Seasonal respiratory illnesses

The COVID-19 pandemic has altered the way we view health risks associated with respiratory viral infections. In health care, universal masking was implemented as an evidence-based source control measure to reduce the risk of nosocomial SARS-CoV-2 transmission among patients and health care professionals (HCP). ^{Reference Harris1,2} The end of the World Health Organization and the U.S. federal government COVID-19 Public Health Emergency declarations ^{Reference Harris1,2} has prompted discussions around the future of masking in health care settings ^{Reference Shenoy, Babcock and Brust3,Reference Palmore and Henderson4} as COVID-19 is increasingly viewed as an “established and ongoing health issue.” ⁵

Regardless of individual perceptions regarding the ongoing health implications of COVID-19, our pre-pandemic approach towards preventing hospital-acquired respiratory viral infections was likely inadequate, and we underappreciated the harm caused by hospital acquired respiratory viral infections preventable by masking. ^{Reference Chow and Mermel6} Lessons learned from the COVID-19 pandemic have led to a greater appreciation of asymptomatic, presymptomatic, and pauci-symptomatic transmission of SARS-CoV-2 and other respiratory viruses ^{Reference Palmore and Henderson4,Reference Cohen, Kleynhans and Moyes7} from patients to HCPs and vice versa. Additionally, pre-pandemic policies assumed patients’ respiratory infections were identified and isolated appropriately, but studies have shown that asymptomatic and presymptomatic cases likely account for most SARS-CoV-2 transmission events ^{Reference Johansson, Quandelacy and Kada8} ; the same may be true for other respiratory viruses. ^{Reference Suess, Remschmidt and Schink9,Reference Patrozou and Mermel10} Thus, reverting to pre-pandemic interventions will not prevent transmission in the health care setting.

While masking is an evidence-based intervention to prevent the transmission of respiratory viruses in direct person-to person encounters, a misinterpretation of the oft-cited Cochrane Review, ¹¹ which was a population level study suggesting masking is not effective at stopping the spread of COVID-19 at the community level, was inappropriately and incorrectly extrapolated to health care facilities.

It is also important to note that one cost of masking is the barrier to clear communication in clinical encounters. Physicians should demand wider access to items such as OSHA-compliant clear masks that enable those with hearing impairments to participate in their care without sacrificing safety. In addition, masking recommendations impacting large sections of the health care system must be balanced against HCP and patient PPE fatigue and the resulting difficulties in attaining compliance.

Staffing

The COVID-19 pandemic led to significant burnout in the infection prevention workforce. ^{Reference Nori, Stevens and Patel14} However, even prior to this, IPC programs were understaffed. A 2019 national survey revealed 25% of programs had at least one open position and that it took 3 to 6 months to recruit trained infection preventionists (IPs). Additionally, 40% of IPs are expected to retire over the next decade. ^{Reference Melnyk, Hsieh and Mu15} Burnout and the decision to leave IPC occurs for a myriad of reasons, as outlined by Nori et al. (Fig. 1). ^{Reference Nori, Stevens and Patel14}

Figure 1.

Complex factors contributing to Infection Prevention burnout (reproduced with permission from Antimicrobial Stewardship & Healthcare Epidemiology).

Critically, IPC staffing support models of 1 IP to every 75–100 ^{Reference O’Boyle, Jackson and Henly16} acute care beds are outdated and do not consider an evolving scope of practice. ^{Reference Wright, Ostrowsky and Fishman17} New staffing models must account for expanded responsibilities, like oversight of infection prevention of hemodialysis centers, same day surgery centers, outpatient clinics, etc. Regarding long-term care facilities (LTCFs), Centers for Medicare and Medicaid Services (CMS) requires at least part-time on-site IPC staffing that “must meet the needs of the facility.” However, the reality is that LTCFs are generally understaffed, may have four-fold fewer IPs than hospitals and suffer from high staff turnover, which has been significantly worsened recently. ^{Reference Stone, Agarwal and Pogorzelska-Maziarz18–Reference Yaraghi, Henfridsson and Gopal20} Staffing models that reflect these realities are needed to ensure adequate IPC infrastructure in LTCFs.

There is also a paucity of trained health care epidemiologists (HCE) in the United States. HCEs should be trained in Infectious Diseases (ID), a specialty facing critical shortages. It is estimated that 79.5% of U.S. counties do not have an ID physician. ^{Reference Walensky, McQuillen, Shahbazi and Goodson21} Forty-four percent of ID fellowship positions were unfilled in the 2022 Match, ^{Reference Huang22} and there is currently no accredited certification in health care epidemiology.

Equity

The importance of health care equity extends to IPC, antimicrobial stewardship and emerging pathogen response. Part of health care equity is ensuring equitable access to the same level of care; however, antimicrobial stewardship (AS), IPC, and infectious diseases resources can vary widely between types of settings. Compared to urban acute care facilities, rural settings often lack AS pharmacist support and access to an ID physician. In addition, rural IPs often have fewer years of experience, limited access to high-quality/comprehensive infection prevention education, are less often to be certified in IPC, and are more likely to have additional non-IPC responsibilities. ^{Reference Reese, Gilmartin, Rich and Price24} Similarly, despite the shift to more complex patients and increasing numbers of invasive procedures in non-acute settings, ^{Reference Jarvis25} experienced infection prevention and stewardship staff remain limited ^{Reference Black, Weaver, Weinstein, Hayden, Lin, Lavin and Gerber26} and staffing benchmarks are unclear in ambulatory, skilled nursing and home-care settings. Antimicrobial use and prescribing practices also have been shown to vary by geographic region, with the southeast issuing the most antimicrobial prescriptions. ^{Reference Evans and Wiley27} While the reasons for disparate outcomes are multiple, differences in IPC and AS staffing, training and education likely contribute, and data on disparities in health care associated infections (HAIs) and antimicrobial resistance outcomes are just emerging.

IPC and AS outcomes vary by type of facility. Past studies have suggested that smaller hospital size was associated with higher central line associated bloodstream infection (CLABSI) rates. ^{Reference Nelson, Wang, Huang and Kuo28} During the COVID-19 pandemic, smaller community hospitals had more marked increases in HAIs compared to academic hospitals. ^{Reference Advani, Sickbert-Bennett and Moehring29} Safety net hospitals have higher CLABSI, catheter associated urinary tract infection, and post-colectomy surgical site infection rates compared to non-safety net hospitals. ^{Reference Hsu, Wang, Broadwell, Horan, Jin, Rhee and Lee30}

Studies also show variability in HAIs by patient demographic characteristics, with higher rates of health care associated bloodstream infections in Black and Hispanic patients compared to white patients. ^{Reference Jeon, Muennig, Furuya, Cohen, Nash and Larson31–Reference Gouel-Cheron, Swihart and Warner36} Racial differences exist for Staphylococcus aureus infections, ^{Reference Gualandi, Mu and Bamberg37} Clostridioides difficile infections ^{Reference Argamany, Delgado and Reveles38} and frequency of antibiotic prescriptions. Social vulnerability, those determinants that adversely affect a community, are receiving more attention as risk factors for adverse health outcomes, including HAIs. A higher social vulnerability index (SVI) ^{Reference Dyas, Carmichael and Bronsert39,Reference Butler, Hranac and Johnston40} and limited English language proficiency have similarly been associated with worse infection outcomes. ^{Reference McGrath, Bettinger and Stimpson33,Reference Karliner, Kim, Meltzer and Auerbach41,Reference Jacobs, Prasad, Fang, Abe-Jones and Kangelaris42} Nevertheless, data suggests many HCPs are unaware of impact of health disparities on HAIs and other health outcomes. ^{Reference Pedersen, Pryor and Bearman43}

Medical education

Education must emphasize the evidence supporting IPC practices and promote long-term compliance with repeated short bursts of engagement to hardwire behavioral change. Knowledge of and compliance with evidence-based IPC practices are required by health care professionals at all levels. However, given the AMA’s priority to ensure physicians and trainees received essential education in IPC, the work group focused on education for these groups.

Medical school is usually the first formative exposure to IPC for physicians. Online training modules for the prevention of infections and environmental hazards are specifically required by the Liaison Committee on Medical Education (LCME), ⁴⁴ but medical schools are otherwise not required to cover IPC in their curricula. Basic concepts like hand hygiene are reinforced through simulated clinical encounters ^{Reference Erasmus, Otto and De Roos45} ; however, a lack of consensus exists on the optimal content and delivery of IPC education in medical school. Multiple studies have shown that medical students have knowledge gaps regarding foundational IPC practices such as hand hygiene, donning/doffing PPE, HAIs, and transmission-based risk assessment. ^{Reference Hunt, Mohammudally, Stone and Dacre46–Reference Nori, Madaline and Munjal49}

Opportunities for IPC education in residency and fellowship are more clinically oriented and guided by the Accreditation Council for Graduate Medical Education (ACGME) Infectious Diseases Milestones for IPC and Antimicrobial Stewardship and Epidemiology. ⁵⁰ These milestones help determine whether a trainee achieves competency in IPC knowledge and practices, and suggest tools to assess competency. ^{Reference Ostrowsky, Nori and Munjal51–Reference Martin and Snyder53} However, they do not indicate specific curricular content, discuss which assessment models and tools are most effective, or consider how education and training should be adapted for different settings. Several studies have identified pervasive knowledge gaps among residents and fellows regarding IPC practices, such as preventing spread of antimicrobial resistance. ^{Reference Navarro-San Francisco, Del Toro and Cobo54} In one study, only half of ID fellows in the greater New York area felt comfortable managing everyday IPC scenarios, ^{Reference Nori, Madaline and Munjal49} and a large survey study of U.S. Pediatric ID fellows showed that less than half participated in a dedicated IPC rotation. ^{Reference Sandora, Esbenshade and Bryant55} A recent survey of ID Fellowship program directors revealed that only one-third have a dedicated IPC/HCE tract, and the average formal didactic hours on IPC topics over the course of the fellowship is less than 5 hours. Directors cited lack of funding, lack of time and lack of a formal curriculum as reasons their programs have not expanded education on this topic. ^{Reference Winkler, Paras, Wright and Shenoy23}

Finally, upon completion of medical training, practicing clinicians may receive minimal continuing education in IPC practices. Many hospitals require completion of online IPC training modules for credentialing, but education is sporadic, may not be engaging, and may address only superficial IPC knowledge. While professional societies and CDC offer courses, the utilization and effectiveness of these resources is largely unknown.

CDC, through Project Firstline and other sources, has educational tools available in various formats. While sources like those developed by the Association for Professionals in Infection Control and Epidemiology (APIC) provide highly specific educational tools for IP specialists, many tools are relevant to all health care professionals (Table 1).

Table 1.

Examples of IPC education and training resources available to health care professionals

* The AMA work group contributed to the development of physician-targeted educational resources as part of the AMA’s collaboration with CDC on Project Firstline.

Environmental impact

The health care industry produces 4%–5% of the world’s greenhouse gasses, ^{Reference Rodríguez-Jiménez, Romero-Martín, Spruell, Steley and Gómez-Salgado56} with the U.S. health care system contributing 8.5% of the nation’s greenhouse gas emissions. ^{Reference Eckelman, Huang, Lagasse, Senay, Dubrow and Sherman57} Climate change can exacerbate pathologies and expand the geography of infectious diseases. The work group felt that the dichotomy between understanding that IPC is important to protect patients and professionals from infection while acknowledging the impact that IPC policies have on health care’s contribution to climate change required scrutiny.

During the pandemic, the consumption of single use PPE skyrocketed in health care and among the public. Increases in waste emerged from test kits, chemical waste, vaccine by-products (syringes, needles, and safety boxes), ⁵⁸ heightened PPE policies, and disinfection.

Prior to the pandemic, the worldwide utilization of facemasks was about 89 million per month, which increased to 129 billion per month during the pandemic, ^{Reference Jiang, Luo, Wang, Zhang, Wang and Wang59} with proper disposal still an area of ongoing research. One study ^{Reference Chu, Ghenand and Collins60} estimated that in the U.S. alone, a new N95 respirator per patient encounter would require 7.41 billion respirators, cost $6.38 billion, and generate 84.0 million kilograms of waste over the course of only 6 months. ^{Reference Chu, Ghenand and Collins60}

However, health care professionals are taking an active role in environmentally conscious policies. For instance, the Green Surgery Report ⁶¹ released on November 14, 2023, details next steps to create more environmentally sustainable clinical practices. Such practices include limiting use of PPE to when it is clearly indicated and prioritizing handwashing over disposable gloves during routine medical care to reduce carbon emissions and potential microorganism transmission. The report also calls for more research on reusable devices, with specific consideration for IPC.

In-home, hospital, clinical and public space disinfecting practices have also increased significantly since the COVID-19 pandemic. Disinfectants contain chemicals such as quaternary ammonium compounds, hydrogen peroxide, bleach, and alcohols, which have significant negative consequences on the environment ^{Reference Dewey, Jones, Keating and Budhathoki-Uprety62} and water supplies. ^{Reference Zhang, Tang, Chen and Yin63} Waste treatment centers are not specifically designed to handle these compounds. ^{Reference Barber and Hartmann64} The Environmental Protection Agency, ⁶⁵ the World Health Organization (2020), ⁶⁶ and CDC (2021) ⁶⁷ have guidance for cleaning and disinfectants but none address environmental concerns.