The commentators at the recent HICPAC meeting had different reactions, ranging from concern to anger.
After almost 4 years of COVID with over 10,000 patients currently hospitalized, a 22% increase over last week, one must ask, what has the CDC been doing? According to many people, the CDC has been trying to roll back our protections and ability to fight the spread of disease when experts are strongly advising those at high-risk to mask up in indoor settings.
Commentators at the Aug 22, 2023, Healthcare Infection Control Practices Advisory Committee (HICPAC) meeting varied from concerned to angry. This is the third public comment period regarding the CDC’s proposed draft guidelines for updating isolation protocols. No commentator has yet spoken up in favor of the proposal of using surgical masks when treating patients with respiratory pathogens or stated that ventilation is safe in health care facilities. Neither has anyone in the public actually seen the current working draft. The public’s concerns are based upon the June 8, 2023, HICPAC presentation regarding the update to the CDC’s isolation precaution guidelines and the lack of transparency and input into the formulation process.
For many years now, HICPAC has largely flown under the radar. But it now appears to be in the crosshairs of patient and health care worker advocacy organizations, including unions, who have been pushed to their limit by unnecessary exposure to dangerous pathogens.
Flawed process of formulating recommendations.
There was almost a disbelief that any health care agency could acquiesce to the use of surgical masks by health care workers when treating patients with an airborne illness. These patients range from those with a simple upper respiratory infection to those infected with a novel pathogen. The lack of firm recommendations for universal N95 masking was justified by the lack of randomized controlled trials (RCTs) showing a positive effect. However, other industrial sectors do not require RTCs for action. Commentators pointed out that no one is advocating to not provide respirators for firefighters, or workers exposed to lead, asbestos, and other harmful substances due to a lack of positive RCTs.
A commentator from the California Occupational Safety and Health Administration (OSHA) stated that CDC recommendations regarding the use of surgical masks inhibited the adoption of California OSHA’s more rigorous masking standards. This ambiguity caused the agency to spend significant additional resources for enforcement to adequately protect workers and encourage the utilization of N95 masks.
The use of RCTs as the primary driving factor in public health recommendations raises concern. RCTs are primarily designed for drug and therapeutic trials. Applying this design to public health is limited because of ethical limitations on trial design and the large number of unavoidable biases which are in the research arms. For example, the lack of abundant RCTs regarding the isolation of colonized MRSA patients has hampered the adoption of the practice in the private sector. This is the underlying cause of the huge performance gap between the Veterans Health Administration and the private sector in the prevention of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infections.
As with previous sessions, the commentators called for HICPAC to be comprised of a wider range of experts, including health care workers, industrial hygienists, occupational health nurses, safety professionals, ventilation engineers, aerosol scientists, and experts in respiratory protection. Medical associations and societies certainly need a voice, but many people feel these are heavily biased toward the industry perspective.
Call for Universal Use of Respirators in Health care
There was a call for universal precautions with N95 masks, including patients in waiting areas, and higher standards set for ventilation. Two-way masking is needed. About half of the transmission of SARS-CoV-2 is from asymptomatic carriers, and source control is needed. Mask wearers are still at risk of exposure through their eyes. However, the mask will interact with most of the viral particles extruded from an asymptomatic carrier. Some studies have found universal masking to reduce aerosols by 69%.
One commentator summed up patient’s concerns with the statement, “The only COVID(-19) risks we are forced to take are when seeking out medical care.” Many vulnerable patients stated that they and their families are afraid to seek medical care and have had to postpone or have been “locked out of” needed care because of COVID-19 risks.
Patients described skepticism, denials, and even hostility when they requested providers wear N95 masks, and it is not the patient’s responsibility to educate a provider regarding safe practices. Commentators also called for health care facilities to comply with the Americans with Disabilities Act.
One might ask, are the risks being exaggerated? However, no one is effectively counting, and we are now faced with a nursing shortage which many believe is largely due to the effects of COVID-19 and long COVID. The CDC should require reporting of health care acquisitions of all major pathogens and should estimate hospital acquisitions of SARS-CoV-2 by determining all hospital presentations which occurred after admission and then adjusting this data with community rates of asymptomatic infections. Currently, the data for SARS-CoV-2 acquisitions after admission are not publicly available through the federal government.
The Economics Make Sense
The economic case for more stringent strategies was also made. The cost of a mask is much less than the thousands of dollars lost through days off work or hundreds of thousands of dollars lost from a disabled worker. According to the United States Department of Human Services, the cost of infectious disease is 9.6 million dollars per life lost. Too many workers and patients have been sacrificed to save facilities the cost and burden of purchasing a $1 N95 mask.
The most worrisome detrimental outcome of the CDC’s possible rollback of guidance is the loss of credibility. During an ongoing pandemic, credibility is of utmost importance. As one commentator stated, “We need consistent messaging to educate the public about the true dangers of COVID[-19] and being disabled by long COVID.” If the public cannot rely on the agency to communicate safe and effective recommendations on masking and ventilation, how then can they be expected to rely on the CDC’s advice on vaccine uptake? And if we minimize the dangers of SARS-CoV-2, how then can we expect the public to see the urgency in obtaining the updated booster?