The approval of the Pfizer and Moderna coronavirus disease 2019 (COVID-19) vaccines for emergency use authorization in the United States has brought much attention and focus to the vaccination process. Because of the high demand for and low initial supply of the vaccines, the government has sought to prioritize them for individuals at highest risk for complications from COVID-19, and those who hold essential service roles that are vital to a functioning economy and health care system.

By all accounts, the rollout is still a work in progress. On January 12, Alex Azar, former head of the Department of Health and Human Services, said that focusing on health care workers and long-term care facilities has led to a vaccine distribution bottleneck. Azar issued a directive saying that people aged 65 years and older and those 16 years and older with a comorbidity should be considered priorities for vaccination. That, in effect, pushed about 163 million more people—about half the population—to the front of the vaccine line.

But back to health care systems. What many people outside the health care realm do not realize is that vaccination logistics and planning is in the yearly wheelhouse of hospital systems. Vaccinations to combat a variety of diseases are given every day, from the first-dose hepatitis B vaccine given to a newborn, to the tetanus, diphtheria, and acellular pertussis (Tdap) booster given after one scrapes against a rusty nail, to the yearly influenza vaccination.

The role of an infection preventionist (IP) in vaccination efforts is important, both to patients and providers, regardless of whether the setting is a large hospital system or a small provider’s office. IPs can help to provide best practice recommendations on immunization, from explaining sterilization techniques, to educating health care staff on the importance of vaccination, to working with occupational health in tracking rates of vaccination.

Not all IPs can administer the vaccine directly as some lack a health care degree, but they can be subject matter experts in the logistics of large-scale vaccinations. As such, it is important they participate in multidisciplinary projects involving vaccination efforts.

Proper infection control practices in vaccine administration are critical to ensuring safety and efficacy. Vaccine vials must be disinfected with sterile alcohol prep pads prior to each withdrawal and a new, sterile needle and syringe used for each injection.

Vaccines should be drawn up in clean medication preparation areas that are not next to any dirty items, and doses should be administered as soon as they have been drawn up to avoid any potential for spoilage. For vaccines that have been prepared for administration, the date and time should be marked on the syringe to alert the administrator to when the vaccine can no longer be given.

A common misconception about vaccine administration is that gloves must be worn. Per Occupational Safety and Health Administration regulations, gloves are not required when administering vaccines unless the individual administering the vaccine has open lesions on their hands or is likely to come in contact with a patient’s body fluids.

 If gloves are worn during vaccine administration, they must be removed between each patient and hand hygiene must be performed before donning a new pair of gloves.

If gloves are not worn, hand hygiene should be performed between each new patient administration.

Vaccine hesitancy is another area in which IPs can aid departments in helping alleviate fears and answering questions. Whether it be the influenza or the COVID-19 vaccine, the misconceptions surrounding them or fear of what may occur post vaccination are just 2 reasons that individuals may choose to not receive the vaccine.

IPs can help to engage health care employees and answer questions while also directing them to primary resources for further information. These include the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). IPs can also coordinate with physicians and other subject matter experts on common areas of vaccine hesitancy among staff, and work with key stakeholders to address them.

As vaccine rollouts begin, IPs can also partner with occupational health teams to track and trend adherence with vaccination. Regarding annual influenza vaccination of health care staff, hospitals must report adherence rates to the National Healthcare Safety Network.

Often, IPs may be the only individuals who have access to this website, so it is vital they work with occupational health to obtain accurate counts of adherent and nonadherent staff. Trending health care vaccination rates by department or role type can also be valuable indicators for how to focus education efforts during the following years to increase adherence.

Although we do not yet know if the COVID-19 vaccine will be recommended yearly or whether it will offer longer immunity against severe acute respiratory syndrome coronavirus 2, health care facilities will continue to provide the influenza vaccine yearly to employees. They will also be prepared to modify their processes to help increase adherence rates, and IPs can collaborate in these efforts as well.

ANJALI BISHT, MPH, CIC, is the lead infection preventionist at an academic medical center that comprises a number of hospitals and an extensive primary care network in the Los Angeles region in California.

Occupational exposure to bloodborne pathogens; needlesticks and other sharps injuries; final rule. Occupational Safety and Health Administration (OSHA), Department of Labor. Final rule; request for comment on the Information Collection (Paperwork) Requirements. 

Surveillance for healthcare personnel vaccination. CDC. Updated December 2, 2020. 

https://www.cdc.gov/nhsn/acute-care-hospital/hcp-vaccination/index.html

Articles

Infection preventionists can coordinate with physicians and other subject matter experts on common areas of vaccine hesitancy among staff, and work with key stakeholders to address them.

How Infection Preventionists Will Handle COVID-19 Vaccinations

A clinician walks out of a patient’s room. Seconds tick by. The clinician takes a bit too long to clean his hands. “Please sanitize,” a calm voice says. It’s coming from his belt, apparently.

Actually, it’s coming from the badge attached to the belt. The badge reel contains Bluetooth technology, which communicates with sensors affixed to soap and sanitizer dispensers parked in various places around the patient care area.

If hospital administrators could have 1 wish, it might be to have 100% adherence with hand hygiene protocols. So, they are doing everything they can to encourage adherence, which is particularly critical now when people (including 3142 health care workers as of January 7, 2021) are still dying of coronavirus disease 2019 (COVID-19).

Electronic monitoring, sensors, and voice prompts aren’t new, and the technology keeps evolving. The Clean Hands–Safe Hands system allows users to customize the audio file reminder with their preferred voice and content, such as an infection preventionist (IP) or a child.

Personalized touches like that are born of experience. Hospital experts know that monitoring alone doesn’t change behavior. In fact, technology alone isn’t always the answer either. Some of the most effective systems are a hybrid of the latest technology and traditional methods such as rewards and recognition.

Take the solutions they came up with at Sentara Healthcare, a not-for-profit integrated health care system based in Norfolk, Virginia. With 12 hospitals, 4 medical groups, and more than 30,000 employees, it’s Virginia’s largest health care system. Nearly 10 years ago, after a large group of health care professionals there did some brainstorming about best hand hygiene practices, Sentara hired QualPro, a quality control consultancy, to test and analyze 21 interventions. Eventually, Sentara decided on interventions that included computer screen savers encouraging hand hygiene and awarding Hero of the Month titles to employees with high adherence rates. Other low-tech interventions included red stop signs to remind staff to wash their hands and random quizzes.

They didn’t stop there. Sentara’s adherence rates “are generally in the 90s, but ‘secret shopper’ audits show lower adherence that varies,” says Linda Estep, manager of infection prevention and control. “This is driving the push for electronic auditing that captures all opportunities we set up, and measures adherence more widely and accurately. Our manual audits are time-consuming and may not cover all shifts consistently. Currently, we’re reviewing electronic hand hygiene monitoring to expand our ability to capture a wider picture of adherence across all shifts.”

In fact, methods such as secret shoppers have underscored the need for more advanced methods of monitoring adherence. Study findings have shown that direct observation captures only a small percentage of all events. What’s more, it can massively overstate actual adherence.

Sentara’s ongoing hand hygiene campaigns are very successful, Estep says. “We update our approach regularly and we pay careful attention to our rates, as well as what we see when rounding on patient care units.” Keeping the message fresh is important, she notes.

Sentara not only has a top-down approach led by divisional leaders, but also peer-coaching efforts that address and overcome the “authority” gradient. “Sentara has a solid, long-standing culture that infection prevention is everyone’s job,” Estep says.

That means getting everyone on board. One of Sentara’s most successful campaigns is All Hands On Deck (AHOD). AHOD is Sentara’s code word to remind staff they forgot to clean their hands when required. “It’s a fun way to deliver the reminder,” Estep remarks. Leaders also model the correct response: Thank the person for the reminder and immediately sanitize hands. “Negative responses prevent our more shy staff from stepping up to coach,” Estep says. “We’re all responsible for creating a culture that promotes coaching.”

The Johns Hopkins Hospital in Baltimore, Maryland, has also found that the personal touch helps keep an adherence program from running out of steam. The hospital doubled rates of adherence with hand hygiene protocols between 2007 and 2008, and increased adherence again by 27% between 2008 and 2009.

 How? With a hospital-wide communication and education campaign called WIPES:

Precautions use (eg, gowns, gloves, and masks)

Hanan J. Aboumatar, MD, MPH, a family practitioner focusing on behavior change and an assistant professor at Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, and Polly Trexler, MS, CIC, director of operations for the Department of Hospital Epidemiology and Infection Control at The Johns Hopkins Hospital, started the program “because there was a lot of work to do.” They spent about a year planning, looking at behavior, and researching how to change it. They used focus groups with hospital staff and leaders to understand the issues and which behavior models to support.

The WIPES project included the usual steps of putting up posters and hosting sessions about the importance of using sanitizers. “The program helped increase adherence significantly,” says Trexler. “Then we stalled for a while. People were lagging behind. So, about 5 years into the project we added [the component of] direct feedback. We hired someone in addition to secret shoppers to address those employees who were a little more resistant to change.”

A successful program includes accountability, she believes, referring to “a new buzzword: Just Culture.” That is, applying discipline in a fair way to be sure staff understand expectations. But it’s also important to make it possible for them to adhere easily, for example, by having dispensers everywhere. “We set expectations to clean hands on entry and exit, changing the behavior of only cleaning on entry and then thinking ‘I didn’t touch anything’ so not cleaning on exit,” Trexler says. “We did it on purpose to create habits, and to make it simple to keep the new habits.”

The accountability model also includes escalating consequences for nonadherence, beginning with a note to the employee, a note to the supervisor, then a talk with the supervisor, and up the chain of command. Nonadherence after 6 observations in the year means termination. But “we never go over 3 observations,” Trexler says.

The traditional methods—positive reinforcement, educational posters, reminders, rewards, recognition, secret shoppers—help keep the day-to-day level of adherence up, but technological innovations can make it easier for administrators to spot and calibrate for weak areas. An online reporting tool allows managers to collect data entered into a phone or iPad. “It’s real-time data that can be pulled up by hospital, service, unit, health care worker type, and timeframe,” Trexler says.

At Johns Hopkins, adherence is rewarded with the old-fashioned kind of positive reinforcement—compliments and congratulations—but also with data-based reinforcement. Taylor McIlquham, MPH, an infection control epidemiologist at The Johns Hopkins Hospital, says, “We present data to the IC [infection control] committee every month about which units are doing well, and which aren’t, and which ones have reached more than 92% adherence in the previous 3 months.” High performers are treated to individually wrapped cookies (pre–COVID-19, they had pizza parties). Leadership comes to the meeting to thank them (the personal touch again).

COVID-19 has intensified just about everything to do with infection control, including the need to find the right tools for the right situations. According to McIlquham, Johns Hopkins has spent the past 2 years looking into electronic monitoring systems, made by everyone from GE to smaller startups. Time constraints make it hard to rely on secret shoppers, she says. “We have over 50 clinical units to observe each month. Also, it can create bias [in the data] if staff begin to recognize the secret shopper.” Badges and digital monitors take out the human element, she adds. “We’re interested in technology primarily to reduce bias and understand what the numbers actually are, to be as accurate as possible. And to use data to target which interventions improve outcomes.”

It’s a big undertaking. “Even just doing studies, it’s a huge, huge infrastructure,” says McIlquham. “Think about thousands and thousands of people on our campus who would need the badges and monitoring tools. But we’ll continue exploring. We were doing short-term trials. Right before COVID-19 we were just about to do another but put it on the back burner for now.”

Hand hygiene is always important, but during this pandemic it’s crucial to preventing transmission. Now technology is making it possible for hospitals not only to monitor adherence, but also potential viral exposure.

SwipeSense, which initially was intended to track whether staff were washing their hands correctly, has a new application: contact tracing. Via sensors added to staff badges, managers can create a virtual “historical” map of staff whereabouts. If someone has received a COVID-19 diagnosis, administrators can better identify where the person was and who might have been in contact with them.

SwipeSense CEO Mert Iseri is fully aware of the implications of the monitoring, but in a recent interview with CNBC insists the company is “taking steps to alleviate the ‘creep’ factor.” For example, the system doesn’t track people throughout their day. Acknowledging the potential for misuse, he said, “We have to be really thoughtful about the technology we’re building.”

Used wisely, the technology is a benefit in fighting COVID-19 spread. At Edward-Elmhurst Health in Illinois, where more than 3000 workers agreed to wear the SwipeSense badge, the data populated a dashboard that, by the end of March 2020, could help administrators monitor exposures. In 1 case, they determined that 75 employees had been in the room of a patient who tested positive, so they tested those workers and isolated them for 72 hours. One tested positive and was further isolated, and the virus was contained.

Hazard Appalachian Regional Healthcare (ARH) in Kentucky is also using the SwipeSense technology for contact tracing. “We are 1 of only 3 hospitals in the nation who are currently utilizing this technology for contact tracing,” James J. Hensley, MLS (ASCP), CIC, system director of infection prevention for ARH, wrote in a blog on the hospital’s website.

 In addition to contact tracing for staff, ARH attaches radio-frequency identification asset tags to mobile equipment such as ventilators. Through the SwipeSense Asset Tracking app, the hospital can virtually map and track equipment throughout the facility.

“This helps us identify equipment that may need [to be] assessed, cleaned, and even quarantined,” Hensley said. “The facility has location hubs connected all over, including in common areas, which ‘talk’ to staff badges and asset tags to log data for asset tracking and also for contact tracing.”

Sentara’s Estep says, “The pandemic has reaffirmed our focus on correct, consistent use of [personal protective equipment] and hand hygiene to prevent exposures. We’re compliant with the Virginia Emergency Temporary Standard for the prevention of SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2], which has a high focus on staff training, including correct hand hygiene technique. We created a training video, Safe at Sentara, that covers all aspects of COVID-19 prevention, and we plan for it to become an annual educational requirement.”

Sentara also continues to explore adherence-enhancing technology. “This will not only emphasize our commitment to 100% hand hygiene adherence,” Estep says, “but also our willingness to identify gaps and opportunities and commit to the technology cost of such a project. We’re also using the more stringent Leapfrog requirements to justify electronic monitoring, since receiving additional points involves a much higher volume of audits than we can achieve manually.” (The Leapfrog Group is a national watchdog organization focused on health care safety.)

The original WIPES program at Johns Hopkins increased adherence in hand hygiene to more than 80%; the enhancements have boosted it to the 90% range, and COVID-19 has made it critical. “Adherence is higher this year than ever before,” Trexler says. “People are more conscientious. We’re hoping this habit will bleed over after the pandemic.” She sees reason for optimism. “COVID-19 will have one benefit: changing behavior.”

Hospitals might get their wish for 100% adherence granted after all.

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

. August 11, 2020. Accessed January 7, 2021. 

https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database

Aboumatar H, Ristaino P, Davis RO. Infection prevention promotion program based on the PRECEDE model: improving hand hygiene behaviors among healthcare personnel. 

Farr C. Some hospitals are tracking Covid-19 by adding sensors to employees’ badges. CNBC. August 2, 2020. Accessed January 7, 2021. 

https://www.cnbc.com/2020/08/02/hospitals-tracking-covid-19-with-badge-sensors-swipesense-technology.html

Hazard ARH uses SwipeSense technology to speed up contact tracing for COVID-19. Appalachian Regional Healthcare blog. Accessed January 7, 2021. 

https://www.arh.org/portfolio_page/hazard-arh-uses-swipesense-technology-to-speed-up-contact-tracing-for-covid-19/

In 1999, Kevin Ashton, of Procter & Gamble, coined the term “Internet of Things” to describe that universe of computers communicating with each other almost independently of humans.

In 2015, in an interview with Smithsonian Magazine, he said, “In the 20th century, computers were brains without senses—they only knew what we told them. That was a huge limitation: There is many billion times more information in the world than people could possibly type in through a keyboard or scan with a barcode. In the 21st century, because of the Internet of Things, computers can sense things for themselves.”1

Consequently, we now have GPS; smart phones, TVs, and refrigerators; and devices that know when we’re home and when we aren’t.

We also have systems that can tell when health care personnel are washing their hands and when they aren’t—and reminds them when they don’t. The data those systems provide also help hospital managers understand transmission risk. In this coronavirus disease 2019 (COVID-19) pandemic, knowing where hotspots might be lurking is critical.

Here’s a brief look at some of the technological tools available:

 (CHSH) technology helps hospitals identify the most efficient path to improving hand hygiene. Its patented process, which includes gamification, “nurtures a culture of proactive HAI [health care–associated infection] prevention.” According to CHSH, hospitals that have used its technology and followed its process for at least 6 months have seen a decrease in HAIs of between 45% and 81%.


https://cleanhands-safehands.com/technology/

 has been named a “Best Infection Prevention Product” by Newsweek, in association with the Leapfrog Group. Its 55-second disinfection “UV Box,” used throughout more than 700 hospitals and hospital groups, provides up to 99.999% disinfection. According to AUVS, the surface disinfection technology in its products is similar to the technology used in the air systems at the US Pentagon to protect against bioterrorism.


, with a configurable dashboard, provides on-demand intelligence and actionable insights about adherence and clinical workflows. The insights are color coded and available in easy-to-read graphs, making it simple to track adherence history. The company says study results have found its use reduces HAIs and staff absenteeism due to illness.


DebMed Electronic Hand Hygiene Adherence System

 is, according to the company, the only research-based, badge-free system that tracks adherence based on the World Health Organization’s 5 Moments, the Canadian 4 Moments, and the Centers for Disease Control and Prevention’s (CDC) hand hygiene standards. The system can capture 100% of hand hygiene events and opportunities, beyond just room entry and exit. Having an accurate number of hand hygiene opportunities and comparing them to 100% of all hand hygiene events collected, the system provides true adherence rates, providing actionable feedback for the group “without singling out individuals.”


 is a cloud-based sensor network that runs multiple applications simultaneously and monitors core metrics in one place. It does this “without the burden of logging in to multiple systems,” and with “little involvement from IT teams,” the company says. The system is compatible with existing or new wall dispensers. At-a-glance insights include time series comparisons, day vs night shifts, and soap vs sanitizer use. According to the company, because SwipeSense relies on proven behavior change methodologies rather than short-term gimmicks such as alerts or reminders, it leads to hospital-wide adoption.


 was recently recognized in Newsweek’s Best in HealthCare 2020 as one of the best monitoring products for infection prevention. The band measures proximity to other SmartBands in the office. If they’re “too close for too long,” the users are notified by Vitalacy that they may have been exposed. The product does not track user location and keeps all user data anonymous from other team members and their employer. The company says the band is also the only adherence-monitoring wearable that records and improves hand wash duration.


Gabbai A. Kevin Ashton describes “the Internet of Things.” 

. January 2015. Accessed January 7, 2021. 

https://www.smithsonianmag.com/innovation/kevin-ashton-describes-the-internet-of-things-180953749/

Hand hygiene is always important, but during this pandemic it’s crucial to preventing transmission. Now technology is making it possible for hospitals not only to monitor compliance, but also potential viral exposure.

Hand Hygiene: Where Technology and Tradition Meet

It’s almost hard to believe the United States has been dealing with coronavirus disease 2019 (COVID-19) since January 20, 2020. The virus is still raging around the world. Health care is still struggling to keep up. Many businesses, large and small, have closed for good. Everyday activities such as getting your hair cut, going to the grocery store, gathering with friends, going to school or work, and eating at your favorite restaurant have changed drastically. These struggles and changes, in the health care and non–health care sectors, may affect things forever, at least in some ways. Fortunately, COVID-19 vaccine distribution has already started for frontline workers and long-term care/congregate facilities. Essential workers will be next in line for vaccination to help to revive the struggling non–health care sector. However, it will be too late for many working in restaurants and other businesses that lacked the same resources and level of preparedness as the health care industry.

Those working in health care have learned a lot during the pandemic about keeping patients and staff safe; managing supply chain items such as personal protective equipment (PPE), disinfectants, and other critical supplies; and preparing for shortages of staff and their emotional needs. Preparedness planning was something most facilities reviewed annually. Now, they are reviewing plans to determine when it might be safe to resume elective surgeries and other procedures placed on hold, as the pandemic becomes more manageable due to vaccination. Health care relies on specific guidance from the Centers for Disease Control and Prevention (CDC), and state and local agencies. They have plenty of resources available, including staff such as infection preventionists (IPs) to safely guide them along the journey to reopening and fully resuming care.

Dentistry has a very strong COVID-19 program guided by the CDC in collaboration with the American Dental Association (ADA). And they should have, as most of what they do involves performing aerosol-generating procedures, placing dentistry into a high-risk group category. The 

ADA offers a robust Return to Work Interim Guidance Toolkit and a COVID-19 Hazard Assessment & Checklist with recommendations for before, during, and after appointments to protect dentists, patients, and staff.1 Dentists and their staff were already well versed in using PPE and cleaning and disinfecting patient care equipment. Typically, they designate someone as their infection control person who can answer questions and provide guidance and training. They were able to ramp up procedures and see patients safely, gradually resuming the provision of dental services.

The American Veterinary Medical Association (AVMA) also had a tremendous number of resources for safely managing their practices and patients during the pandemic.

They produced a comprehensive risk management guide, Resuming Veterinary Practice Operations During the COVID 19 Pandemic (described as a “playbook to help our veterinary practices recover by addressing specific issues that relate to your team, patients and clients, property, and the practice’s profitability”).2

The CDC also provided additional guidance for veterinarians, including specific recommendations about companion animal practice, recommending screening companion animals for exposure to people with COVID-19. Additionally, veterinarians are familiar with PPE use, cleaning, and disinfection,3 and had many resources to guide practice and answer questions. Their practices were up and running fairly quickly with mitigation procedures in place to keep staff, clients, and pets safe.

Health care, be it for animals, humans, or teeth, had plenty of experience with the nuts and bolts of providing care. They had PPE use, disinfectants, and a wealth of resources at their fingertips, including financial ones.

However, the non–health care sector—corporations, schools, fitness centers, libraries, hair salons, restaurants, and other businesses—was not so fortunate. They did not have access to an abundance of resources, exposing a huge, glaring knowledge and resource gap that threatened their existence. Very few, if any, had a preparedness plan. Their guidance has been general, mostly “one size fits all,” at best, from the CDC, the World Health Organization, and state and local agencies.

This is not to fault any agency, because saving lives was and still is the priority; health care was overwhelmed with patients, so resources were naturally directed to patient care. But the non–health care sector was left to struggle more or less on its own, interpreting guidelines that were ambiguous at best, with terminology and processes that few were familiar with, such as contact time and PPE. Their experience was not in PPE or pandemics but in cutting hair, preparing food, providing fitness classes, teaching children, and helping you find a good book. And we thought health care had been turned on its head!

As an IP, I was shocked and worried about my safety and others’ when I ventured out to a grocery store or small business. I saw single-layer bandanas open at the bottom, gaiters soaked in water in hopes of preventing virus spread, a homemade face shield made from a plastic page protector attached to a cloth headband, face shields without masks, welding helmets, and even a swim mask with a snorkel attached—I kid you not. The vast, creative interpretation of PPE took my breath away. And everyone seemed to touch or adjust their mask every few seconds. It was maddening. And don’t get me started on social distancing.

Human resource departments, store managers, librarians, hair stylists, and restaurant owners were thrown into the role of figuring out for themselves how to continue to operate safely for their employees and clients. No 2 businesses are alike. There are lots of similarities, but just enough differences to make many physical setups unique. Most businesses, unlike health care, had no one to walk through their space with them and talk through risk mitigation strategies such as using physical barriers, adequately spacing out tables and chairs, establishing occupancy limits, and setting up or improving ventilation so they could safely continue to operate.

They had no one trained in hand hygiene, respiratory etiquette, cleaning and disinfection, or PPE selection and how to wear it, and who could work with their staff. There was no one to call or page in the middle of the night with questions. They were essentially figuring it out for themselves to the best of their abilities. As the pandemic wears on, the toll it has taken on businesses of every kind, both large and small, is enormous. Livelihoods are at stake. The non–health care sector needs more than a bunch of guidelines to help them.

In response to this need, some programs became available for businesses or individual employees, such as an online course covering what COVID is and how it spreads; masking, hand hygiene, and cleaning; and basic safe workplace practices. Upon completion of one 50-minute course you can be “COVID certified.” These basic courses are a good start but may also lead to a level of competency that isn’t really there. Passing a computerized course, putting what was learned into place, and making sure it “sticks” are not easy to do.

As an IP, I know that practices drift, not everyone learns in the same way, and auditing practices are vital, especially those you are unfamiliar with.

What is required is a more robust program specifically fine-tuned to a particular business. A relationship such as the one IPs have with their units—someone designated to guide them, answer questions, and be there for them—would be ideal. And there are IP consultants who work with non–health care sectors in exactly this way.

They provide hands-on training, auditing, and protocols, and act as a resource to help those in the non–health care sector operate safely during the COVID-19 pandemic.

I spoke with Phenelle Segal, RN, CIC, FAPIC, the president of Infection Control Consulting Services, LLC, to get her take on the struggles of the non–health care sector. She said, “The challenge for the non–health care industry has been the extensive volume of guidance coming from nationally recognized agencies. Guidelines are often confusing, and the non–health care sector has done a good job of interpreting general guidelines and adapting them to the best of their ability. The gray areas subject to interpretation and finer details are definitely challenging, and that is where external assistance is needed.

“Our experience has been very positive as these industries rely on our expertise to guide them to…keep their employees and customers or clients as safe as possible. We are amazed at the conscientious approach of our non–health care clients and their level of involvement to do the best for their employees and customers or clients. Several clients had already implemented policies and procedures…and needed us to validate and provide further guidance.” This is what is needed to help the non–health care sector survive and thrive during COVID-19—an ongoing relationship with an expert who is there for them every step of the way.

Unfortunately, there will be other pandemics and outbreaks in the future. So, I see this as an opportunity for IPs, specifically, to use what they have learned in their health care roles to help guide the non–health care sector to success. IPs have the skill set to provide guidance beyond the health care setting. We know how to select PPE and how to use it. Cleaning and disinfection are like breathing to us. Issues concerning construction and renovation, including heating, ventilation, and air conditioning systems and the importance of air exchanges, are something we deal with all the time. We routinely train others, answer questions, and provide guidance and resources. We can and should begin to look at helping the non–health care sector so they can safely thrive now and in the future. Perhaps, working with our local public health departments, we can model the approach health department inspectors use for restaurants, salons, schools, and businesses, focusing on COVID-19 mitigation and staff training. We can visit businesses and help them make a plan. The need is there: we can help guide the non–health care sector and validate their best practices so they can safely open their business, school, or church during the pandemic. Their employees need us. Our economy needs us. We should think about how we can step up and help because this is what we are good at. We can do this.

SHARON WARD-FORE, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago, Illinois. She is also a member of the Infection Control Today® Editorial Advisory Board.

Get the Return to Work Interim Guidance Toolkit. ADA. Accessed December 18, 2020. https://pages.ada.org/return-to-work-toolkit-american-dental-association?utm_campaign=covid-19-Return-to-Work-Toolkit&utm_source=cpsorg-alert-bar&utm_medium=cpsalertbar-virus&utm_content=covid-19-interim-return-to-work&_ga=2.148380273.75969005.1610378717-1039469849.1610378717

Practicing veterinary medicine during COVID-19. AMVA. Updated July 2, 2020. Accessed December 18, 2020. https://www.avma.org/resources-tools/animal-health-and-welfare/covid-19/practicing-veterinary-medicine-during-covid-19

Interim infection prevention and control guidance for veterinary clinics treating companion animals during the COVID-19 response. CDC. Updated August 12, 2020. Accessed December 18, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/community/veterinarians.html

Infection preventionists have the skill set to provide guidance beyond the health care setting. We know how to select PPE and how to use it. Cleaning and disinfection are like breathing to us.

Infection Preventionists Can Help the Non–Health Care Sector Thrive

As the coronavirus disease 2019 (COVID-19) pandemic continues to rage 

, the need for infection preventionists and other healthcare professionals to man the frontlines against the novel coronavirus (with daunting 

 of complexity still being discovered) grows every day. They’re exhausted from holding off a disease for more than a year that now reaches unprecedented levels every 24 hours; caught in a cycle in which each day is worse than the day before.

When a health care professional is infected by SARS-CoV-2, if the symptoms are manageable, they’re quarantined for 7 or 10 or 14 days, as the US Centers for Disease Control and Prevention adjusts 

. Then many of those professionals—they’ve been called “heroes” with good reason—get right back into the battle. Because they’ve already gotten the disease, they’re now immune. But for how long?

About five months for about 17% of those workers, says a study by Public Health England (PHE) of about 20,000 health care workers in Great Britain. “The study found that antibody protection after infection lasts for at least 5 months, on average, and scientists are currently studying whether protection may last for longer,” PHE said in a 

. “This means that many people who contracted the disease in the first wave may now be vulnerable to catching it again.”

The PHE’s SIREN (SARS-CoV-2 Immunity and Reinfection EvaluatioN) study examines data of health care workers collected from June 18 to November 24, 2020, and found 44 reinfections—2 classified as “probable” and 42 as “possible—among 6614 workers who’d tested positive for antibodies. That’s an 83% protection rate from being reinfected by COVID-19.

However, asymptomatic carriers continue to be a 

 of COVID-19 spread. And the fact that 83% of health care workers appear to be immune from reinfection after 5 months, those who work, live, or gather with them may not be so lucky. These findings represent only the first stage of the SIREN study.

The PHE press release says that “although those with antibodies have some protection from becoming ill with COVID-19 themselves, early evidence from the next stage of the study suggests that some of these individuals carry high levels of virus and could continue to transmit the virus to others.”

Just how much protection and for how long the COVID-19 vaccines provide were not part of the investigation. As is the case with nearly all expert advice about avoiding COVID-19 infection, the SIREN investigators emphasize that the so-called 

 of infection prevention still need to be followed: hand hygiene, social distancing, masking.

“We now know that most of those who have had the virus, and developed antibodies, are protected from reinfection, but this is not total and we do not yet know how long protection lasts. Crucially, we believe people may still be able to pass the virus on,” PHE says in its press release. “This means even if you believe you already had the disease and are protected, you can be reassured it is highly unlikely you will develop severe infections but there is still a risk that you could acquire an infection and transmit to others. Now more than ever it is vital we all stay at home to protect our health service and save lives.”

It’s possible that infection preventionists and other health care workers who caught COVID-19 in the first wave can be reinfected.

Health Care Workers Can Get COVID Twice (at Least)

Environmental services (EVS) teams play a crucial (but often unsung)

 role in preventing infection at hospitals and long-term care facilities (LTCFs). However, they are not trained as well as they should be and see themselves as having a low social status, according to findings from a study in the 

 Investigators with Clemson University carried out a systematic literature review of English language studies about EVS conducted between 2000 and 2009.

Although environmental services workers (ESWs) felt they provided little value to the organizations they worked for, most nonetheless believed that the work itself was important in keeping patients safe from infections. The problem is that ESWs are not trained in any systematic and ongoing manner, the investigators note.

“To sustain improvements in disinfection practices, education/training sessions need to be continuous,” they write. “The long-term commitment of an organization is also essential for continuous improvement in disinfection outcomes. While knowledge transfer is critical for behavior change, education/training also needs to focus on the skills and perceptions of ESWs.”

On reviewing 31 studies, the investigators noted that although ESWs know how to do their jobs, that knowledge “does not address many of the barriers identified by ESWs, such as high work demands, ‘me/us versus them,’ interruptions, low status or value for ESWs, and lack of communication.”

ESW training should focus not only on organizational and work environment elements, but on intrapersonal and interpersonal skills. “Even in a skills-focused field like environmental services, leadership, self-management, conflict resolution, communication, emotional intelligence, and other ‘soft skills’ are necessary to perform the job effectively,” the investigators state.

But how to measure how well ESWs perform? In the best of all worlds, that would be done by microbial assessments before and after cleaning. However, substantial barriers to doing so exist, including time constraints, cost, and the need to have the microbial samples examined in a laboratory.

At any rate, training about pathogens and microbials should be handled with care. “Many ESWs may not be able to understand advanced microbiology,so information in some areas (eg, pathogens) should be simple.” Rather than giving detailed descriptions of what pathogens are, for example, educators should focus on how they can spread in hospital environments and the procedures ESWs can implement to prevent their spread.

Investigators also noted a dearth of data about EVS at LTCFs, which have been a nexus for the coronavirus disease 2019 (COVID-19) pandemic. Only 1 study looked at the role of EVS in LTCFs.

“Long-term care facilities have been reported to pay considerably less attention [to] disinfection than hospitals, perhaps because of limited staff, insufficient infection prevention education, and staff perception of isolation and contact precautions,” say the investigators.

According to findings from the 31 studies, ESW training involved presentations, instruction booklets, photographs, checklists, and online education modules. Training interventions covered the importance of environmental disinfection, importance of disinfecting frequently touched objects, and transmission of health care–associated pathogens and infections. “Opportunities for providing feedback during the intervention was reported as a motivational strategy in many studies to improve performance,” write the Clemson University authors.

The main point of the current study is that hospitals and LTCFs must make more of an effort to train ESWs and make them feel welcome.

“Even with the ongoing COVID-19 pandemic highlighting disease transmission in health care facilities, environmental services is still an occupation that receives little attention in society, and carries low occupational prestige in the United States,” the authors note. “In the United States, many ESWs are immigrants, people of color, and receive low wages. The reviewed studies identified many ESWs who feel limited respect, appreciation, or positive feedback at work, yet ESWs consistently identified the need to do the job well. They are concerned about patient safety, which forces them to do a good job even if it takes too much time and they are possibly underappreciated.”

Dyer J. Environmental services during COVID-19: no longer ‘unsung’ heroes. 

https://www.infectioncontroltoday.com/view/environmental-services-during-covid-19-no-longer-unsung-heroes

Hewage SCN, Cao LTT, Jones RM, Fraser AM. Factors associated with environmental service worker cleaning practices in healthcare settings: a systematic review of the literature. 

Many members of environmental service teams feel underappreciated and these health care professionals are not trained in any systematic and continuous way, a study states.

Environmental Service Workers Not Feeling the Love

The winter of 2020-2021 can’t end soon enough for infection preventionists and other exhausted health care professionals battling coronavirus disease 2019 (COVID-19). It is a winter that has seen spikes in COVID-19 infections, hospitalizations, and deaths. Back in early November 2020, experts were telling 

that the public needed to greatly curtail their participation in social gatherings over the upcoming holidays. That might have happened to some extent, but not to the extent needed to avoid what has turned out to be one of the most brutal stretches in the history of US public health care.

 for a long time that asymptomatic carriers make the disease particularly difficult to control. Linda Spaulding RN, BC, CIC, CHEC, warned her fellow infection preventionists back in April 2020.

 that they might become unknowing carriers of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). “[We] could possibly give it to our coworkers and everybody we’re around and we’re never going to know we’re an asymptomatic carrier,” she said.

The role of asymptomatic carriers continues to be explored in 2 recent studies in the 

. In 1 of the studies, investigators with the University of Louisville in Kentucky found that 37% of patients presenting at a hospital are asymptomatic carriers of SARS-CoV-2.

 “The proportion of asymptomatic patients admitted with SARS-CoV-2 was significant,” the authors conclude. “Identifying and isolating asymptomatic patients likely prevented exposure and development of hospital-acquired COVID-19 cases among health care workers and other patients, supporting the universal surveillance of all admitted patients.”

In the other study, investigators with Autonomous University of Zacatecas in Mexico found that “34 (42%) contacts in the study were positive for SARS-CoV-2. Twenty-three (67.6%) manifested less than 2 respiratory symptoms, and 5 (14.7%) remained asymptomatic…The average of positive contacts by index COVID-19 case (R0) was 4.3 and the mean of time of positive COVID-19 test at sampling time was 18.9 days. Positive antibody test against SARS-CoV-2 was observed in 16% of the participants.”

In the University of Louisville study, investigators collected data from patients who had tested positive for COVID-19 and were admitted from April 9 to July 1, 2020, to UofL Health, an acute care hospital in Louisville.

“All patients admitted to the hospital with positive SARS-CoV-2 RT-PCR tests were identified,” say the authors. “The patients who had COVID-19 symptoms on admission were analyzed separately from those who were asymptomatic.”

Of the 103 patients who tested positive for the coronavirus, 65 were symptomatic and 38 were asymptomatic. “The proportion of SARS-CoV-2 patients who were asymptomatic varied over the duration of the study, but trended up from 20% at the onset of the study period to 60% at the end,” the investigators write.

Assume that everybody in a hospital setting might be an asymptomatic carrier of COVID-19. This will better protect not only patients but infection preventionists and other health care workers as well.

“An important strategy to protect health care workers and other patients is to perform a surveillance test on all patients admitted to the hospital,” the University of Louisville investigators state. “In addition to surveillance testing for SARS-CoV-2, other strategies utilized were standard and transmission-based precautions, as well as universal masking of all staff.”

Investigators with the Autonomous University of Zacatecas found that respiratory symptoms alone might not be enough of an indicator to identify those infected with COVID-19. “The proportion of close contacts of COVID-19 patients infected with SARS-CoV-2 (42%) and with less than 2 or with no respiratory symptoms (82.4%) was high in the study population,” they say. “A low proportion of COVID-19 patients had a positive test for antibodies against SARS-CoV-2. The screening for SARS-CoV-2 in close contacts of COVID-19 positive patients should be encouraged to avoid spreading the infection and the expansion of the disease.”

The investigators examined data collected from 100 patients from June to July 2020. They found that 34 of the subjects tested positive for COVID-19, 23 of whom exhibited fewer than 2 respiratory symptoms whereas 5 were asymptomatic.

“The proportion of close contacts of COVID-19 patients infected with SARS-CoV-2 (42%) and with less than 2 or with no respiratory symptoms (82.4%) was high in the study population,” the investigators write. “A low proportion of COVID-19 patients had a positive test for antibodies against SARS-CoV-2. The screening for SARS-CoV-2 in close contacts of COVID-19 positive patients should be encouraged to avoid spreading the infection and the expansion of the disease.”

Diamond F. A Q&A with Linda Spaulding on the frontlines of COVID-19. 

®. April 15, 2020. https://www.infectioncontroltoday.com/view/qa-linda-spaulding-frontlines-covid-19

Arnold FW, Bishop S, Oppy L, Scott L, Stevenson G. Surveillance testing reveals a significant proportion of hospitalized patients with SARS-CoV-2 are asymptomatic. 

. Published online January 8, 2021. doi.10.1016/j.ajic.2021.01.005

Martinez-Fierro ML, Ríos-Jasso J, Garza-Veloz I, et al. The role of close contacts of COVID-19 patients in the SARS-CoV-2 transmission: an emphasis on the percentage of nonevaluated positivity in Mexico. 

. 2021;49(1):15-20. doi.10.1016/j.ajic.2020.10.002

Assume that everybody in a hospital setting is an asymptomatic carrier of COVID-19, two recent studies suggest.

Asymptomatic Carriers May Play a Huge Part in COVID-19 Surge

That coronavirus disease 2019 (COVID-19) might be here to stay doesn’t mean the United States and the rest of the world can’t return to something closely resembling pre-pandemic life, says Kevin Kavanagh, MD, MS. However, the fact that animals can catch COVID-19 is just one reason why the disease is endemic, he notes. “We really do need to learn to live with the virus,” Kavanagh tells Infection Control Today® (ICT®). “Things will get much better, but I don’t think we’re going to be able to eliminate this virus off the face of the earth, similar to what we did with smallpox.” On the other hand, Kavanagh, a member of the ICT® Editorial Advisory Board, says he believes the new COVID-19 vaccines will be effective against the variants of the disease that have recently cropped up. Because, as he points out, “a vaccine causes a myriad of antibodies to be formed to that spike protein, and a virus would have to evade every single one of them to be successful. And that’s a tall order.”

 The appearance of the new COVID-19 strains made many people wonder what they might have to fear from these mutations. What are your thoughts?

 Well, I think it was because it was timed with the vaccine that people started to pay attention to these mutations. But actually, these mutations have been going on since March 2020. And I wish at that time people [had] said, “Hey, we need to slow down the spread of this virus,” and really observed social distancing, wearing masks and obeying public health advice. You need to remember that the first mutation of significance was probably the D614G mutation, which came to the United States from Europe. That’s the prevalent strain, and it is also thought to be more infectious. This mutation just ratchets up the infectivity of this virus, which is of course a major concern. The more people get infected, the more people will potentially die or become disabled from this disease. However, currently, there’s no indication that the disease it produces is more severe. The jury’s still out on whether or not it can avoid vaccines. But looking at the science, that’s a tall order for the virus…, and it probably will not do that at this point.

 You mentioned people who might “die or become disabled from this disease.” What disabilities might result from COVID-19?

 Well, one of the things that’s really frustrated me with this epidemic and pandemic is that people are totally focused on dying. In other words, who is going to have a fatality or a fatal result. But in actuality, the disabilities are much, much more concerning because [they are] even affecting the young people. And [COVID-19] can be chronically disabling to people. I’m not saying death isn’t a terrible factor or a terrible outcome, but the disability can be long term. You’ve heard the term long-haulers. And people who are hospitalized oftentimes are discharged with chronic lung, chronic kidney, and chronic heart disease. As you know, I’ve written an article in Infection Control Today® that advocated that, in many ways, COVID-19 is a heart and lung virus because it can have asymptomatic mild carditis, which can present decades later as a cardiac myopathy. This is to me very concerning. And as with any disease, as we learn more and more about [COVID-19], unless people die, those individuals who escaped death are often severely sick and have chronic long-lasting effects…. We really do need to also focus on that. In other words, what is the true toll on our society?

How many mutations could we possibly see with severe acute respiratory syndrome coronavirus 2?

 There’s literally been thousands of mutations with this virus. If you go to nextstrain.org, you can see them plotted over time, and over distance and location. But only the mutations which affect either infectivity or affect the spike protein which causes attachment of this virus to the ACE2 enzyme…are important. [They’re] the ones which are discussed in the media and tend to be tracked. This is an RNA virus. It mutates quite a bit. We shouldn’t be surprised at that. But the important mutations are ones of concern and they need to be followed. Now, I should add that infectivity is a lot easier for the virus to mutate than to mutate away from a vaccine. Because as you know, a vaccine causes a myriad of antibodies to be formed to that spike protein. And a virus would have to evade every single one of them to be successful. And that’s a tall order, because in that evasion, the virus also still needs to maintain the ability of that spike protein to attach to the ACE2 inhibitor. Otherwise, it trades survival from the vaccine for loss of being able to infect and reproduce itself within the cell. This is kind of the situation we see with the measles virus, where it does a lot of mutations. But it can’t mutate out of the vaccine’s coverage because if it does, it can’t become infectious. Now, as far as for monoclonal antibodies, or monoclonal cocktails, where you just have a small number of different types of antibodies the virus could evade…. There are some strains now, [including] one that I believe was detected in Scotland and in Romania, …able to mutate and evade, for example, a single monoclonal antibody. But that’s different than evading the whole vaccine. Of course, it’s still possible. And if it does happen, that will be a grave concern. Luckily, with the new types of vaccines we have, they’re kind of printed out in the lab. They’re not cultured, they’re not grown. You type in the sequence of that new spike protein, and out comes an mRNA, which can be inserted into the vaccine. It really is revolutionary, and it adds to safety. That would take 4 to 6 weeks to do. But nevertheless, the big problem is how do you revaccinate the entire world? We need to slow down the spread of the virus so we can slow down its mutations. That is of utmost importance. I think they have to be able to articulate this message to the public, to give this as another reason why they shouldn’t be out and about and gathering. You have to remember, it’s not the vaccines which prevent disease, it’s vaccinations. And we don’t have enough vaccinations that have been performed [yet]. And so, they need to do that. And they also need to remember that if they do see something strange, or they do see a spike in cases, or they see people…developing reinfection, they need to culture that virus and get it genetically sequenced. Contact the local health department. I’m sure they’ll…have instructions on how to do that. And certainly, the state and the CDC [Centers for Disease Control and Prevention] would be interested, because you want to make sure that a spike in reinfections is not being caused by a viral mutant. So that’s going to be of utmost importance, and something they need to be looking out for. [The vaccines] will still be effective. That’s what the good money is on. Can’t guarantee it, but certainly, that is the likelihood and what is expected to happen. But that doesn’t mean we should keep spreading around the virus, because eventually the virus may find a combination that can both maintain its attachment to the ACE2 receptor plus evade the vaccine. It’s just not good to do. This is another reason why this whole philosophy of herd immunity is just rubbish and magical thinking. We’re going to have to learn to live with the virus. We’ve talked about this before. We’re not going to have everybody taking the vaccine, and the virus has already showed up in the animal population of multiple species. It is unlikely that we’re going to totally eliminate the virus. I think getting a vaccine may become a yearly or every-other-year type of ritual that [we’ll] have to start to undertake.

Why do you think herd immunity is magical thinking?

 Herd immunity is where there are enough infected individuals who will stop the spread of the virus, and the percentage will depend upon the infectivity of the virus. The more infectious the virus is, the more people who need to be immune. The problem is, if you have animal hosts, if your immunity drops––and it will over a couple of years––they’ll just reinfect you. You won’t be able to truly wipe out the virus. It’s not a good strategy of getting over this, we really do need to learn to live with [it]. Things will get much better, but I don’t think we’re going to be able to eliminate this virus off the face of the earth, similar to what we did with smallpox. And the reason for that is it has an animal host. The idea of going out getting infected and the virus will go away, that’s not going to happen. It’ll get better, infections will drop dramatically, [and] we can return to a more normal life. But I think right now, it’s going to be pretty much endemic either in animals or in ourselves. And that will see it reoccurring in spots or in areas. And if we all let down our guard and let down our ability to fight off the virus by not getting vaccinations, we may go through this again a decade from now. We do need to follow public health advice. And we really need to get vaccinated at this point, especially if you’re a frontline worker. And it’s not if, but when you’ll come down with COVID-19.

 It seems you’re describing something like the measles and also, in a way, something like influenza [flu] that comes back every year.

 Well, it’s going to be kind of like the flu in that it can mutate and come back, although maybe not mutate quite as fast as the flu. It’s unlike the flu in that it affects every organ of the body. And I think it’s the people who are asymptomatic who have the primary heart and vascular involvement. Although it’s asymptomatic, it still can be affecting those organs. And as you know, they account for up to 50% of the transmissions. And so, in that way, it’s very different. We’ve really never seen anything quite like this. And I believe it’s definitely deadlier than the flu…back in 1918. There are 2 reasons for this. One, the 1918 flu had a tremendous amount of bacterial coinfections, up to 90% in the lungs of individuals. And at that time, medicine couldn’t treat that. So that resulted in a large excess mortality. [Two], when you look at the infectivity of the virus, the 1918 virus was probably more infective. But it wasn’t because of the characteristics of the virus, it was because of the characteristics and behavior of the human population. At that time, we were in World War I. There was an initial outbreak, I believe it was in Kansas at one of the barracks. And from there, it just spread. And you talk about packing people into trains, into ships, into training camps, on the front lines, and [in the] trenches. It just spread the virus like wildfire, and so you had a huge amount of spiking in cases, along with fatalities…. And this occurred worldwide because it was a world war. So yes, you may see more actual fatalities in total from the 1918 flu. But that doesn’t mean that the virus was more deadly, because we were involved at that time in a world war which was optimizing the transmission of that virus throughout our population. And remember, fatalities from a pandemic are equal to both the case fatality rate but also the transmission of the virus. And that is a function of both the infectivity of the virus and the behavior of the population it has infected. So I know that’s kind of a long answer, but this virus is entirely new, although it does have some similarities to some other viruses and other infections, which allows us to predict what’s going to happen.

 What’s your reaction when you hear about famous people who are caught violating the social distancing rules that they’re telling the rest of us to follow?

 [I feel] massive amounts of frustration, because that creates doubt in the public as to the validity of their advice. And this has been happening, as you know, fairly commonly. You have a number of leaders who are not preaching the message that they are following. But there are also many leaders who are on both sides of the aisle. You can look at Governor Charlie Baker, Governor Larry Hogan, and Senators Mitch McConnell and Bill Frist, all of whom are preaching the correct public health messaging of wearing masks and social distancing. …Frist… recently called upon both his governor and all governors to enact mask mandates during this [terrible surge] that we’re currently undergoing for these few weeks. I do think the messaging is a problem. We need to keep people on track. And I’ll be honest with you, the thing that bothers me more than anything is that it seems like some of our leaders who have voiced so much that this virus is not much to worry about—“don’t wear masks”—seem to be at the front of the line to get the vaccine. …I am [rather] of the opinion, and I hate to say this on record, [that] if you haven’t been following public health advice—you should get a vaccine, of course—maybe you should let others [go] in front of you because you’re responsible for creating the predicament…we’re in. So that is another area that I think is very frustrating.

 Isn’t that the crux of the situation? Human nature, isn’t that what we’re up against here?

 Oh, yeah, it’s all human nature, but it drives the public crazy. But this virus doesn’t care. The best example I know of is what happened at the Louisville Zoo [in Kentucky] with the snow leopards. I think I mentioned this in my article. The snow leopards, they’re very good at enforcing physical distancing, not so good at wearing masks, and they caught COVID-19. You have to do both. The virus doesn’t care. If you congregate, you give it a chance, and it’s going to spread. Your best defense right now is following public health advice. And when the vaccines are available, please get the vaccine.

 Any final words of advice for infection preventionists?

 Just that they should reassure people at this point to get the vaccine. The vaccine will in all likelihood be effective because, again, it’s very difficult for the virus to evade the myriad of antibodies that your body will produce to the spike protein, and at the same time maintain its infectivity and ability to attach to the receptor on the cell. So please message your patients not to panic but to…be diligent and follow public health advice, because an even more infectious virus can cause more deaths and is more dangerous. But the good news is, the vaccine still should work [despite the new strains], as should social distancing and wearing masks make you safer. Although this is not good news, it’s not anything I feel panic over. But it is something that should increase our diligence in following public health advice.

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Kevin Kavanagh, MD:  “One of the things that’s really frustrated me with this epidemic and pandemic is that people are totally focused on dying…. But in actuality, the disabilities are much, much more concerning because that is even affecting the young people.”

Q&A: COVID-19 Is Here to Stay

The airflow in your facility may have been overlooked prior to coronavirus disease 2019 (COVID-19) but that has changed. When it comes to infection control and prevention, it’s time to focus on this critical element for patient and provider safety. Take a moment to consider where the air supply directly overhead comes from. Infectious agents or suboptimal environmental conditions, perpetuated by the air supply, will exacerbate infections.

To manage a highly transmittable disease such as COVID-19, organizations have used altered airflows, or more specifically negative pressure, within their facilities to increase air exchanges and optimize fresh outdoor air. I first became involved in such a project while serving at a skilled nursing facility. To manage the oncoming crisis and uncertainty associated with admissions, quarantine procedures, and hospital capacities, I worked with Shelly Miller and a group of colleagues at the University of Colorado to convert a rehabilitation hallway into a negative pressure space. We performed computational fluid dynamics and particle-based modeling to test containment. The isolation space was successful both in our model and in practice at controlling transmission between residents and staff.

 Due to the cancelation of elective surgeries and the subsequent pause in rehabilitation services, the negative pressure space provided an important revenue stream and community resource for older people requiring skilled COVID-19 nursing care.

When the Boston Globe recorded Steward Health Care’s preparations at Carney Hospital in Dorchester, Massachusetts, to make the institution the nation’s first dedicated coronavirus care center, Steward stressed the transformation of a floor into negative pressure.

 Carney designated a team of doctors and an operating room within the coronavirus care center to prevent transmission to the broader hospital population. But it was the negative pressure and separate airflow that was arguably the largest factor making it a “hospital within a hospital.”

Outbreaks such as the Ebola virus disease of 2014-2016 encouraged the thinking behind building designs to include the capability of achieving negative pressure over large areas. Engine ers at Children’s Hospital of Philadelphia foresaw a looming pandemic and designed their buildings with the ability to respond. Hospital officials can convert several floors into airborne infection isolation (AII) rooms, more commonly termed negative pressure rooms, with the flip of a switch. In the most recent pandemic, this innovation and foresight has proved to be tremendously beneficial.

According to Rachel McCarthy, vice president of plant operations at Children’s Hospital of Philadelphia, the hospital’s newest design has the ability to convert 2 floors, 3 wards, and more than 150 rooms to AII rooms. The building management system (BMS) uses computer software to adjust the mechanical and electrical equipment throughout the building to achieve the desired results. At the request of administration and the infection control and prevention team, this system can be turned on to achieve the desired airflows throughout the building. But this requires the necessary infrastructure. Controls, equipment, and sensors need to be installed and building management must be trained. I’m convinced these improvements should be a future investment in public health that should not only be in hospitals but in other health care settings, such as skilled nursing facilities. As McCarthy puts it, “Managing a pandemic without a problem requires [personal protective equipment], testing, and negative pressure,” a 3-pronged approach.

Nick Clements, PhD, is a lead consultant at WSP USA, a globally recognized professional services firm specializing in infrastructure, and an expert in building technology systems. He envisions a smart building with integrated infection controls. In a recent conversation, he outlined some innovations and challenges currently being explored in new building design across transportation, manufacturing, and health care. “Smart building,” or building automation, is used to denote buildings with integrated controls and data collection. This often involves the automation of multiple interrelated systems such as heating, ventilation, and air conditioning, electrical, lighting, access control, and security systems through a BMS. Imagine taking this a step further where patient data and health care provider information are integrated into the building. Clements discussed a scenario in which future infections would be identified rapidly before they could spread. This could be done through a BMS that contained integrated patient data and diagnostic technologies employed in monitoring airflows.

For example, microfluidic systems and biosensors, used for clinical diagnostic purposes, could be integrated into a building system to provide clinical data. One type, the local evanescent array coupled (LEAC) biosensor, uses optical immunoassay sensors that permit the detection of up to hundreds of target biomolecules and viruses.

 The chemical and biological engineering program at Colorado State University has a group focused on this technology. These sensors require no reagents, are low cost, and operate as a lab-on-a-chip with integrated circuits.

These diagnostic tools could alert building occupants and confirm the spread of an infection. An integrated BMS that contains pressure monitors could also adjust pressure zones and air supply, further protecting a region within a hospital. When combined with patient and health care tracking, this information could be used to identify the source of an infection. According to Clements, “the challenges of a smart building require the whole organization to innovate.”

Regulations
In a truly integrated BMS, many monitors and systems need to feed back into the control platform. Currently, these systems are often standalone or siloed in a BMS and require a control engineer to integrate the data—a significant burden. A cloud-based system could alleviate difficulties in staffing information technology technicians and data management scientists.

The current COVID-19 pandemic will spur innovation most likely in the direction of vaccines, testing, and airflows. When it comes to airflows, keep an eye on ANSI/ASHRAE/ASHE Standard 170-2017, which currently details guidelines for environmental controls within health care facilities. The standard, which establishes the parameters for ventilation of health care facilities, will need to guide decisions between infection control teams and building management. Standard 170-2017 allows retrofits to be made to convert standard patient rooms into AII facilities. Infection control teams should be in discussion with facility management on these possibilities if we are to expect any future improvement in managing infectious agents similar to COVID-19. I expect the future holds some exciting building management tools for the infection control preventionist. p

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

Officials at the Children’s Hospital of Philadelphia have the ability to convert several floors into airborne infection isolation rooms (AII), or more commonly termed negative pressure rooms, with the flip of a switch.

Infection Control Today, March 2021 (Vol. 25 No. 2)