The SARS-CoV-2 pandemic has been the biggest challenge in the history of modern infection prevention, but it also has raised the profile and importance of infection preventionists (IPs) in a way that should secure future program resources, says Ann Marie Pettis, RN, BSN, CIC, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology (APIC).

“None of us have experienced anything like this,” says Pettis, director of infection prevention at University of Rochester (NY) Medicine. “My grandmother used to talk about the Spanish flu and how [childhood] friends of hers died in the middle of the night. This pandemic is as [challenging] as it has ever been for me and our field in healthcare. You know, all these years I’ve been saying to groups, it’s not ‘if’ but ‘when’ we will have a pandemic. We are in the ‘when’ now.” 

With more than 500,000 dead of COVID-19 in the United States, the pandemic has raised awareness of the bitter toll infectious diseases can take, and, importantly, why investing in public health and infection prevention is critical to close the glaring gaps that have been exposed. 

“For many years, our tagline has been ‘infection prevention is everyone’s business,’” says Pettis, who has been an IP for more than 30 years. “I’m not sure leadership took it as seriously as we would have liked. I think the pandemic has shone a light on infection prevention and really made them realize the value we bring to the table. The money that they put into supporting an infection control program is well worth it and really has an unbelievable value. Moving forward from the pandemic, I see the glass as half-full.” Indeed, a recent study revealed how costly drug-resistant infections are, a problem that will remain front and center well after the pandemic is over. National healthcare costs associated with infections caused by six multidrug-resistant pathogens are more than $4.6 billion annually, reports the Centers for Disease Control and Prevention (CDC).

“The highest cost was seen in hospital-onset invasive infections, with attributable costs ranging from $30,998 ($25,272-$36,724) for methicillin-resistant Staphylococcus aureus to $74,306 ($20,377-$128,235) for carbapenem-resistant Acinetobacter,” the CDC and fellow researchers found.1

Whether it is drug-resistant infections or an emerging pandemic, money spent on preparation and prevention is cost-effective, says Neil Clancy, MD, chief of infectious diseases at the VA Pittsburgh Health Care System.

A member of the Infectious Diseases Society of America, Clancy was not part of the CDC study on infection costs.

“If you have an infectious problem whether it is a virus like SARS-CoV-2 or a new resistant bacterium once into an environment, the costs in terms of lives and economically, can accelerate really quickly, he says. “The upfront investments to try to do what we can to limit these can be relatively trivial compared to what they cost after the fact.”

The rapidly developed COVID-19 vaccines were the culmination of investments in research after the original severe acute respiratory syndrome (SARS) outbreak in 2002-2003, Clancy adds.

“The fact that they were able to turn around a coronavirus vaccine so quickly was because they weren’t starting from scratch in March of 2020,” he says. “If a problem emerges, then the work and investment you put in over time pays off many times over.”

Could Have Been Worse

Although the pandemic vaccines largely have been a success story, other aspects of the initial national response were plagued by testing problems, personal protective equipment shortages, mask compliance, and mixed (and sometimes contradictory) public health messages in a politicized election year. Moreover, there is an emerging consensus that even scientists underestimated the global threat the pandemic coronavirus ultimately would pose.

The warnings were there, in a series of outbreaks and epidemics, and even one flu pandemic, in the 21st century. These include the original SARS (2002-2003) and the largest outbreak of Ebola virus in history (2014-2016). Other outbreaks of novel viruses during this period include yet another coronavirus, Middle East Respiratory Syndrome (MERS) (2012-present). Having emerged in 2012, MERS still is circulating, primarily in Saudi Arabia in an animal reservoir of dromedary camels ubiquitous in the country. Finally, there was a full-blown influenza pandemic in 2009. It was not a devastatingly virulent strain of H1N1 influenza in 2009, but it was highly transmissible and there was no immediately available vaccine.

As it circulated the globe, it infected a staggering 1 billion people, suggesting that some future antigenic shift of influenza could include the high-virulence code that virus was lacking genetically. Although not considered as virulent as other flu stains, the CDC estimates mortality in the range of 151,700 to 575,400 people.2

Indeed, it is somewhat sobering to realize that as bad as the COVID-19 pandemic has been, it could have been worse. For example, for all the legitimate concern expressed about the emerging variants of SARS-CoV-2, other viruses are much more mutable than the pandemic coronavirus.

“We are lucky that SARS-CoV-2 is not that variable a virus compared to influenza, and certainly (human immunodeficiency virus). But it does vary, and you will see more and more [variants] over time as more people are infected,” John Moore, PhD, a professor of microbiology and immunology at Cornell University said in a recent interview.3

While emphasizing she is not downplaying the pandemic, Pettis says that, from an infection control standpoint, a pathogen that was harder to kill in the environment would raise the stakes considerably.

“[SARS-CoV-2] is incredibly easy to kill in the environment you look at it and it dies,” she says. “In terms of the germ causing it, it could have been a whole lot worse. Let’s hope this is not a dress rehearsal for an even worse pandemic.”

There remain concerns, for example, that some version of avian influenza will jump to humans, triggering the recurrent scenario where a zoonotic pathogen mutates and begins transmitting in a population with no existing immunity.

“It could be an avian flu that has a high mortality rate,” Pettis says. “Or it could be ‘organism x’ that we can’t even imagine. It’s so important as we move through this and see the light at the end of the tunnel with this pandemic, that we strategize how to close the gaps that have been identified. That is really imperative.”

The Tragedy in Nursing Homes

There is no bigger gap than nursing homes, which have lost more than 172,000 residents to COVID-19 about a third of all U.S. deaths in the pandemic.4 In the absence of federal regulation, typically nursing homes assign infection prevention as a part-time function to an employee who already has a lot of responsibilities, Pettis says.

“One of the biggest tragedies out of all of this is what has happened to our elderly in this country,” she says. “It has really brought this to light, and one of the main shortcomings is to have no one in nursing homes who are experts in infection prevention and can really devote time to it.”

New York nursing homes have particularly been hit hard, with a recent state attorney general report finding egregious lapses in infection control and thousands of deaths that were not properly reported. In a call to action, APIC urged New York to require a full-time IP in every state long-term care facility.

“We feel that the timing is right, given what New York State has experienced with nursing homes,” she says. “If not now when? We can no longer ignore the need for excellent infection prevention and protection for our elderly in long-term care.”

APIC calls on New York State nursing homes to require a minimum of one full-time trained and certified IP in each nursing home. Seeking transparency, APIC also said health departments should collect and publicly report data on nursing home infection rates and the number of certified IPs.

The report by New York Attorney General Letitia James found infection control lapses and errors in long-term care that include the following:5

  • Failing to properly isolate residents who tested positive for COVID-19.
  • Failing to adequately screen or test employees for COVID-19.
  • Demanding that sick employees continue to work and care for residents or face retaliation or termination.
  • Failing to train employees in infection control protocols.
  • Failing to obtain, fit, and train caregivers with PPE.

For example, infected patients transferred to one long-term facility after a hospital stay were supposed to be placed in a separate COVID-19 unit, the report notes.

“[They] were, in fact, scattered throughout the facility despite available beds in the COVID-19 unit,” James’ report states. “This situation was allegedly resolved only after someone at the facility learned of an impending [health department] infection control visit scheduled for the next day, before which those residents were hurriedly transferred to the appropriate designated unit.”

Regarding employee screening, the report found that workers at another nursing home were bypassing symptom checks by coming through a back entrance.

“Preexisting insufficient staffing levels in many nursing homes put residents at increased risk of harm during the COVID-19 pandemic,” the investigation revealed. “As nursing home resident and staff COVID-19 infections rose during the initial wave of the pandemic, staffing absences increased at many nursing homes. As a result, preexisting low staffing levels decreased further to especially dangerous levels in some homes, even as the need for care increased due to the need to comply with COVID-19 infection control protocols and the loss of assistance from family visitors.”

LTC Staff Refusing Vaccine

Compounding such problems nationally is the recent report that 62.5% of staff at thousands of skilled nursing facilities have turned down COVID-19 vaccine.6 (See “The Struggle to Immunize Long-Term Care Staff.”)

In contrast, an APIC survey found that 85% of IPs who have been offered the COVID-19 vaccine have received it.7 Another 2% had an appointment to take it soon, and 5% said they intend to get the vaccine at a later time. The APIC survey, conducted January 20-25, 2021, netted 1,598 respondents. Of those, 1,497 (94%) said they have been offered the vaccine.

“IPs are in a unique position to influence and encourage vaccine uptake among other healthcare professionals and the public,” Pettis says. “If we think the vaccines are safe, we believe others should feel assured.”

REFERENCES

  1. Nelson RE, Hatfield KM, Wolford H, et al. National estimates of healthcare costs associated with multidrug-resistant bacterial infections among hospitalized patients in the United States. Clin Infect Dis 2021;72:S17-S26.
  2. Centers for Disease Control and Prevention. 2009 H1N1 pandemic (H1N1pdm09 virus). Last reviewed June 11, 2019. https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html
  3. JAMA Network. Coronavirus variants. YouTube. Published March 4, 2021. https://www.youtube.com/watch?v=R8aYNc0mePY
  4. The New York Times. More than one-third of U.S. coronavirus deaths are linked to nursing homes. Updated Feb. 26, 2021. https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html
  5. New York State Office of the Attorney General Letitia James. Nursing Home Response to COVID-19 Pandemic. Updated Jan. 30, 2021. https://ag.ny.gov/sites/default/files/2021-nursinghomesreport.pdf
  6. Gharpure R, Guo A, Bishnoi CK, et al. Early COVID-19 first-dose vaccination coverage among residents and staff members of skilled nursing facilities participating in the Pharmacy Partnership for Long-Term Care Program — United States, December 2020-January 2021. MMWR Morb Mortal Wkly Rep 2021;70:178-182.
  7. Association for Professionals in Infection Control and Epidemiology. National survey shows high COVID-19 vaccine acceptance among infection preventionists. Feb. 10, 2021. https://apic.org/news/national-survey-shows-high-covid-19-vaccine-acceptance-among-infection-preventionists/