Looking to future viral pandemics as well as the current one of COVID-19, the Society of Healthcare Epidemiology of America (SHEA) has set an ambitious research agenda to improve preparation and response to these cataclysmic events.
“It will come. The next pandemic will come in five years, 10 years, 20 years,” says Lona Mody, MD, lead author of the paper. “We don’t know when, but we should be better prepared at that time based on what we are facing right now.”
The research agenda was developed by 40 experts in healthcare epidemiology and infectious diseases to identify the critical areas of study for clinical practice, policy, and prevention.
“This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to COVID-19 with a focus on core principles of healthcare epidemiology,” the authors note.1 “These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections.”
Each of these sections list three critical research issues, which should be subjected to translational studies from laboratory-based basic science to well-designed, large-scale studies. These five agenda items may be of interest to infection preventionists.
- Understand heterogeneity in epidemiology and transmission dynamics of SARS-CoV-2.
- Define characteristics and effect of asymptomatic/pre-symptomatic patients infected with SARS-CoV-2.
- Characterize risk factors that lead to severe disease outcomes, including age, sex, and race, with special emphasis on health disparities, socioeconomic status, and comorbidities.
- Identify critical interventions required to stop COVID-19 outbreaks.
- Determine optimal personnel, expertise, and training required to conduct rapid SARS-CoV-2 and other outbreak investigations.
- Identify optimal resources and technology (reporting tools, software, and hardware) to support outbreak investigation.
Isolation Precaution Practices
- Determine when and how to initiate transmission-based isolation precautions for COVID-19.
- Determine how to optimize management and care delivery while isolation precautions are in place.
- Determine when to discontinue COVID-19 isolation precautions and reinstitute isolation in cases of possible re-infection.
Personal Protective Equipment
- What is the appropriate level of universal personal protective equipment (PPE) for the current pandemic and in the post-pandemic state?
- What are the sociobehavioral, adaptive, and contextual factors required to improve appropriate PPE use?
- Are PPE interventions made during the COVID-19 pandemic likely to be effective against other commonly circulating respiratory viruses?
Healthcare Occupational Safety
- Define the risks that increase healthcare personnel (HCP) exposure to and acquisition of SARS-CoV-2 and interventions that can mitigate these risks.
- Determine optimized strategies to protect the emotional and psychological health of HCP.
- Determine effect of social and organizational strategies to maintain the health and wellness of HCP.
Q & A
Hospital Infection Control & Prevention asked Mody for additional comment on the research agenda in the following interview, which has been edited for length and content.
HIC: Can you elaborate on the point that this research is needed not just for COVID-19, but future viral pandemics?
Mody: This pandemic has exposed the weaknesses and dangerous gaps in our understanding of the epidemiology, transmission, and the short- and long-term public health consequences of viral diseases. I personally believe that a lot of work emphasis and focus has been placed on bacterial transmission of antibiotic-resistant organisms. We need to focus on viral conditions — how they spread, how we can control them and minimize the consequences by broad public health research into infection prevention. Certainly, we have many unanswered COVID-19 questions, but in a broader, long-term view of things, it has shown us the global impact on health and economy. Every possible population and country across the globe has been impacted. There is no global economy without global public health. Another reason we wrote this article is that we hope that not only the [United States] but people across the world will [research] some of the questions that we have proposed as a starting point.
HIC: One research area calls for better understanding of how this virus transmits asymptomatically. Healthcare workers are sometimes reminded that they can transmit influenza shortly before symptoms appear, but COVID-19 has taken this insidious feature to a whole new level.
Mody: I’m sure there is asymptomatic spread of several [other] conditions as well, because we all have bugs and organisms in our microbiome. What is good for me may not be good for you. The epidemiology — the way that [COVID-19] evolved, we do not know who remains asymptomatic and is able to transmit. A big chunk of disease spread happened because of asymptomatic and pre-symptomatic people. Now there are some folks, older adults for example, they may not have symptoms as such. If you think about pneumonia, urinary tract infections [UTIs], we have seen people actually have atypical symptoms of infection and we don’t treat them appropriately — we often treat them too late. That’s where I think we need to have thoughtful studies about who are the asymptomatic and pre-symptomatic spreaders.
HIC: The research would look at risk factors for various aspects of disease, including the respiratory, neurological, and psychological effects of the virus, all of which can manifest in one way or another in long-COVID patients. This syndrome has been one of the more nightmarish aspects of the pandemic.
Mody: The percentage varies by studies, but a significant percentage of people do not return to full health even after mild cases. There are in the hospitals and sometimes in the intensive care unit [ICU], and we see them transferred to rehab units. It takes time for them to come back to full health. If they are not able to come back to full health, what type of services will they need, short-term and long-term? What kind of outpatient clinics will they need? So, number one, we need to describe what kind of symptoms [they] have, like fatigue, brain fog and shortness of breath, and then determine what kind of health services and expertise we need to manage this. Then, there is the societal aspect of it — what about their jobs? What is their quality of life? This is also true of other patients who have recovered from COVID-19 but have diabetes or obesity. What are their needs for the future?
HIC: The research agenda calls for developing tools to identify outbreaks more rapidly in hospitals. There certainly have been institutional outbreaks, but given the predominance of spread in the community, is COVID-19 a true nosocomial pathogen?
Mody: Whether it is nosocomial or not, we have to do more research on it. I don’t think that COVID-19 is a huge nosocomial pathogen for patients. From an occupational standpoint, certainly healthcare providers are more likely to get it if they do certain procedures and are not well protected. We need more research on the risk to healthcare providers — what kind of procedures, what kind of infection control precautions are needed? All of this needs to be studied to determine whether it is nosocomial or not. A hospital stay is short, but long-stay patients are typically in nursing homes in close quarters. In that case, COVID-19 is not nosocomial in the traditional sense we use in hospital epidemiology, but it is acquired in the nursing homes. That needs to be teased out as well.
HIC: As part of improving the use and understanding of PPE, the paper cites the need for research on the “sociobehavioral reasons for not following PPE guidance.” This became a political dividing line and undermined the public health pandemic response considerably.
Mody: My personal feelings aside, COVID-19 has shown us that we need buy-in from a large proportion of our population to really make effective change. We are all interdependent on each other. What is the public health responsibility of a person who is occupying this globe, this place of birth of human beings? What is our responsibility? I think this is a question that needs to be asked and talked about by thought leaders, and considered deeply. There is a personal freedom to it — people do not like to wear masks. They feel they cannot show their smile — they cannot interact very well. It is something they are being told to do and there is some thinking of independence of choice. But does that outweigh public health responsibility? If the outbreak is not controlled, then the consequences are incredible and far-reaching. I think that is a big debate that we should all have through research on behavioral aspects [of the pandemic], but then that research has to translate to policy.
- Mody L, Akinboyo IC, Babcock HM, et al. COVID-19 research agenda for healthcare epidemiology. Infect Control Hosp Epidemiol 2021; Jan 25:1-81. doi: 10.1017/ice.2021.25. [Online ahead of print].