M. Konwar in Health
Distortion of science for political and economic ends has prevented the allocation of needed resources to stop the spread of dangerous pathogens. This places all of society as a whole at risk, but exacting an insufferable toll of death and disability on our front-line healthcare workers, along with our most vulnerable populations. COVID-19 has demonstrated how dangerous this scenario has become.
We have seen the United States top officials publicly flaunt the wearing of masks and use substandard infection control practices. A super-spreader event was even created at the White House’s Rose Garden when rapid testing was used to prevent the spread of SARS-CoV-2. This type of test is known for high false negatives especially with trying to detect asymptomatic carriers. And a security guard for the president was seen wearing an N95-mask with an exhalation value, a setup for spreading the disease.
There also have been reports that the federal government has impeded or mitigated CDC recommendations for cruise ship No-Sail orders, and to pressure the CDC regarding school openings. Having consistent scientifically based messaging on a national level is of utmost importance. The messaging in the United States can be characterized as nothing short of bizarre.
The CDC has flip-flopped on guidance regarding the use of masks on public transportation, the testing of asymptomatic carriers, and was late to stress the importance of spread with viral aerosols – too many of our buildings are not healthy. Significant infrastructural changes are needed to allow for proper social distancing, increase in ventilation, and air sanitization. Infrastructure upgrades are expensive and so far the United States does not have the political will to actualize these changes.
Needless to say, it is a warning that the abandonment of scientific evidence-based recommendations has all but stymied effective public health responses in the United States.
Health Care Worker and Patient Safety is of Paramount Importance
One of the worst aspects of the United States’ response is the failure to provide adequate personnel protective equipment (PPE). The United States’ federal government has not invoked the Defense Production Act to assure an adequate supply of N95-masks for our workers. These masks require a key ingredient ‘melt blown textile’ which is difficult to manufacture. Relying solely on the free market is ill-advised since, similar to the N1H1 pandemic, industry is reluctant to retool for manufacture when they may not recoup their startup costs. This reluctance has its roots in the ideology and the desire of leaders not to create excess mandates and government overreach.
Some feel the delay in recognition of aerosolization as a major mode of spread of SAR-CoV-2 was related to the paucity of N95-masks and the desire not to alarm workers. As of this writing, N95-masks are still in short supply.
The impact that this lack of basic protective gear has had may never be known, for no one is counting SARS-CoV-2 infections and deaths in front-line workers. A lack of mandatory reporting of work-related illness has resulted in incomplete reporting on healthcare personnel; the number of healthcare workers who died from COVID-19 could be between 752 to above 4000. The bottom line is, we need to do better.
We have stressed in the past the importance of establishing a surveillance system and regular screening of healthcare workers for endemic dangerous pathogens and those pathogens which have frequent outbreaks in a facility, including pathogens CRE, Clostridioides difficile, MRSA, and SARS-CoV-2.
Healthcare workers also need to have an economic and healthcare safety net for both themselves and their families. Paid sick leave is of paramount importance, since it is not ethical to have a healthcare worker making the untenable choice between the safety of patients and placing food on their family’s table. Acquisitions of dangerous pathogens that occur during an outbreak or pandemic should qualify the worker for presumptive disability.
Additionally, no one is counting patients who contract COVID-19 in hospital settings. The U.S. Department of Health and Human Services’ definition for a SARS-CoV-2 hospital-acquired infection is unfortunately next to useless; “Total current inpatients with the onset of suspected or laboratory-confirmed COVID-19 fourteen or more days after admission for a condition other than COVID-19.” Unfortunately, this definition is next to useless.
For many patients, the greatest chance of catching SARS-CoV-2 is on the day of admission, due to being placed in a freshly turned over room and possibly going through the emergency room for initial treatment. Thus it is unlikely that few SARS-CoV-2 HAIs will be captured. The most accurate metric would be a diagnosis of SARS-CoV-2 acquisition which would occur 5 days after admission, including those which present after discharge. This metric would balance false positive and negative results and give a much better estimate of overall system performance. This mitigation of SARS-CoV-2 data is reminiscent of past pandemics where countries have a long history of hiding the numbers, as opposed to reporting them and correcting the problem.
The Need to Take Care of Disparate Populations, Even the Elderly
Initially, the virus emerged in the northwest region of the United States and devastated Nursing Homes where infectious disease regulations were all too lax. In 2019, the CDC attempted to strengthen infection prevention in nursing homes by enacting the strategy of Enhanced Barrier Precautions.. ‘Enhanced’ a deceptive word, since these precautions are less stringent than Contact Precautions (these precautions were being advocated for the control of the CDC’s ‘Urgent Threats’ of carbapenem-resistant Enterobacteriaceae (CRE) and Candida Auris and can also be applied to patients colonized with MRSA). Recommendations for Enhanced Barrier Precautions state: “Residents are not restricted to their rooms and do not require placement in a private room.”
Enhanced Barrier Precautions allow carriers to participate in nursing home activities and only require healthcare workers to implement contact precautions for high-risk activities, but even low-risk activities, such as passing meds, occur so frequently that one would expect frequent healthcare worker contamination.
These precautions do not appear to be based upon how the MDRO spreads, but instead on avoiding more stringent and resource-intense strategies.
Such strategies would include: Healthcare worker screening and availability of abundant PPE, along with determining the patient’s microbiome, and if dangerous pathogens are present, decolonization, and as a last resort cohorting patients with similar pathogens in dedicated facilities. Pathogens do not care about politics or the needs of the individual, they are genetically programmed to spread.
Dangerous pathogens are genetically programmed to spread. Strategies need to be based upon the pathogen and not the political expediency of our leaders or to lessen the economic impact on our healthcare system. The COVID-19 pandemic has taught us the need for public support and embracement of scientifically based public health strategies to stop the spread of dangerous pathogens (proper building ventilation, widespread testing, social distancing, wearing masks, and hand hygiene). These strategies can be expensive to implement and may cause a severe short-term economic burden but are the fastest path to a full economic recovery.
Whether one deals with MRSA or COVID-19, screening, and decolonization or self-isolation of healthcare workers is of utmost importance. Their health, the health of their families along with their patients depend upon it.
This post is by Dr. Kevin Kavanagh, and originally appeared on the BMC blog network.