By Gary Evans, Medical Writer
Inundated with criticism from healthcare workers, highly vulnerable patients, and those with long COVID, advisors to the Centers for Disease Control and Prevention (CDC) must make a Solomonic decision. At a time when the CDC is trying to simplify and normalize community precautions for SARS-CoV-2, initial efforts to do so in the hospital have backfired spectacularly.
Citing pushback from such stakeholder groups, the CDC rejected new draft recommendations for air transmission precautions by its Healthcare Infection Control Practices Advisory Committee (HICPAC) on Jan. 23, 2024. The situation remains in limbo, with HICPAC next regularly scheduled meetings in 2024 on June 6-7, Aug. 22, and Nov 14-15. At the top of the HICPAC list, there is a meeting with no date listed, designated To Be Determined.
“Should N95 respirators be recommended for all pathogens that spread by the air?” the CDC asked in a letter to HICPAC. “Additional subject matter experts will be added to the workgroup to assist with preparing responses.”1
In draft guidelines approved Nov. 2, 2023, HICPAC dropped the controversial droplet/airborne dichotomy in favor of a continuum approach with three tiers of air precautions dubbed routine, special, and extended.2 It was kicked back by the CDC in the January letter, which also asked the committee, “Should source control be recommended at all times in healthcare facilities?” So-called “universal masking” was previously dropped by the CDC, but many hospitals reinstated it at the height of the 2023-2024 respiratory illness season.
The aforementioned question about universal N95 use was asked regarding draft Routine Air Precautions, which recommend healthcare workers wear a surgical mask. The other two tiers of air precautions in the draft call for N95 or higher-level respirators to protect healthcare workers and patients. The draft guidelines did not assign specific pathogens to the three tiers, which opened speculation and fear about where COVID-19 would be placed.
“We feel these questions, largely related to when masks and respirators (such as N-95) are recommended in healthcare settings, reflect concerns or areas of confusion that continue to be raised by stakeholders in response to the draft guideline,” the CDC stated.
More Pages Than Crime and Punishment
In addition to oral comments by the public during the Nov. 1-2, 2023, meeting, the HICPAC minutes include more than 600 pages of written comments, some of them posted by healthcare workers.3
C.D. McNaughton, MD, PhD, MPH, is an adjunct associate professor of emergency medicine at Vanderbilt University Medical Center. “I have cared for many COVID patients, and because I have maintained airborne precautions since March 2020, I have yet to be infected with SARS-CoV-2,” she stated in comments to HICPAC. “I watched with horror in the early stages of the pandemic as old, unfounded ‘droplet’ dogma was pushed out and then reinforced, clearly driven by concerns regarding the cost and access to N95s and other appropriate PPE [personal protective equipment]. Those of us who continued to work clinically despite these conditions did so while quietly changing our infection control practices, often at considerable personal financial cost. Since January 2020, it has been clear that SARS-CoV-2 spreads through the air, in the same way that smoke spreads. We have known — and now have a veritable mountain of evidence to further back up assertions based on well-known and well-documented experiences from SARS-1 — that N95s are necessary for healthcare workers, regardless of vaccination status. Ideally, healthcare workers should have access to and be encouraged to use reusable elastomeric [respirators] that provide N95 or better protection. This provides the minimum appropriate level of safety while reducing waste and has been shown repeatedly to be a cost-effective strategy.”
Janice Prudhomme, DO, MPH, is an occupational and environmental medicine physician in California. “Fortunately, our [state] Aerosol Transmissible Diseases (ATD) regulation, CCR Title 8 Section 5199 (5199), calls for specific protections for novel viruses, so we had a strong foundation for how best to protect against this novel viral agent,” she commented. “But CDC recommendations carry tremendous weight and should align and be defensible. The draft proposal passed by HICPAC does not support the requirements embedded in California’s ATD standard. This is concerning. Cal/OSHA went through a lengthy process when promulgating this regulation, incorporating input from multiple experts and stakeholders from all sides of this issue to ensure that appropriate provisions were included. I am sincerely perplexed and deeply concerned that HICPAC has refused to acknowledge the process and other specific concerns raised by stakeholders and experts, including industrial hygienists, aerosol scientists, state and federal public health officials and advocates, healthcare workers, patients, and families advocating for vulnerable family members.”
Laura Fochtmann, MD, is a SUNY Distinguished Service Professor at Stony Brook University. “With the continued propagation of COVID, including intermittent waves and ongoing evolution of the virus, it is imperative to require greater attention to ventilation and methods to reduce transmission of all airborne infections,” she commented. “Healthcare workers should be able to go to work feeling reasonably confident that their safety is not being intentionally jeopardized by regulatory agencies.”
Zenei Triunfo-Cortez, RN, commented on behalf of National Nurses United (NNU), the largest labor union for registered nurses in the United States. “HICPAC is missing the perspective of frontline nurses, other healthcare workers, and our unions,” she told the committee. “During the COVID pandemic, nurses saw too many patients and colleagues become infected, get sick, and even die because of inadequate infection prevention. Too many continue to experience the impacts of long COVID, and now extensive research has documented what nurses have advocated for since the beginning of the COVID pandemic. We need a multiple measures approach that combines ventilation; PPE, including respiratory protection anytime we are exposed to an aerosol-transmissible disease like COVID; screening and isolation; exposure notification; and other measures.”
Community Changes Draw Ire
While HICPAC is weighing such concerns, on March 1, the CDC revised community guidelines for COVID-19. The CDC guidelines suggest returning to normal activities if symptoms are improving overall, and no fever is present without the use of fever-reducing medication for at least 24 hours.4
NNU condemned the CDC recommendations, saying, “slashing the COVID isolation guidance from five days to potentially just 24 hours based on the presence of fever ignores the available scientific evidence that people with COVID infections often remain infectious well beyond five days.”5
“We are deeply disheartened to once again see the CDC weakening protections for public health, which will mean more transmission, illness, hospitalizations, and cases of long COVID,” stated Jean Ross, RN, president of the NNU. “We must protect nurses’ health and safety so that they can continue to care for their patients, especially due to the staffing crisis that many hospitals face.”
The move “reflects the progress we have made in protecting against severe illness from COVID-19,” Mandy Cohen, MD, director of the CDC, said in a statement. “However, we still must use the common-sense solutions we know work to protect ourselves and others from serious illness from respiratory viruses — this includes vaccination, treatment, and staying home when we get sick.”6
NNU tried to head off the CDC in a Feb. 23 letter to Cohen.7 The letter cited research that concluded that a “recommendation to end isolation based solely on the presence of improving symptoms risks releasing culture-positive, potentially infectious individuals prematurely.”8
In a frequently asked questions section of the guidelines, the CDC said the previous recommendation for a minimum isolation period of five days plus a period of post-isolation precautions was created during the public health emergency with lower population immunity and fewer tools to prevent serious outcomes.
“It is important to note that the guidance doesn’t end with staying home and away from others when sick,” the CDC stated. “The guidance encourages added precaution over the next five days after time at home, away from others, is over. Since some people remain contagious beyond the ‘stay-at-home’ period, a period of added precaution using prevention strategies, such as taking more steps for cleaner air, enhancing hygiene practices, wearing a well-fitting mask, keeping a distance from others, and/or getting tested for respiratory viruses can lower the chance of spreading respiratory viruses to others.”9
The Feb. 23 NNU letter to Cohen cites the union’s ninth COVID-19 survey, released in January 2024, which found 43.7% of nurses reported being infected two or more times. There is accumulating evidence that the more times someone is infected with SARS-CoV-2, the cumulative risk of developing long COVID, a post-infection condition with multiple symptoms that can be debilitating, increases.
“After recovery from initial infection, a majority of RNs reported ongoing symptoms, including tiredness or fatigue, memory or concentration difficulties, joint or muscle pain, headaches or migraines, difficulty breathing or shortness of breath,” the NNU stated.
Overall, 28% of the nurses reported symptoms lasting one year, the union reported. Moreover, the NNU accused the CDC of not prioritizing the prevention of long COVID.
“Long COVID can develop even after initial mild or asymptomatic infections; in fact, a large multicountry study reported that 90% of people living with long COVID had an initial mild infection,”the NNU stated in the letter.10 “While the CDC recognizes that long COVID is a condition, it has not adequately prioritized prevention of long COVID in crafting public health and infection prevention guidance. Research indicates that, at best, vaccines and antiviral medications offer only partial reduction in long COVID risk and that reinfections with SARS-CoV-2 significantly increase the risk of developing long COVID.11,12 This means that the only way to prevent long COVID is to prevent infections.”
The CDC’s revised respiratory guidelines are aimed at the community, and there were no changes in recommendations for healthcare settings. In adopting a “unified approach” to respiratory pathogens — including SARS-CoV-2 — the CDC stressed the following in an executive summary of the document.13
“Due in part to the high degree of population immunity, there are now fewer hospitalizations and deaths due to COVID-19. Weekly hospital admissions for COVID-19 have decreased by more than 75% and deaths by more than 90% compared to January 2022, the peak of the initial omicron wave. Protective tools, like vaccines and treatments, that decrease the risk of COVID-19 disease — particularly severe disease — are widely available. Complications like multisystem inflammatory syndrome in children are now also less common, and prevalence of long COVID also appears to be decreasing,” the CDC stated.
The CDC emphasized “active” recommendations on core prevention strategies that include:
- Staying up to date with vaccinations for COVID-19, influenza, and respiratory syncytial virus if eligible;
- Practicing good hygiene by covering coughs and sneezes, washing or sanitizing hands often, and cleaning frequently touched surfaces;
- Taking steps for cleaner air, such as bringing in more fresh outside air, purifying indoor air, or gathering outdoors.
REFERENCES
- Kallen A. CDC letter to HICPAC Workgroup. Jan. 23, 2024. https://www.cdc.gov/hicpac/pdf...
- Centers for Disease Control and Prevention. Draft 2024 Guideline to Prevent Transmission of Pathogens in Healthcare Settings. October 2023. https://www.cdc.gov/hicpac/pdf...
- Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee Record of the proceedings. Nov. 2-3, 2023. https://www.cdc.gov/hicpac/pdf...
- Centers for Disease Control and Prevention. Respiratory virus guidance. Last reviewed March 1, 2024. https://www.cdc.gov/respirator...
- National Nurses United. NNU condemns CDC’s decision to shorten the five-day isolation guidance for Covid-19. March 6, 2024. https://www.nationalnursesunit...
- Centers for Disease Control and Prevention. CDC updates and simplifies respiratory virus recommendations. March 1, 2024. https://www.cdc.gov/media/rele...
- National Nurses United. Letter to Dr. Mandy Cohen. Feb. 23, 2024. https://www.nationalnursesunit...
- Cosimi LA, Kelly C, Esposito S, et al. Duration of symptoms and association with positive home rapid antigen test results after infection with SARS-CoV-2. JAMA Netw Open 2022;5:e2225331.
- Centers for Disease Control and Prevention. Respiratory virus guidance update FAQs. Last reviewed March 25, 2024. https://www.cdc.gov/respirator...
- Global Burden of Disease Long COVID Collaborators, et al. Estimated global proportions of individuals with persistent fatigue, cognitive, and respiratory symptom clusters following symptomatic COVID-19 in 2020 and 2021. JAMA 2022;328:1604-1615.
- Al-Aly Z, Bowe B, Xie Y. Long COVID after breakthrough SARS-CoV-2 infection. Nat Med 2022;28:1461-1467.
- Bowe B, Xie Y, Al-Aly Z. Acute and postacute sequelae associated with SARS-CoV-2 reinfection. Nat Med 2022;28:2398-2405.
- Centers for Disease Control and Prevention. Background for CDC’s updated respiratory virus guidance. Last reviewed March 1, 2024. https://www.cdc.gov/respirator...
Inundated with criticism from healthcare workers, highly vulnerable patients, and those with long COVID, advisors to the CDC must make a Solomonic decision. At a time when the CDC is trying to simplify and normalize community precautions for SARS-CoV-2, initial efforts to do so in the hospital have backfired spectacularly.
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