The COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic, by far, has been the major factor influencing healthcare epidemiology since early 2020. Not only has the presence of patients infected with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in hospitals had a direct impact on the day-to-day responsibilities of hospital epidemiologists and infection preventionists, the pandemic has also had myriad effects on several aspects of healthcare delivery in the United States and the world. Hospitalized COVID-19 patients require aggressive and meticulous isolation precautions, techniques to monitor adherence to these precautions, and detailed epidemiologic evaluation and contact tracing, all of which dramatically increase the workload for healthcare epidemiology teams. During surges, institutions experienced shortages of personal protective equipment, some of which were severe, including shortages of masks, gowns, respirators, and face shields. Shortages of laboratory and testing supplies were also common. Hospital epidemiologists were required to be creative and rapidly responsive. The repeated surges of infection have created extraordinary stress for hospital staff, as well as substantial pandemic fatigue, as the pandemic has continued. The mental health impact of the pandemic on society in general and on healthcare personnel, in particular, cannot be overemphasized.

The pandemic also had a devastating effect on the healthcare economy. During surges, hospitals deferred elective surgeries and admissions. Patients were reluctant to come to hospitals or even to physicians’ offices, fearing exposure to COVID-19. Hospital censuses plunged, and leaders of many large hospitals found themselves in dire financial straits. Some hospitals closed. Many institutions laid-off staff, cut salaries, and downsized departments (including healthcare epidemiology staff in some institutions), and many institutions experienced pandemic admissions that stressed their institutional systems to their absolute limits.

Another effect of the pandemic and the pandemic response on healthcare epidemiology is the fact that the role and standing of healthcare epidemiology teams in their institutions tended to increase substantially and the importance of these teams was underscored. This increased visibility has afforded the SHEA the opportunity to expand the organization’s ‘tent’ to include individuals who were given expanded roles in the pandemic, such as public health professionals and infectious diseases pharmacists, among others. At the same time, the pandemic spawned armchair epidemiologists with uninformed opinions about infection prevention. These included individuals in medical professional societies who independently wrote SARS-COV-2 infection prevention guidelines that were not always based on the best available scientific evidence. This situation poses a threat to SHEA’s authority, but it also presents an opportunity to collaborate and contribute our expertise.

Additionally, the pandemic accelerated changes in healthcare delivery processes. Our country has undergone a dramatic increase in reliance on telemedicine. Many outpatient visits have been converted to videoconferencing or telephone encounters. Patients who might have been transferred to inpatient postacute care rehabilitation were cared for at home instead. As many staff as possible have been working from home. Whereas many healthcare personnel must be physically present in the workplace, many operational staff, particularly those who do not have direct patient responsibilities, are able to work remotely. The extent to which these changes in the processes of healthcare delivery may be adopted in postpandemic society and the impact of these changes on the ability to provide sustainably safe healthcare remains to be delineated.

Both the pandemic and the economy will likely influence the organization’s ability to sponsor conferences. The travel restrictions and physical distancing requirements related to the pandemic have effectively eliminated meeting travel and in-person meetings and conferences; numerous conferences have either been cancelled or conducted virtually. Mandated hospital economizing will likely have a dramatic effect on travel by SHEA members. These conference patterns may continue. In addition, some hospitals have frozen all discretionary spending, including support for SHEA memberships.

Some processes, policies and behaviors that were adopted during the pandemic to protect patients and healthcare providers from COVID-19 may continue far into the future. For example, the concept of aggressive visitor screening for infectious diseases—especially for institutions housing large populations of immunosuppressed patients—makes implicit sense. Other possible changes include adoption of universal, bidirectional masking during respiratory virus season. Intolerance of “presenteeism” is likely to increase. Managing the complex presenteeism issue in all healthcare settings, including long-term and postacute care, is likely to require increasing sick time or paid time off for employees, which could put additional financial stress on healthcare systems. Finally, healthcare facilities will need to decide whether to mandate SARS-CoV-2 vaccination for their employees or to limit the clinical exposure of staff who are not immunized. For institutions that have not already done so, this approach may lead to mandating other vaccines, such as influenze vaccine, for healthcare personnel. SHEA members who work in occupational health will be well positioned to lead decision making in these areas. In addition to these modifications, SHEA guidance will also be needed to identify parameters that can be used to make decisions about whether and when some of the supplemental prevention practices that were put into place by many healthcare facilities at the height of COVID-19 surges should be relaxed. Such measures include, for example, the use of eye protection for all patient encounters, admission and preprocedure SARS-CoV-2 testing of asymptomatic patients, and the use of N95-level respiratory protection during aerosol-generating procedures for all patients regardless of COVID-19 status.

Identifying which metrics to use to determine how society at large can get back to ‘normal’ continues to be a challenge. In fact, a new ‘normal’ may need to be defined. Developing a science-based strategy for how to reopen safely will likely be a major issue for this and subsequent pandemics. Finally, the SHEA board has recognized the nearly complete lack of a robust public health infrastructure to support a pandemic response across the United States. SHEA could play a major role in advocating for this critical public health infrastructure.

Systemic changes in healthcare

In the past decade, a substantial increase in the rise of expanded care systems, both vertically and horizontally, has occured as large healthcare corporations standardize processes to take advantage of the ways in which the healthcare market is changing. These change have effectively invented a new role for a corporate infection-prevention leader. Many SHEA members who were initially 1-hospital healthcare-epidemiologists now occupy systemwide roles. SHEA has not traditionally advocated for such positions, nor have we trained our membership for such systemwide roles. SHEA should learn from these members’ experiences to begin to offer its members support as they move into such roles.

Additional changes, driven at least in part by pandemic requirements (discussed above), may lend additional complexity to the role of healthcare epidemiologist. One could envision a much closer relationship with the C-suite (based on risks of pandemic and highly communicable diseases). Pandemic planning and management has also resulted in healthcare epidemiologists having more interaction with local and state public health authorities and with healthcare epidemiologists outside their own institutions. We envision, at least in the short to mid-term as the pandemic winds down but COVID-19 continues, that such interactions will persist. Such interactions offer SHEA the opportunity both for expanded influence and peer mentoring as well as expansion of the SHEA ‘tent.’

Technological advances that affect healthcare epidemiology

Recently, several major healthcare-associated outbreaks have been linked to contaminated medical equipment, such as outbreaks of carbapenemase-producing Enterobacterales related to exposure to duodenoscopes and outbreaks of Mycobacteria chimaera related to exposure to heater-cooler devices during open-heart surgery. In both of these examples, outbreaks occurred despite devices being used, cleaned, disinfected, and/or reprocessed according to manufacturers’ recommendations; the fault was determined to be in the design of the devices. Although hindsight is 20/20, as they say, it seems plausible that involvement of SHEA members with expertise in sterilization, disinfection, and/or surgical-site and device-associated infection prevention in the design phase of these devices may have resulted in changes that could have averted the outbreaks. These outbreaks present an opportunity for SHEA to advocate for a (more) rigorous process for review of infection risk associated with medical devices.

Use of the electronic medical record (EMR) for patient screening, electronic surveillance, computerized physician order entry, and antibiotic and diagnostic stewardship continues to expand. SHEA should take advantage of the opportunities inherent in these EMR systems to standardize and implement evidenced-based practices for infection prevention, especially for antimicrobial stewardship purposes (an area of substantial interest for SHEA leadership), while recognizing their limitations and potential for unintended harms.

Similarly, technological advances are affecting the clinical microbiology laboratory, particularly in the area of genomics. For example, whole-genome sequencing (WGS) of microbes is the current ‘gold standard’ molecular epidemiologic tool for outbreak investigation and for monitoring endemic microbes of concern. Although it is currently available primarily to SHEA members in academic medical centers, access to WGS will almost certainly expand over the next 5 years. Educating SHEA members about the uses and interpretation of WGS and other molecular diagnostic methods will be important. Establishment of a framework for diagnostic stewardship in infection prevention is also needed.

Political influences that affect healthcare epidemiology

The bipolar political nature of our current society at large suggests a substantial risk for widely divergent policies relating to patient safety, healthcare quality, and hospital epidemiology in the near future. To the extent that it is possible, SHEA should prioritize efforts to inform and influence politicians on both sides of the political aisle about these important patient safety and clinical quality issues. The partisanship associated with these polar positions also increases the complexity of our organization’s approaches to policy development or advocacy for policy positions. Perhaps one of the best examples of how these widely divergent positions can influence policy has been the response to masking, mitigation strategies, and vaccine acceptance—all of which have been politicized. At SHEA, we believe that awareness of this remarkable polarity and the need to take this polarity under consideration will be extremely important as we formulate our operational and strategic plans going forward. The political climate will likely have substantial influence on several important issues affecting the organization: changes in funding for healthcare and public health, changes in funding for prevention activities, and modifications of regulatory requirements, among others. Congressional gridlock has resulted in the last 3 administrations legislating primarily by executive order, with new administrations essentially reversing many of the orders of their predecessors. If this pattern continues, policies critical to infection prevention and patient safety may change every 4 years. From a broader perspective, scientific issues that are linked to political postures—such as the use of embryonal stems cells for research, the extent of investment in public health, changes in healthcare financing strategies, and changes in models of healthcare delivery—all require SHEA’s attention.

The pandemic has highlighted the decrease in scientific literacy and an increase in scientific skepticism in the general population. As the pandemic has progressed, this problem has actually increased. We are now dealing with substantial vaccine skepticism in the country, and if this problem is not overcome, it will prolong the pandemic. In addition, much of the country expresses belief in conspiracy theories and in the validity of so-called alternative facts. Although challenging for our small organization, the SHEA should address these issues directly. One way we could address these concerns is through improved communication strategies—by adopting communication approaches that message effectively to multiple different audiences in our own healthcare systems and beyond. The internet and the electronic information age have altered modes of delivery of education and training (eg, more podcasts, web conferences, use of social media) and dissemination of research knowledge.

SHEA recently launched an open-access, online companion journal Antimicrobial Stewardship and Healthcare Epidemiology, and the editorial staff of Infection Control and Hospital Epidemiology long ago adopted a strategy of electronically publishing papers immediately on acceptance, long before they appear in print. We are witnessing major increases in the use of nonprint modes of information transfer, some of which may be associated with a potential to mislead (eg, prepublication of research findings prior to peer review).

Prior to the pandemic, the Centers for Disease Control and Prevention (CDC) was widely viewed by our membership, by our nation at-large, and by countries around the world as the pinnacle of credibility, expertise, scientific knowledge, and trust with respect to infectious disease epidemiology. During the first pandemic year, the CDC was effectively undermined by the previous federal administration. Administration officials repeatedly cast doubt on CDC guidance, and frequently questioned scientific fact, which negatively influencied public opinion and confidence. In some instances, CDC publications were either altered or completely authored by people other than CDC staff. The net result of these interventions was catastrophic. SHEA members cannot recall ever seeing the CDC sidelined in such a manner. SHEA leadership believes this to be an important cautionary tale for our organization and for the country. The new administration has appointed a new CDC director and appears to be relying heavily on CDC staff and CDC advice. SHEA needs to develop a strategy, perhaps in collaboration with other medical societies interested in public health epidemiology and infectious diseases, for addressing the problems posed by the undermining of the CDC, and for developing interventions to counteract it if it happens again. SHEA leadership directly experienced, in their own institutions, the negative effects of the previous administration’s undermining of the CDC. Many board members noted that these activities severely hampered their ability to be successful in everyday work. All of our efforts can be undermined by forces out of our control; thus, the SHEA leadership believes that we should position the organization to better weather a similar chain of events. SHEA should be prepared to offer guidance and recommendations based on scientific evidence, and when evidence is not available, based on thoughtful opinions of healthcare epidemiology experts, even if the guidance contradicts that which is offered by the CDC.

Future pandemic preparedness

One of the major lessons learned from this pandemic is that our nation was unprepared for a major pandemic. Despite having dealt with SARS, Ebola, and the potential for pandemic influenza in the past, when COVID-19 arrived we found ourselves woefully unprepared for the pandemic in a variety of areas. In the next 5 years, we must emphasize preparedness for the next pandemic. This necessity positions the SHEA for an expert role in helping the country prepare for subsequent novel infections. The SHEA needs to be able to identify the resources needed to respond, but more, importantly, to determine what is practical and possible to prepare the country for the next pandemic. The SHEA should foster global cooperation for this mission and should continue its efforts to connect with healthcare epidemiologists outside the United States to understand, learn from, and contribute to solutions to infection prevention challenges in different international settings. Programs such as the SHEA International Ambassadors and the work of the External Affairs Committee will remain important, as will ensuring international representation on the SHEA Board of Trustees and on the editorial boards of the SHEA journals. The increase in virtual conferences and meetings necessitated by the pandemic is likely to persist, which may benefit international collaborations. The SHEA should consider ways to expand international membership in our organization.

Health equity and social justice in the United States and in SHEA

The fact that clear health disparities have been highly evident in the pandemic, with underserved minorities at markedly increased risk for infection and serious complications of SARS-CoV-2 infection, has underscored the need to address health disparities throughout our country. Some of the inequities in US society have been painfully highlighted by this pandemic.

Several highly visible events during the past year have also underscored the presence of systemic racism in the country. The linkage between health inequities, social justice, and systemic racism is clear. SHEA board members want to ensure that the organization is working toward social justice, health equity, and antiracism. The highly visible health inequities in the pandemic provide an opportune impetus for our organization to examine the issues of diversity and equity within SHEA. The SHEA board aims to develop an agenda for equity and antiracism for our membership and for the healthcare epidemiology workforce, as well as an agenda related to access to optimal infection prevention resources. SHEA leadership believes that, as a first step, the organization should assure diversity in terms of committee leadership, membership, and composition. SHEA board members also believe that we should challenge each of our committees to engage issues relating to social justice, health inequities, and antiracism whenever possible. Furthermore, we must learn what committee members believe that SHEA can do to address these critical issues. Assisting with assuring equitable vaccine distribution is one area for consideration. Whereas we cannot possibly engage on every problem in society, our organizational positions in general should address issues in a manner that reflects the broadest possible representation of our membership. One board member emphasized that staying silent represents complicity—a position no board member would endorse.