Just when should a health care professional return to work after a high-risk COVID-19 exposure? In a Q&A, Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC, explains the CDC’s changing recommendations.
Isolation recommendations by the Centers for Disease Control and Prevention (CDC) for those exposed to COVID-19 have changed several times in the last month for both the public and health care professionals. A lot of factors go into the calculation: staffing shortages at hospitals, just how much of a threat Omicron poses, vaccination and booster status. It can be difficult to follow, but Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC, a member of Infection Control Today®’s Editorial Advisory Board explains how infection preventionists (IPs) can best help their health care colleagues follow the recommendations. There’s a lot of frustration about the pandemic, but Ward-Fore says that “we should start to focus on those people who know and feel that, morally, they have to do the right thing, and the right thing is to show up and do whatever they can to help. Health care does that. IPs do that. IPs help bolster health care staff by supporting them.”
Infection Control Today®: The Centers for Disease Control and Prevention (CDC) has changed recommendations for when health care workers who’ve been exposed to COVID-19 can come back to work several times in the last month or so. Where does that stand now?
Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC: I’m actually really confused too. But I’m hoping that health care workers will refer to the CDC website, which was updated on 12-23-21, where there’s a nice table that explains everything you just said, but in a chart form. When I read through what had been written, I was confused. But once I look at this, it sort of helps clarify things. There’s a table on vaccination status, and then they break it down to conventional, contingency, and crisis staffing, which I think will help clarify for a lot of instances. For example, for work restrictions for health care workers with an infection—and as you said, if they’re boosted, vaccinated, or unvaccinated—the conventional strategy is exactly what you said: 10 days or seven days with a negative test, if asymptomatic or mildly symptomatic with improving symptoms. That’s the conventional recommendation for if you have a normal workforce. If you’re now on a contingency workforce, they say five days with or without a negative test. If asymptomatic, or mildly symptomatic with improving symptoms. And then they go on to an actual crisis standard, which is no work restrictions with prioritization considerations, asymptomatic or mildly symptomatic. To give the CDC a little credit this has really been a moving target with so many different nuances that I think if we provide this chart, it should clarify a lot of things. And if you have a conventional workforce, of course, you know, you can do what’s in the best interest of your staff and patients. And remember, these are recommendations. Take that with a grain of salt. You always want to be as strict as this, but you can be even stricter, if you can. Now I know there are some institutions that are following the conventional method with 10 days or seven days and a negative test. But now they’re also looking at, “Well, how can we prevent having to even deal with this in the first place?” And for those facilities that have enough PPE, they’re recommending that their health care workers all wear N95s. And we know that this is an airborne respiratory virus. And the number one way we protect ourselves from airborne particles is with an N95. I think that’s a good step in the right direction. If you have the amount of N95s to be able to allow that.
ICT®: You’re an expert on infection prevention issues, a consultant for infection preventionists. What should IPs be doing now with these recommendations? Where do they fit in here?
Ward-Fore: As an IP, because this is so confusing, I would definitely have a copy of this thing on me at all times. I probably would hang it in the units and be ready to answer questions on it. And I would try to clarify between the recommendations the CDC put out for the general public, versus what they’re recommending for health care personnel. Because they are very different. And I think in the beginning, most people took those initial recommendations for five-day isolation to mean that they applied to health care workers, when it was to the general public. I would be ready to answer questions about both of those. And as an IP, depending on how many health care personnel you have that fall into these boosted, vaccinated, unvaccinated categories, I’d try to keep some kind of a spreadsheet about who’s caring for who. And if I have to work at a crisis capacity, I might try and limit those health care workers that are coming out of a quarantine after a shorter period of time and have them not work with immunocompromised patients. IPs are used to working with outbreaks, so they need to wear their outbreak hat and
understand that this is a respiratory virus, but they’ve worked with these kinds of things before. Treat it like a respiratory virus you’ve had before, whether it’s from measles or chickenpox, which are airborne. How can I communicate to staff that I’m quasi-comfortable with how to not contaminate or transmit this to other people? And that would be don’t let them care for high-risk patients if you’re able to do so?
ICT®: National Nurses United pushed back strongly against the guidelines, saying it puts nurses at risk. If I’m an infection preventionist at a hospital or other health care setting, how do you tread on that terrain? I guess with some delicacy, right?
Ward-Fore: Absolutely. I mean, nurses are the frontline caregivers for any patient in the hospital. If they’re worried about acquiring COVID: Number one, vaccination, and boosting is going to be your best protection. I would also provide them with N95 masks if I have them. PPE [personal protective equipment] is going to be your next method of protection. You can do things like limiting the number of visitors that come into a patient space. That way you’ll control what comes into your facility. There are some resources that are available. It’s not one size fits all. They’re going to have to look at facility by facility by facility, and even by the units. We’ve always, when there’s an outbreak situation, tried to cohort staff as well as patients. If you’re able to cohort your staff and have the same staff caring for those COVID-19 patients and not moving throughout the unit, that’s the best way to do it. Or if you can’t do that, then you work from … like we do, we go from clean to dirty. Work from the patients that are well to those that are ill, so that you’re not transmitting anything in the beginning to those patients. There are strategies out there that they can try to help keep these caregivers well. Number one, though, vaccination. I just want to give a statistic here that I looked up. To date, there have been 3.9 billion people vaccinated in the world—49.8%. That’s a huge clinical trial. And of the people that have been vaccinated less than 0.0022% have had any kind of adverse reaction to this vaccine. First and foremost, the clinical staff need to be vaccinated, because this is the largest clinical trial on any vaccine ever. And we know it works. Secondly, provide them with PPE, and then figure out a way how to minimize their risk either through cohorting or working from the well folks to the more critically ill.
ICT®: Where do IPs fit in with testing efforts?
Ward-Fore: I’m an advocate of testing, but I understand the reluctance because tests are so hard to get now. But if you look at the guidelines by CDC, they recommend a negative test and 10 days or seven days with a negative test. And that negative test has to be taken within 48 hours before returning to work. There is that caveat in there. And I am a believer in it because this virus is so tricky, and it’s the asymptomatic spread that we have to be worried about. Yes, I believe that if you’re coming out of quarantine or isolation and you’re going to work that you should have negative tests. And even in the general public, I would love to see … if you’ve got it you’ve been isolating at home, and now you feel you can come out. If you can get hold of a test and the test is the negative, it’s just safer for you and your neighbors and family and friends.
ICT®: What’s the foremost concern now in hospitals?
Ward-Fore:The foremost concern now is staffing shortages. When your staff are short, that means their workload is heavier, the level of fatigue that health care workers are feeling now, since we’re a year and a half into this, all of those things, as well as supply shortages, like PPE, all of those things play a part in people maybe losing their focus a little bit. Not being fully protected. They’re in a hurry to do the job of five people instead of just one. That’s the number one thing on IPs’ minds is how all of those things are affecting staff. Because IPs don’t provide care but they see firsthand those that do. And they see the struggles they have with those things. That their colleagues are out with COVID. There’s not enough PPE, and the volume of patients is just overwhelming. I think, in general, this pandemic has taken a toll on health care workers, like no one would ever imagine. And it’s that mental health component too that IPs worry about.
ICT®: There is something like 20% fewer health care workers now then there were in March 2020.
Ward-Fore: They’re either out of the workforce because they don’t want to be vaccinated, or they’re completely burned out, or they know that they’re done with this, and they want to do something else. I completely understand. I’ve seen in the paper where sign-on bonuses have been offered to health care workers similar to what they’re offering to airline pilots, you know, three times their salary or whatever. We knew before the pandemic that we had a nursing shortage. And I think the pandemic has really placed eyes on that. And now the pandemic itself has increased the staffing shortage. Staff are generally frustrated. And as an IP, sometimes you feel that frustration, sometimes you don’t. I think it’s a reflection of the general population, though, that is so over this pandemic, even though we’re not over it. The isolation is taking its toll on people. Patients are coming in angrier. Staff have been isolated from their family and friends and their colleagues. I don’t think it’s unique to health care. I think this is in general what we’re seeing in the world as a response to all of our things having been taken away by this pandemic. And because it is a novel virus, people forget that we’ve never seen anything like this. You know, these variants, we knew that there were variants with viruses, but this thing keeps throwing variant after variant at us. And I think we’re responding as quickly as we can, based on the science that we’re getting from other countries. They’re ahead of us in, unfortunately, being affected by this, but we’re learning from them. I think the advice I would give people everywhere, including health care workers, is patience, because this is evolving, and everyone is doing the best they can.
ICT®: What surprised you the most about this pandemic?
Ward-Fore: I think what surprised me about this, the entire pandemic, is how unprepared we were for it. In health care, and globally, all these supply chain issues, which we’re still seeing now. And it’s affecting health care, but it’s affecting people’s personal lives, too. You’re seeing people react to that. It’s like we’re getting hit on all fronts. I’m surprised at the level of lack of preparedness, even though hospitals trained for this kind of thing. We have government bodies that are supposed to help prepare us for this, but we were really blindsided by this. I think health care in general has stepped up to the best of their ability to try and just kind of push on and we hear about resiliency and things like that. But I will commend anyone who’s out there in the public who’s facing this virus every day. And it’s health care workers. It’s the person who works in the grocery store that comes in. It’s the CTA [Chicago Transit Authority] driver. We hear about all the people who are grousing about it, but I think we should start to focus on those people who know and feel that, morally, they have to do the right thing, and the right thing is to show up and do whatever they can to help. Health care does that. IPs do that. IPs help bolster health care staff by supporting them. I sound like a cliché, but I think rather than flipping this on the dark side, we flip it on the bright side and realize how you react to things shows what kind of person you are. And majority of the population has been the person who steps up and does the right thing.
This interview has been edited for clarity and length.