COVID-19, 3 Years Later: What Questions Are Still Unanswered?

More than 1100 days after the start of the COVID-19 pandemic, everything has changed: our knowledge of SARS-CoV-2, the medical world, and all our lives. However, as much as we know, questions remain. To find out what those questions are—and perhaps get a glimpse of what the answers might be—Infection Control Today® reached out to 7 leaders in the infection control and prevention field, including those in sterile processing, surgery, environmental hygiene, microbiology, and infection prevention, for their take on what the medical world still needs to learn.

These interviews have been lightly edited for clarity and space.

SHANNON SIMMONS, DHSC, MPH, CIC, MLS (ASCP), ambulatory infection preventionist for CHRISTUS Health in Irving, Texas.

The year 2020 marked a moment in history when infection preventionists around the world were forced out of cruise control and into an uncontrollable level of high gear in an effort to recognize and combat a novel respiratory virus now known as COVID-19. Although nurses and physicians became the face of COVID-19 rescue efforts, infection preventionists also had long days and sleepless nights trying to develop and implement protocols to keep patients and health care workers safe during that uncertain time. The chaos of the COVID-19 pandemic rejuvenated many infection preventionists’ sense of purpose as health care leadership looked to us for validation of the protocols being suggested by various health care agencies. Now in 2023, there is a greater need to elevate infection preventionists as essential advocates, leaders, and experts. We are still looking to engage and influence key leaders on the value of the infection prevention field and profession.

Transmission-based precautions were fundamental in the fight against COVID-19, but there is still a need to understand whether many of the improvisational methods implemented during the pandemic can be used to consistently break the chains of transmission. Understanding how, when, and in which settings infected individuals transmit the virus will be beneficial in efforts to influence permanent change in policies and protocols. Ultimately, many infection preventionists are still asking, “Was it all worth it?” while considering which protocols were only necessary during crisis circumstances and which protocols are effective in continued transmission mitigation efforts.

HENRY G. SPRATT JR, PHD, senior microbiologist and professor in the Department of Biology, Geology, and Environmental Science at the University of Tennessee at Chattanooga;

DAVID LEVINE, PHD, DPT, PT, professor and the Walter M. Cline Chair of Excellence in Physical Therapy at the University of Tennessee at Chattanooga.

The past 3 years with the SARSCoV-2 coronavirus have been a sobering period of time for health care providers. After 3 years with this novel coronavirus, 2 critical question areas have emerged: How effective are the vaccines against SARS-CoV-2? And how do we deal with the growing number of antivaccine and antiscience voices that have spread misinformation related to vaccines and scientific measures to target SARS-CoV-2? The answers to these questions will help guide us as we work to maneuver newly evolving strains of this virus.

The development of new types of vaccines targeting the SARS-CoV-2 virus has provided a new tool to use against pathogens. Much of the data on the effectiveness of these COVID-19 vaccines have pointed to reduced hospitalizations and deaths in vaccinated individuals.¹ Some naysayers have raised the alarm at the potential for negative [adverse] effects, particularly the mRNA vaccines. After administration of hundreds of millions of doses of these vaccines in the US, studies of the incidence of negative adverse effects suggest that there are no significant problems with the administration of these vaccines.2 Of course, limited complications exist as they do for most vaccines, but these have limited impact. Examining data on individuals over 50 years old who were either vaccinated (and boosted) or not, the number of deaths reported for unvaccinated was from 5 to 10 times greater than for individuals who have had at least 1 booster shot.² Infectious-disease experts estimate that vaccinating 70% to 85% of the population could enable a return to normalcy. We are currently far from this goal.

There are those individuals who reject scientific measures to fight the COVID-19 virus based on misinformation, mistrust, or other reasons. As populations of the unvaccinated grow, these populations allow for mutations in the virus, allowing for the development of new strains of the virus. In fact, as new variants of COVID-19 have accumulated, even the monoclonal antibodies developed for the earliest strains now do not work to kill the virus. These new strains of the virus also impact the efficacy of the vaccines (and boosters) currently available. A study of parental regrets of unvaccinated children contracting childhood diseases suggested several factors contributed to the decision not to vaccinate.³ One of the key factors that encouraged parents to have their children vaccinated was the information received from their doctors. Thus, the education of parents and physicians regarding the importance of becoming vaccinated is a must.

DAMIEN BERG, BA, BS, CRCST, AAMIF, vice president of strategic initiatives for Healthcare Sterile Processing Association.

With the 3-year mark of the “start” of COVID-19 upon us now and the events that changed our world, our hospitals, and our personal lives forever, I can’t help but reflect on the early days and all the confusion and questions we had in the sterile processing (SP) profession to where we are today. I think about those early days and the approach we took. Was it right, effective, and able to be sustained? After 3 years, we know that it is a trust in the basics, an understanding of standards, and a reliable education and competency program around cleaning, disinfecting, and sterilizing that helps us focus on the process that is key to safely working in this challenging environment.

As I speak, travel, and meet with SP professionals around the globe, the common theme is we had—and continue to have—an opportunity to be the experts in reprocessing and the science behind disinfection. We have been working in this space for years; however, COVID-19 put a bright spotlight on what we do and how we do it. Contact time, dwell time, and various chemical names are now common languages in hospitals outside our departments. The work that the SP department performs finally has us at the table with decisions on these items, and that is one of the positive byproducts of the pandemic.

It is also important to discuss the supply chain disruption that happened and is a challenge today as we struggle to get must change or substitute products. However, that comes with risks because of the training, compatibility, and efficacy of these changes. I also see the opportunity to share knowledge, supplies, and support with our peers worldwide.

DIDIER PITTET, MD, MS, CBE, hospital epidemiologist and director of the Infection Control Programme & World Health Organization (WHO) Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance.

ALEXANDRA PETERS, PHD, scientific lead for Clean Hospitals, both in Geneva, Switzerland.

Many questions still surround COVID-19; we still need to better understand the phenomena of exactly how SARS-CoV-2 spreads and infects individuals, its tendency for extreme dispersion, the precise role of aerosolization, the long-term impact of infection, etc. But if we can only pick 1, the most pressing question is: How can we find ways to better address the challenges of cooperation and communication at crucial interfaces to improve future responses to new health emergencies? Throughout the pandemic, decision- and policy-making and implementation have centered on a few different interfaces—the relationship between WHO, governmental bodies (on both national and local levels), the scientific and expert community, and, more indirectly, lobbies, industry, and the behavioral tendencies of different populations.

All these actors influence the others and account for the vast differences in protective measures implemented globally. The impacts of both the pandemic and response have health effects reaching far beyond the scope of the disease itself.

When coupled with the “fog of war” of an emerging pathogen, decision-making and implementation become far more complex. An inevitable scientific learning curve occurred about the physical attributes of SARS-Cov-2, the etiology, and the impact of the disease. This created challenges for deciding on protective measures, communication, as well as a mistrust of said measures, and a fertile breeding ground for misinformation. We need to encourage interdisciplinary cooperation to address these issues to have a better global response in future.

FRANKLIN DEXTER, MD, PHD, FASA, professor of anesthesia and health management and policy at the University of Iowa Carver College of Medicine in Iowa City.

COVID-19, influenza, and respiratory syncytial virus (RSV) cause severe perioperative pulmonary complications. Some worldwide and US regions perform preoperative polymerase chain reaction testing (eg, for patients who are expected to be hospitalized after surgery) that includes not only SARS-CoV-2, but also influenza and RSV. Even during influenza and RSV “season,” the prevalence of asymptomatic COVID-19 tests among these patients can be greater than 20-fold more. Why, and does this matter clinically? In addition, whereas some countries and US regions report asymptomatic testing having COVID-19 positive rates very low (eg, 0.2%), other regions simultaneously have sustained rates greater than 20-fold more. Such differences are obtained when county and state agencies report few COVID-19 cases.⁴ Why? Is COVID-19 fundamentally different from influenza and RSV with greater infectivity or greater prevalence of asymptomatic infection? Suppose that to prevent infection of health care workers and other patients that all patients having inpatient surgery should be tested preoperatively unless the percentage prevalence of asymptomatic patients testing positive was very low (eg, 0.2%).⁴ Then, what would be the rationale for not testing patients preoperatively because the asymptomatic prevalence rate would no longer be known? Can community-reported COVID-19 prevalence rates be used instead, even if most patients with symptoms are using rapid home tests? For the patients who are asymptomatic (or symptomatic) but infected, and for whom surgery proceeds, what treatments are beneficial for the patient and for preventing infection of health care workers and other patients? If there will be a patient in the operating room soon after a patient with symptomatic COVID-19, should terminal cleaning be applied between cases, or is routine cleaning sufficient?