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After decades of reluctance to implement a national reporting system, when COVID-19 came along we witnessed almost overnight the formulation of case definitions and comprehensive national reporting from all healthcare facilities.
The United States has long lacked the needed infrastructure for the reporting of resistant organisms. Outbreaks have largely gone undocumented and, in many cases, ignored. Nursing homes largely flew under the radar for infectious disease reporting and accountability.
The healthcare industry cites the burden of reporting and lack of resources as justification for its inaction. Infection preventionists (IPs) are stretched to the limit with both reporting and patient responsibilities with an unwillingness of facilities to prioritize infectious disease prevention in their operating budgets. In addition to financial concerns, accountability was also at the heart of the inertia in implementing the infrastructure needed for a comprehensive national reporting system for dangerous pathogens.
All of this changed with coronavirus disease 2019 (COVID-19). After decades of reluctance to implement a national reporting system, we witnessed almost overnight the formulation of case definitions and comprehensive national reporting from all healthcare facilities. One must ask the question: Why has this not been done for other dangerous pathogens?
Intense concern has been focused on nursing homes. On May 6, 2020, the US Centers for Medicaid and Medicare Services (CMS) issued an interim final rule regarding COVID-19 cases among residents in nursing homes.1 Nursing homes are now required to report COVID-19 resident and staff infections to the US Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) and to the other facility residents along with their families and/or representatives. The regulation states: “Inform residents, their representatives, and families of those residing in facilities by 5 pm the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or 3 or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.”
Health Watch USAsm has called for a national tracking system for both employees and patients/residents of all facilities for all dangerous pathogens.2
Of the CDC’s 5 urgent bacterial threats only one—Clostridioides difficile—has required reporting, but participation is only mandated for hospitals, and only those which participate in Medicare’s prospective payment system. Thus, critical access hospitals are not included. Carbapenem-resistant enterobacteriaceae (CRE) is not required to be reported on a national basis, even though its bloodstream infections have close to a 50% fatality rate. Candida auris and carbapenem-resistant Acinetobacter are also not required to be reported. Of the CDC’s 11 Serious Threats, only methicillin-resistant Staphylococcus aureus is required to be reported, and only in hospitals.3 Nursing homes, surgery centers, dialysis centers, critical access hospitals, along with private physician offices are not required to report in a national system.
States may have additional requirements and a few states have comprehensive mandatory reporting laws. This is the case for the state of Kentucky,4 which implemented a comprehensive reporting law in October 2016 which mandates all healthcare facilities to report outbreaks of dangerous pathogens to the NHSN and to confer rights of the Kentucky Health Department to access NHSN data. There are a few important points which need to be explained:
State health departments only have delayed access to NHSN data. Healthcare facilities need to give them permission, or permission granted by state law, for state health departments to have access to the actionable current data.
The definition of an outbreak is defined by the CDC as an infection rate above a facility’s baseline. The baseline is defined by the facility, so it is in the eye of the beholder. The Kentucky regulation closes this loophole by defining an outbreak as “2 or more cases, including HAIs (healthcare-associated infections), that are epidemiologically linked or connected by person, place, or time, or a single case of an HAI not commonly diagnosed.”
A healthcare facility is defined as any place, building or agency which is “operated, or designed to provide medical diagnosis, treatment, nursing, rehabilitative, or preventive care and includes alcohol abuse, drug abuse, and mental health services.”
A long list of dangerous pathogens and definitions is also specified. One shortcoming of the law is that public reporting and report verification is prefaced by “may,” which means it may not happen.
However, this type of a comprehensive system, whether through statue or regulation, is lacking on the national level.
A comprehensive reporting system is not just needed for infections solely caused by dangerous pathogens but also for co-infections which all too commonly affect those inflicted with COVID-19.5 It is known that when death occurs with viral pneumonia that there is often a bacterial co-infection. Bacterial co-infections occurred in up to 95% of fatal cases with the Spanish flu.6 The most common organisms were Staphylococcus aureus, Streptococcus pneumonia, and Hemophilus influenzae. Secondary infections were identified in 50% of COVID-19 fatalities.7 Obviously, if these co-infections are caused by antibiotic resistant bacteria, then one would expect the fatality rate to increase.
During the March 11 Senate HELP committee hearing on COVID-19, Sen. Mitt Romney asked CDC Director Robert Redfield, MD, why the CDC has not established an accurate real time data site for hospitalization and treatment data at the CDC.8 Redfield responded: “…the reality is there is an archaic system a non-integrated public healthcare system. Each public health department has their own systems. This nation needs a modern highly capable data analytic system that can do predictive analysis. I think it is one of the many shortcomings that have been identified…It is time to get that corrected.”
CMS’s COVID-19 Focused Survey of Nursing Homes also requires screening of all staff at the beginning of their shift for COVID-19, including temperature and signs of illness.1 Deborah Birx, MD, the White House’s Coronavirus Response Coordinator, called for testing all nursing home residents and staff in the immediate term. The CDC’s Anthony Fauci, MD, agreed with Birx and took the recommendation a step further.9
“In the long range we will have to have infection control capabilities in nursing homes that are really pristine and really unassailable,” Fauci said. “We have to do the kind of surveillances and have to have the capability of when you identify someone you get them out of that particular environment so that they don’t spread the infection throughout. General testing for all, I think, is a good start, but you look where are you going to go in the future. There has to be a considerable degree of surveillance capability.”
It is of utmost importance to screen healthcare staff and patients for dangerous pathogens along with the establishment of a national tracking system. In addition, an economic and healthcare safety net for healthcare workers needs to be established.
However, national data for healthcare worker acquisition of dangerous pathogens can only be found for cases of SARS-CoV-2, the virus which causes COVID-19. So far, more than 69,000 cases are reported. Of these, there are over 350 deaths, but this is an underestimate because the final disposition of cases is not known in many of the reports. Even with this degree of reporting of COVID-19, there is no guarantee of workers’ compensation benefits. Some frontline workers do not even have paid sick leave. Healthcare workers and, through them, their families are also at risk of acquiring a myriad of drug-resistant dangerous pathogens. Active screening of workers, along with the provision of health benefits and an economic safety net, needs to be enacted.
A dangerous pathogen is a dangerous pathogen; we should not discriminate on our approach to COVID-19. The frequency of an outbreak should not be used to deter a policy that an outbreak of a dangerous contagious pathogen should be publicly reported in real time. The nursing home reporting policies for COVID-19 need to be adopted systemwide for all dangerous pathogens and our infrastructure permanently enhanced.
One may think that enhancement is a forgone conclusion. But we did not learn these lessons from the 1918 Spanish flu or from the Ebola, severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS) outbreaks. Six months or 6 years after this epidemic our resolve may wane. IPs need to document their experiences and keep telling their stories so our memories of this horrific ordeal do not fade.
Kevin Kavanagh, MD, is the founder of the patient advocacy group Health Watch USAsm and a frequent contributor to Infection Control Today®.
1. Centers for Medicare and Medicaid Services. Interim final rule updating requirements for notification of confirmed and suspected COVID-19 cases among residents and staff in nursing homes. CMS website. https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/interim-final-rule-updating-requirements-notification-confirmed-and-suspected-covid-19-cases-among
2. Kavanagh KT, Abusalem S, Calderon LE. View point: gaps in the current guidelines for the prevention of methicillin-resistant staphylococcus aureus surgical site infections. Antimicrob Resist Infect Control. 2018; 7: 112. Published online 2018 Sep 18. doi: 10.1186/s13756-018-0407-0
3. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2019. CDC website. www.cdc.gov/DrugResistance/Biggest-Threats.html
4. Law: Reportable disease surveillance. 902 KAR 2:020 (2016). Reportable Disease Surveillance. Kentucky Administrative Regulation. https://apps.legislature.ky.gov/law/kar/902/002/020.pdf
5. Diamond F. Q&A: how bacterial infections can complicate COVID-19 cases. Infection Control Today. May 15, 2020. https://www.infectioncontroltoday.com/covid-19/qa-how-bacterial-infections-can-complicate-covid-19-cases
6. Morris DE, Cleary DW, Clarke SC. Secondary bacterial infections associated with influenza pandemics. Front Microbiol. 2017;8:1041.doi: 10.3389/fmicb.2017.01041.
7. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;28;395(10229):1054-1062. doi: 10.1016/S0140-6736(20)30566-3.Epub 2020 Mar 11.
8. Sen. Romney: Despite being months into the COVID-19 pandemic, we still lack real-time data. Senate HELP Committee. Washington DC. May 12, 2020. https://www.youtube.com/watch?v=ssdEtsOiABE
9. Fauci, A. Testimony. Senate HELP Committee. Washington DC. Timeline 2:43:35. May 12, 2020. https://www.help.senate.gov/hearings/covid-19-safely-getting-back-to-work-and-back-to-school