Nurses, patients, and professional groups are pushing for more rigorous infection control standards from the CDC following a preview of proposed changes to its isolation precaution guidelines and an advisory group meeting this week during which a vote on the changes was postponed.
Opponents have said the changes, detailed in a presentation in June, are based on a flawed evidence review and omit key infection control tools. Some have called attention to a CDC approval process that they say is sometimes inscrutable to the public.
The agency last revised the guidelines, “Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings,” in 2007, and now the group that advises the CDC on infection control practices — the Healthcare Infection Control Practices Advisory Committee (HICPAC) — is drafting proposed 2024 changes for CDC approval.
“While the CDC is updating their language, they’re not actually updating their precautions in ways that they should based on the science,” Jane Thomason, RN, MSPH, CIH, an industrial hygienist for National Nurses United (NNU), told MedPage Today. NNU has taken a strong stance against the HICPAC recommendations and called for more robust infection protections in healthcare.
NNU and others say the proposed guidelines weaken existing infection control standards, privileging employer and hospital bottom lines over employee and patient safety. “The guidance that they’re updating applies to every infectious disease in healthcare settings, from tuberculosis, to measles, to influenza, to MDROs [multidrug-resistant organisms], to COVID. All of it,” said Thomason.
“If they take that approach, it enables employers … to prioritize costs over protections, and that will lead directly to preventable infections amongst healthcare workers and patients,” she added.
Notably, at least six of nine currently listed HICPAC voting members are affiliated with major hospitals or healthcare systems, including Ascension, Genesis Healthcare, Mass General Brigham, and Beth Israel Lahey Health.
The Shadow of COVID Crisis Standards
At the height of the pandemic, the CDC adopted a set of guidelines including “contingency” and “crisis capacity” strategies meant to address staffing shortages, which let healthcare facilities and employers implement varying levels of COVID-19 infection precautions based on self-assessment and staffing needs, including “as a last resort,” allowing healthcare personnel with active COVID infections to work anyway. The guidelines recognized the use of face masks, including surgical masks, as acceptable even in these cases.
Thomason said this gave hospitals and employers the discretion to provide only the bare minimum of protections. In some instances, she said, nurses caring for COVID-positive patients were told they weren’t allowed to access existing N95s.
NNU and other public health professionals have drawn parallels between the CDC’s pandemic-era protocols and the new proposed guidelines. A letter sent to CDC Director Mandy Cohen, MD, MPH, and signed by hundreds of public and occupational health experts, noted that the proposed change “allows healthcare employers undefined broad discretion in creating and implementing their infection control and prevention plans,” based in part on staffing levels, patient populations, and a distinction between “pandemic-phase” and “seasonal” pathogens.
The guidelines, experts wrote in the letter, should be “clear and explicit on the precautions that are needed in situations where infectious pathogens are or may be present,” since transmission modes are the same regardless of timing.
Evidence Review Opposition
At the heart of the backlash lies a review of evidence on masking and other forms of personal protective equipment (PPE), detailed in part in the June presentation. In the review of 27 studies comparing N95 respirators to surgical masks, the HICPAC work group concluded that there is “no difference between N95s and surgical masks” in protecting against viral respiratory infections. They also conducted a review of “adverse events” of masking with both.
The letter to Cohen stated that the review “omitt[ed] other applicable data and studies,” including occupational and lab studies, drew conclusions despite study flaws (like improper mask use), and contrasted it with the CDC’s own respirator certification system through the National Institute for Occupational Safety and Health (NIOSH), which they wrote “is based on sound science and research.”
And despite new language that delineates both “air” and “touch” transmission, the letter asserted that “the draft recommendations fail to reflect what has been confirmed about aerosol transmission by inhalation during the COVID-19 pandemic” and “continue to recommend use of surgical/medical masks, which do not provide respiratory protection against infectious aerosols.” Some of the most effective methods of infection control and prevention were given little to no airtime in HICPAC’s June presentation. Ventilation was not addressed, and the use of airborne infection isolation rooms was limited.
The letter asked that aerosol scientists, industrial hygienists, ventilation engineers, and respiratory protection experts be included in discussions about infection control in healthcare settings.
In a meeting on August 22 where the guidelines were previously slated for a vote by HICPAC, Sharon Wright, MD, MPH, a HICPAC member and chief infection prevention officer at Beth Israel Lahey Health in Cambridge, Massachusetts, said the vote would be postponed until the next meeting in November because quorum for the meeting was not met. In a public comment portion of the meeting, patients, members of advocacy groups, and researchers voiced strong opposition to the proposed measures.
One public commenter named Liv Grace said that as a physically disabled and immunocompromised patient, they (Grace uses they/them pronouns) caught RSV and COVID at healthcare facilities after medical professionals refused to wear N95 masks during treatment. They called for a new evidence review, and said, “I am literally begging for something to be done.”
Another public commenter, Shea O’Neil, identified herself as a volunteer for the World Health Network and a parent to a son who is high risk and has disability. “It is really clear in wildfire smoke messaging that you wear N95 respirator masks — that surgical cloth and dust masks aren’t going to cut it. You’d never, in peak wildfire times … [say], ‘Wear surgicals for now, or actually, wildfires typically aren’t all year long, so we will change the guidance to surgical instead,'” she said. “These things do not make sense, do not protect people, not for fires, not for COVID-19 — both aerosols.”
A Murky Approval Process?
Kevin Kavanagh, MD, of Health Watch USA, a patient advocacy and research organization, and co-authors wrote in an article for Infection Control Today that “the process of recommendation formulation is flawed and lacks transparency,” citing HICPAC committee votes held before public comment and meeting presentations not publicly posted.
In a public comment, a representative from the California Division of Occupational Safety and Health said repeated requests for a full draft of the proposed guidelines and previous meeting minutes were denied.
During the meeting, HICPAC detailed their approval process for the guidelines, which included the HICPAC Isolation Precautions work group, two alternating reviews and votes each by HICPAC and the CDC, public comment in the Federal Register, and another “concurrence” clearance process.
Another commenter said her elderly father was left with permanent heart and lung damage from flu, and can’t risk getting COVID. “My dad and so many real people … don’t deserve to be abandoned, and their lives or long-term health put in serious risk just because they need a doctor, or a surgery, or are fighting cancer, or are elderly or immunocompromised, or work as a healthcare worker trying to help all of those people,” she said. “You are in a position to help all of them — to help all of us. Please help us.”
The Infectious Diseases Society of America declined to comment for this story. The Society for Healthcare Epidemiology of America did not respond by press time, and the Association for Professionals in Infection Control and Epidemiology wrote in an email to MedPage Today, “APIC is supportive of HICPAC’s process for updating their infection control guidelines and will await the final draft before commenting further.”