Infection Preventionists Must Ward Off a COVID Comeback

May 4, 2021
Kevin Kavanagh, MD

What happens in India, or anywhere else in the world, doesn't stay there. The longer COVID-19 hangs around, the more chance it has of mutating into a variant that the vaccines won't stop.

One of the most challenging tasks that infection preventionists (IPs) have is the encouragement of patients to follow effective control strategies. There is abundant mixed messaging. Last year, we had the federal government advising individuals to wear masks while the White House blatantly ignored this advice. This year, as pointed out by CNN, the federal government is currently advising vaccinated individuals that they no longer need to wear masks outdoors at small gatherings but President Biden and the White House staff seem to be wearing them everywhere. What gives? No wonder everyone is confused.

Countries such as India and Brazil have adopted the United States’ laissez-faire approach to COVID-19 and are now suffering a similar but far worse fate, having a fragile health care infrastructure and only a fraction of available vaccines.

But it is in these countries where the United States’ conspiracy theories break down and are even shown to be blatantly false. These countries have confirmed many of the assertions made by Infection Control Today® earlier last year and IPs can use these valuable lessons to help educate the public.

Lesson 1: The pandemic is not a hoax. Anyone now can go on the foreign news services and see the devastation in India, from the piles of empty oxygen tanks to the overflowing makeshift crematoriums. It is easy for some to discount statistics, but not these horrific pictures.

Lesson 2: Herd immunity without a vaccine is not an option. The devastation’s case count and body toll in India has no end in sight, and no one is effectively counting. Patients have been turned away from overflowing facilities and testing infrastructure has collapsed. Unfortunately, the situation is still getting worse, and cases are skyrocketing. Attempts to achieve herd immunity carry too heavy a price and affords the virus ample opportunity to mutate. India has already cultivated a “double mutation” (B.1.617) variant which possesses two very worrisome spike protein mutations, making it more infectious and capable of causing reinfections. With the virus ever mutating and large segments of the public vaccine adverse, many experts now believe we will never truly reach herd immunity in the foreseeable future.

Lesson 3: Hydroxychloroquine does not work. One of the prevalent misinformation campaigns involves around countries with high rates of malaria had low rates of COVID-19. The theory was that large segments of the public were taking hydroxychloroquine as a prophylaxis for malaria. This theory was widely circulated despite having multiple negative randomized controlled trials being not able to demonstrate hydroxychloroquine effectiveness in treating COVID-19. India serves as a testament to the fallacy of this assertion.

Lesson 4: Large outdoor gatherings can spread the virus. Similar to the US, India had very large outdoor gatherings during the pandemic where Individuals were packed together in large political and religious events. Insanity is doing the same thing multiple times and expecting a different result. That is what I fear is happening here. Yes, outdoors is safer than indoors, but not in crowded conditions. Both are dangerous.

Lesson 5: The pandemic is a world problem. Controlling the pandemic in just one country is highly problematic. With abundant readily accessible means of travel, the virus can easily enter a country being carried by asymptomatic individuals seeking a safe haven from the devastation of COVID-19. Snuffing out variants as they arise in foreign countries as opposed to on our soil is preferable. We adopted this strategy with international terrorism but for viruses we became isolationists with massive reductions in the CDC’s foreign service. We need to increase funding for both supplies and boots on the ground in foreign countries with dangerous emerging pathogens.

Lesson 6: The virus rules. Political posturing, repeated denials and displays of hubris will not stop this virus. It is a relentless pathogen which is out to win. No amount of fudging case definitions with requiring a positive test or not counting deaths from COVID-19 heart and kidney disease can cover up the enormity of the pandemic.

So, what should we advise with all the mixed messaging? Recently the CDC has stated one can exercise outdoors without a mask, with your household. I am not sure this helps much, since I assumed you could do this anyway, even indoors. The not needing to wear a mask outdoors in small gatherings but having to wear one in large gatherings is confusing for individuals. First of all, the size of the gathering is not defined. This appears to be based more upon what is safe for the community not safety for the individual. And with the new variants, we really do not know what precautions are necessary to prevent spread.

What we do know is that SARS-CoV-2 spreads by both droplet and aerosolization Most policymakers have only focused on droplet spread. Indoors, researchers at MIT have published in the Proceedings of the National Academies of Science that because of aerosolization, no one can be truly safe in an indoor setting with poor ventilation. Sixty feet offers no better protection than six feet. Outdoors, aerosolized particles rapidly dissipate, making it safer, up to 20 times safer. But droplet spread (within 6 feet) can still readily occur.

Thus, policymakers have falsely equated outdoor safety, produced by the rapid dissipation of aerosols, with safety from droplets and have ill-advised not wearing masks at some outdoor events. This may be effective in suppressing community spread, but it will not afford adequate protection for the individual.

Real life advice which I would give: Avoid indoor settings and if you have to go inside, wear a mask; outdoors stay at least 6 feet away from others and wear a mask if you want maximum assurance of not catching COVID-19. With the new immunity avoiding variants, vaccinations may provide protection from severe disease and death; and will help but not necessarily prevent infections. Survival is a low bar for community health. Ten to thirty percent of mildly affected individuals can develop long-haulers syndrome. And, it must be remembered that the more we spread the virus, even asymptomatically, the more it will mutate.

I believe that if we all would have followed public health strategies last year, we would be largely out of the pandemic and suppressing minor outbreaks with case tracking. With the emerging immunity avoiding variants and the high rate of SARS-CoV-2 in our population, the best advice is for all of us is to become vaccinated, wear a mask, avoid indoor settings and socially distance from others not in your households.