control reports were less often conducted for other laboratory tests. These biosafety risk assessments should be re-enforced before testing COVID-19 patients’ specimens.

“Biosafety risk assessment and risk control of clinical laboratory in designated hospitals for treating COVID-19 in Chongquing, China,”

 discussed this topic and the conclusions. During the COVID-19 pandemic, the Chinese health authorities have adopted a series of effective measures, including nucleic acid testing of SARS-CoV-2 among large-scale populations along with the timely and effective diagnosis and treatment of COVID-19, which has played a key role in the control of the epidemic in China.

The investigators found that “[t]he most important aspect of biosafety risk assessment is to take appropriate but not excessive control measures for biosafety risk against the risks of different hazard degrees, which can not only reduce the risk to an acceptable range but also save resources and improve the work efficiency,” the investigators wrote in the study. “For the same pathogenic microorganism tested in different test activities, the hazard degrees of biosafety risk existing in those test activities are different, and they should be operated in laboratories with different biosafety levels. Therefore, it is inappropriate to unilaterally emphasize that the biosafety level of the laboratory should be consistent with the hazard level of pathogenic microorganisms tested in the laboratory.”

At present, despite many laboratory leadership members emphasizing biosafety assessment, the leadership has ignored biosafety risk management after the assessment. “Even if the subsequent test activities or the pathogenic microorganisms exposed to the laboratory personnel had changed, the biosafety risk assessment was not restarted, and the biosafety risk control did not change accordingly. Biosafety risk management is based on self-inspection and dynamic monitoring.” the investigators said.

The investigators determined that the residual risk after the implementation of the control measures was acceptable.

If clinical laboratory workers testing SARS-CoV-2 used a nucleic acid preservation solution containing viral inactivators, the biosafety risk in the process of detecting the nucleic acid of SARS-CoV-2 will be low. Since patients in China infected with SARS-CoV-2 are sent to designated hospitals for treatment, except for detecting nucleic acid of SARS-CoV-2, other laboratory tests such as bacterial culture may also be carried out while the patients are being treated. However, the investigators said, in addition to nucleic acid testing, biosafety risks in the testing of these items for patients with COVID-19 might be ignored. “Therefore, we identified and evaluated risks in these detection processes and formulated appropriate, but not excessive control measures for biosafety risk, to improve the work efficiency and prevent biosafety accidents.”

The investigators identified 32 risks in total in the following categories:

A risk of personal infection or environmental contamination due to malfunction of the airflow or filtration of the biological safety cabinet (BSC),

A risk of environmental contamination, or personnel infection resulting from the concentration of laboratory disinfectants being improperly selected, and the disinfection effect is not achieved,

A risk that the personnel's hands are contaminated by the specimen tubes, which are contaminated during specimen collection during the process of specimen reception,

A risk of contaminating the environment or items by hands contaminated when remove from the BSC during the process of operation in the BSC,

A risk of the lens and stage of the microscope being contaminated by the specimen during the microscopic examination of fecal specimens.

Biosafety risk monitoring includes monitoring changes in test activity, pathogenic microorganisms involved, monitoring changes in the dose of pathogenic microorganisms used, specimen types, and monitoring for unidentified risks.

Finally, the investigators recommend that the laboratory leadership should annually review the suitability of laboratory biosafety risk assessment and biosafety risk control, and start risk assessment promptly, which is also a part of risk management.

Biosafety risks for patients with SARS-CoV-2 may be overlooked, and some control measures may bring about cross-contamination of the tests being done and cause biosafety accidents. 



Testing Biosafety Measures Should Be Appropriate Not Excessive 

“Lions and tigers and bears, oh, my!” is an iconic quote from 

, but in the world of infection prevention, that quote is starting to sound more like “Influenza and COVID-19 and (now) Monkeypox, oh, my!” It has been a long, arduous, and taxing 2 and a half years of COVID-19, and health care workers are tired, numb, or have given up to pursue non-health care careers.

 Now, with the emergence of monkeypox in over 

 in the United States, some infection preventionists (IPs) in local government, hospitals, long-term care, and other health care settings are emotionally and mentally paralytic with the fear of yet another pandemic—one, potentially, more catastrophic than before.

 In these times, it is paramount that IPs get back to basics, refocus, and get their second wind. They must 

 the threat, educate themselves and others, and implement best practices.

: Monkeypox sounds like an altered version of smallpox, which it is in a sense that it belongs to the same family—

. Since the development of the live vaccinia-based vaccine, smallpox was declared eradicated in 1980; however, other genera of the virus, like monkeypox, remain in underdeveloped parts of the world.5 Since the enveloped (lipid capsule) poxvirus contains its own transcription machinery and is a double-stranded DNA genome, it is renowned for its large size. Because of this, it can replicate within the host cell’s cytoplasm in conjunction with using its endoplasmic reticulum (ER) and ribosomes for latent replication.

 When the virus duplicates and is ready, it leaves the host cell to infect another.

 According to the latest reports from the Centers for Diseases Control and Prevention (CDC), the incubation period for monkeypox is typically between 7 and 14 days but can range anywhere between 5 and 21 days. Symptoms of monkeypox begin with fever, headache, muscle aches, and exhaustion, as well as swollen lymph nodes and chills. Within 1 to 3 days of symptom onset, most patients will experience a rash on the face, palms of hands, and soles of the feet. Additionally, cases will develop lesions, a little smaller than a centimeter, in the following stages: macules (flat lesion), papules (slightly raised), vesicles (thin-walled sac with clear fluid), pustules (bulging sac filled with yellowish fluid), and finally, scab; this process can last anywhere between 2 to 4 weeks.

Although it is named “monkeypox,” animals like squirrels, rats, and mice are also susceptible to the virus. Humans can obtain it from infected humans, infected animals, and contaminated materials. Monkeypox is primarily transmitted through the contact of the infectious sores but can also be transmitted through bodily fluid exchange; it is even possible for the virus to cross the placenta from mother to fetus, as well as through respiratory secretions during prolonged face-to-face contact (such as kissing).

 Whether you receive your updates from the news, work, or other sources, the dangers of monkeypox in our population can be interpreted in 2 main ways—mortality rate and R naught (R0). The World Health Organization (WHO) has recorded higher mortality rates (10.6%) in countries that do not have accessibility to adequate health care facilities, whereas, in many developed countries (ie, European and the Americas), the mortality rate is around 3.6%.

These numbers may sound a little frightening, but the R0 may put you more at ease. The R0 is a rough calculation of how transmissible a disease is from person-to-person. Although we do not have a precise figure, it is estimated to be less than 1%. To provide some perspective, the R0 for the recent SARS-CoV-2 Omicron variant is an 8.2%.

: Since monkeypox is primarily spread through physical contact, the following are best practices: Avoid infected persons or animals, isolate infected patients and use effective PPE practices for contact precautions, perform proper hand hygiene techniques with soap and water, and ensure quality environmental services disinfection procedures are conducted with EPA-approved products. 15 For most people born before the early 1970s and a handful of others (military members, laboratory staff, etc), they may have an 85% immunity to monkeypox if they received the smalllpox vaccine in the past.10, 16 For now, the FDA is evaluating the JYNNEOS vaccine for people who may be at high risk of occupational exposure and has approved TPOXX, Cidofovir (Vistide), and VIGIV as antiviral treatments.

All IPs should take a deep breath, hold their heads high, and rise to the challenge. Inform and educate those within their area of influence, lead the initiative of quality training, procedures, and service; and most importantly, reclaim the reputable paradigm of health care. To stay up-to-date on the most current monkeypox information, please visit the CDC’s 

1. Yong, E. Why health-care workers are quitting in droves. The Atlantic. Posted November 16, 2021. Accessed June 1, 2022. https://www.theatlantic.com/health/archive/2021/11/the-mass-exodus-of-americas-health-care-workers/620713/?utm_source=STAT+Newsletters&utm_campaign=49ab812eb4-MR_COPY_01&utm_medium=email&utm_term=0_8cab1d7961-49ab812eb4-151759045.

2. Altarum. Health care employment falls slightly in August, remaining 3.1% below Feb 2020. Altarum Health Sector Economic Indicators. Posted September 17, 2021. Accessed June 1, 2022. https://altarum.org/sites/default/files/uploaded-publication-files/SHSS-Labor-Brief_Sept_2021.pdf.

3. Global health. Monkeypox tracker. Global health: a data science initiative. Accessed June 1, 2022. https://monkeypox.healthmap.org/.

4. Centers for Disease Control and Prevention. U.S. monkeypox 2022: Situation summary. Centers for Disease Control and Prevention. Accessed June 1, 2022. https://www.cdc.gov/poxvirus/monkeypox/response/2022/index.html.

5. About monkeypox. Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of High-Consequence Pathogens and Pathology (DHCPP). Posted November 23, 2021. Accessed June 1, 2022. https://www.cdc.gov/poxvirus/monkeypox/about.html.

6. Malone, B, et al. Structures and functions of coronavirus replication–transcription complexes and their relevance for SARS-CoV-2 drug design. 2021, Nature Reviews Molecular Cell Biology, pp. Volume 23; Pages 22-39.

7. Takele T, Huaijie J, Guohua C, Fang X, et al. Methodical review on poxvirus replication, Genes responsible for the development of infection and host immune response against the disease. 2019, Archives of Microbiology & Immunology, pp. Vol. 3 No. 2 Pg. 3-19.

 2013, Cold Spring Harbor Perspectives in Biology, p. doi: 10.1101/cshperspect.a010199.

9. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of High-Consequence Pathogens and Pathology (DHCPP). Monkeypox: Signs and symptoms. Posted July 16, 2021. Accessed June 1, 2022. https://www.cdc.gov/poxvirus/monkeypox/symptoms.html.

 Monkeypox: What we do and don't know about recent outbreaks. American Society for Microbiology. Posted May 24, 2022. Accesed June 1, 2022. https://asm.org/Articles/2022/May/Monkeypox-What-We-Do-and-Don-t-Know-About-Recent-O#:~:text=Monkeypox%20Virus%20Structure%20and%20Replication%20Cycle&text=Like%20all%20poxviruses%2C%20monkeypox%20virions,for%20virus%20uncoating%20and%20replication..

11. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of High-Consequence Pathogens and Pathology (DHCPP). Monkeypox: Transmission. Posted May 29, 2022. Accessed June 1, 2022. https://www.cdc.gov/poxvirus/monkeypox/transmission.html.

12. World Health Organization. Multi-country monkeypox outbreak in non-endemic countries. Posted May 21, 2022. Accessed June 1, 2022. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385.

13. Liu, Y, Rocklov, J. The effective reproductive number of the Omicron variant of SARS-CoV-2 is several times relative to Delta. 2022, Journal of Travel Medicine, pp. 1-4.

 A CDC expert answers questions on monkeypox. STAT. Posted May 19, 2022. Accessed June 1, 2022. https://www.statnews.com/2022/05/19/a-cdc-expert-answers-questions-on-monkeypox/.

15. United States Environmental Protection Agency. EPA releases list of disinfectants for emerging viral pathogens (EVPs) Including monkeypox. Posted May 26, 2022. Accessed June 1, 2022. https://www.epa.gov/pesticides/epa-releases-list-disinfectants-emerging-viral-pathogens-evps-including-monkeypox.

 Monkeypox. Posted May 19, 2022. Accessed June 1, 2022. https://www.who.int/news-room/fact-sheets/detail/monkeypox#:~:text=Monkeypox%20is%20caused%20by%20monkeypox,been%20around%203%E2%80%936%25..

17. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of High-Consequence Pathogens and Pathology (DHCPP). Monkeypox: Prevention. Posted December 2, 2019. Accessed June 1, 2022. https://www.cdc.gov/poxvirus/monkeypox/prevention.html.

18. Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of monkeypox. Posted May 26, 2022. Accessed June 1, 2022. https://www.cdc.gov/poxvirus/monkeypox/treatment.html.

Adding to their exhaustion because of other diseases rampant worldwide, like influenza and COVID-19, infection preventionists need to understand and recognize the basics of monkeypox as well since it has made its debut in the US.   


Monkeypox Details for Infection Preventionists

The COVID-19 pandemic has contributed to rapid adjustments and innovations in infection prevention and public health practices over the past 2 years. Health care cleaning and disinfection also gained a spotlight as a key piece to the infection prevention program in facilities. While this was not a new concept for infection preventionists and environmental services departments, it brought a public awareness to the various types of disinfectants and how crucial cleaning of surfaces is to decrease risk of disease transmission.

Continuously Active Disinfection (CAD) Chemicals

The first innovation in cleaning and disinfection is continuously active disinfection (CAD) chemicals. Previously, CAD was a focus of materials, not chemicals. Copper- and silver-infused items, such as bedside tables, bed rails, IV poles, linens, and curtains were brought to the market as solutions to contamination of objects and a passive way to break the chain of infection for indirect and direct contact. Ultimately, there were challenges with this type of solution, including the cost of implementation and evidence to support the effectiveness. A 2016 ECRI report found that there was not a statistically significant difference between copper treated rooms and control rooms with no copper fixtures

. Based on the review, the return on investment was not evident for having a room full of copper fixtures—let alone an entire ward.

Infection preventionists and the equipment and cleansers they use gained a spotlight during the COVID-19 pandemic. These include both established and innovative materials. 


Infection Control Today, July-August 2022, (Vol. 26, No. 6)