CDC weighs lowering infection protection even more heavily

Last June, an obscure federal advisory committee – the Advisory Committee on Infection Control in Healthcare to the Centers for Disease Control — first shocked many in the public health community by suggesting that the CDC might relax infection control practices in hospitals and health care facilities. Their most controversial recommendation was that surgical masks (also called “baggy blues”) could generally be replaced by the more protective N95 respirators. This is despite the fact that their own data shows that respirators provide superior protection.

Last fall, the CDC Advisory Committee sent their formal recommendations for overhauling infection control in health care facilities to the CDC Director (?). During the public comment period, there was significant resistance from patients and families. Concerns centered around people with weakened immune systems who were afraid to seek help because staff refused to mask up, people contracting infections in the hospital, and the issue of masking versus using N95 respirators. The CDC did not accept the HICPAC committee’s recommendations and sent them back to the committee for review comment on some questions regarding transmission and protection.

Months later, HICPAC met again, but they have not yet resolved the questions or concerns. These are the issues raised by the CDC.

Are surgical masks sufficient against airborne insects?

The first question was whether surgical masks or NIOSH approved N95 [or higher-level] Respirators should be used for airborne pathogens.

Erica Shenoy, MD, PhD, chief of infection control at Mass General Brigham, and a prominent voice on the committee that published against masking in healthcare argued that wearing an N95 mask during first patient contact was excessive. She told the committee that her practice is to enter a patient’s room (without a ventilator), ask a few questions and then determine the level of protection needed. I understand that because I sometimes did the same thing, but that was a long time ago, and back then I suspected my exposure would be minimal for that short period of time.

Times have changed. We are still in the middle of a COVID-19 pandemic – despite statements to the contrary – with a virus that we know is airborne. Furthermore, at least 10% of those infected develop a long bout of Covid-19, which often has life-changing consequences. These include autoimmune diseases, dysautonomia (autonomic dysfunction that causes fainting, heart rate and blood pressure fluctuations, and more), and chronic disabilities. Since we know that COVID is an airborne disease, it makes sense to wear an N95 mask during the first encounter with the patient and then lower precautions when COVID has been ruled out.

OSHA and NIOSH make that clear Surgical masks do not provide sufficient protection. OSHA says, “Surgical masks are not designed or certified to prevent the inhalation of small airborne contaminants.” NIOSH agreesconcluding that a surgical mask ‘is not considered respiratory protection’. Yet, with one exception, HICPAC concluded that they were equivalent.

Wearing an N95 mask will become even more important as bird flu becomes more widespread, especially if/when it mutates to become easily infected. spread from person to person. The highly pathogenic bird flu H5N1 can be spread by direct contact with animals or contaminated surfaces, by ingesting milk or by inhalation. Some data says so The transmission of HPAI H5N1 through the air is not very efficient. A major concern is that influenza viruses mutate easily and can acquire mutations that increase their ability to transmit through the air. The first case of bird flu without “immediate exposure to animals” occurred in September in Missouri. There is now a seriously ill teenager with respiratory problems due to bird flu in British Columbia, Canada.

Should healthcare workers be allowed to wear N95 masks?

Question 2 concerned the classification of pathogens and when different types of precautions would apply. Influenza is classified as ‘standard’ and droplet precautions in the 2007 guidelines, which are now under review. This would mean that a surgical mask would be sufficient.

There was much debate about whether a healthcare worker should have the flexibility and right to decide what level of respiratory protection they feel is necessary, based on their own health and that of family members they may expose to disease.

In the non-binding vote, almost all members supported the idea that health care workers should not be given that voluntary right.

Peg Seminario, director of occupational safety and health at the AFL-CIO from 1990 to 2019, told me that employers think they know best and that workers “don’t really know when to wear this respiratory protection.” upsets patients.” Seminario also said, “I think the decision-making reflects the continued dominance of the infectious disease professionals who represent the interests of health care hospitals,” who find the regulations overly burdensome.

“The reasons they gave were, quite frankly, very paternalistic,” is how Lisa Baum, an occupational health and safety specialist with the New York State Nurses Association, described this decision-making process. “They know what is needed in terms of protection, and if they determine that a respirator is not necessary, then a respirator is not necessary, period,” she added.

HICPAC membership does not meet its own requirements

The World Health Network has filed an additional complaint with the Inspector General of Health and Human Services because their committee should have fourteen members from diverse backgrounds, but that is not the case. Airborne transmission experts are still not voting members. In addition, many of the members are “from management positions in hospitals that benefit financially from the treatment of healthcare associated infections (HAIs)” with “perverse financial incentives that prioritize treatment over prevention.” The Isolation Precautions Guideline Workgroup “operates in secret, in violation of FACA’s requirements for transparency and public involvement.”

The fourth question concerns “source control,” or whether healthcare providers, patients and visitors should mask up in hospitals. HICPAC voted – again with one difference of opinion – that this should be left to local decision-making.

When and where can infected healthcare workers return to work?

Finally, there was discussion in the Working Group on Infection Control in Healthcare Personnel about when healthcare professionals recovering from flu or Covid can return to work. If they are working with people who are high risk, have weakened immune systems, or for other reasons, should there be special places and circumstances where they should not be assigned?

The committee recommended only a three-day work restriction from the onset of symptoms, even if HCW are still symptomatic, if they are improved and afebrile – this despite abundant data that many people shed the SARS-CoV2 virus for ten days or more . The healthcare provider must wear a surgical mask for seven days from the start. There were also no recommendations to restrict sick caregivers from caring for high-risk or immunocompromised patients because “this is not feasible.”

Baum was the lone dissenting voice on almost all of these questions. Notably, she was also the only committee member who was masked during the meeting. Baum was particularly disturbed by this decision because “many employers are pressuring health care workers to return to work after the number of days the CDC says employees should be excluded from work, even if the employee still feels too sick to work.”

Opposition to HICPAC recommendations

The death rate of hospital-acquired Covid dropped to about 10%but is still higher than community-acquired infection. So it makes sense that hospitals do what they can to prevent transmission within the hospital.

As I previously noted: “More than 900 experts in infectious diseases, public health, industrial hygiene, aerosol science and ventilation engineering signed a letter to Mandy CohenMD, the new CDC director, explaining how the new draft guidelines weaken protections for healthcare workers. They state: “Surgical masks cannot be recommended to protect healthcare workers from inhaling infectious aerosols.”

Additionally, as with previous HICPAC meetings, numerous public comments protested the committee’s decision. Many patients are now afraid to seek help because they know they risk becoming infected in the hospital or doctor’s office. One commenter, Amanda Finley Diggs (@rubyslippahs) is a Covid long-hauler, staunch advocate of masks and defender of vulnerable patients. She urged HICPAC: “Please take action and fulfill the public mandate in your own name: the Centers for Disease Control **and prevention.**”

Baum said, “There are still people at HICPAC who refuse to accept that this is happening on a widespread basis, that there is exposure and infection in health care settings.” Neither professional nor public concerns appear to have any influence on HICPAC’s decision-making process.

HICPAC also appears unaware that the NIH has resumed requiring masking in all patient care areas and testing for SARS-CoV-2, Influenza A, Influenza B, and Respiratory Syncytial Virus (RSV) in inpatients. Sonoma County also requires masks in all hospitals. But #HICPAC doesn’t think face masks are necessary.

Despite her frustrations, Baum emphasized, “We actually strongly support the CDC.” She added: “Our job is to push them to better protect patients and staff and to better follow the science, but we want them to have the opportunity to do so.”

Remark: You can submit comments until November 22, 2024. To advocate for isolation of infectious personnel + ASHRAE 241 Indoor Air Standard + N95s in healthcare, email HICPAC@cdc.gov.

Note: Dr. Shenoy and the CDC/HICPAC have not yet responded to a request for comment.