HIC at 50: Looking Back, Looking Forward in a Time of Pandemic
A succession of threats, but the fundamental things apply
Gary Evans
February 1, 2023 12 minutes read
By Gary Evans, Medical Writer
In Hospital Infection Control & Prevention’s (HIC) 50th year of publication, we find ourselves in a perilous world, where the emergence of viral infections and antibiotic-resistant organisms seems to be accelerating.
Infection preventionists (IPs) have weathered the storm of the COVID-19 pandemic for three years and are trying to rebuild and strengthen a field that has a proven efficacy in preventing healthcare-associated infections (HAIs) and protecting patients.
In addition, the Association for Professionals in Infection Control and Epidemiology (APIC) is preparing its members for emerging and re-emerging infections, says Pat Jackson, RN, BSN, CIC, APIC president.
“The reality of our future is that there are likely going to be other pandemics and emerging infections for all the reasons we have talked about — infringing on animal habitats, climate change,” she says. “We want to make sure that we can respond nimbly, so we have formed an emerging infectious disease taskforce. We are creating some just-in-time playbooks to help our members with tools to respond to infections like measles, highly pathogenic avian influenza, Ebola, and polio.”
Of course, preventing HAIs still is the prime mission, but the surge of COVID-19 patients in 2020 deluged many infection control programs, wiping out years of steady progress. For example, national surveillance by the Centers for Disease Control and Prevention (CDC) revealed that central line-associated bloodstream infections — which have a mortality rate in the 20% range — were about 47% higher in 2020 compared to 2019.1
“The pandemic was very hard for IPs,” Jackson says. “The guidance was changing a lot, and it was a very stressful. Certainly, in my 29 years of doing this, I’ve never even come close to being as stressed. We are trying to rejuvenate our members and attract new people into the field.”
Going forward, hospital infection prevention must be prepared to stop this recurrence: a high census of incoming patients with a novel infection disrupts traditional surveillance and control activities, leading to an increase in HAIs in the resulting chaos. However, the strengthened ties with public health, if they can be maintained, should help the hospital infection control response in the next emergence of a novel pathogen, says Monica Gandhi, MD, a human immunodeficiency virus (HIV) specialist at UC San Francisco.
“There is more communication and cooperation between these entities, and that will only strengthen our response for the next pandemic,” she says. “We learned a lot about the best infection control interventions during COVID-19 through this cooperation, and we should apply them to the next pandemic. For instance, paradoxically, masks work but mask mandates do not. Imposing mask mandates on the public does not have the weight of evidence behind it. On the other hand, ventilation has emerged as one of the most important non-pharmaceutical intervention strategies for COVID-19.”
The Roots of Infection Control and Prevention
The public realization that hospitalized patients could be infected with something they were not admitted with began in the 1950s with widespread outbreaks of penicillin-resistant Staphylococcus aureus. The development of antibiotic alternatives to penicillin quelled S. aureus infections in the 1960s, but the seemingly endless battle with what now is deemed methicillin-resistant S. aureus continues to this day.
Momentum was building for the creation of hospital infection control programs, and the nascent field was solidified by several key developments in the 1970s. In 1974, when HIC was founded, infection control programs were being set up in large part because of the grassroots efforts of pioneers in the field, primarily a group of nurses who formed APIC in 1972. The Joint Commission followed in 1976, creating standards that required accredited hospitals to track and control infections.
At the same time, the CDC was forming infection surveillance systems and had begun a landmark research project to measure the efficacy of hospital infection control programs. The Study on the Efficacy of Nosocomial Infection Control (SENIC Project), was directed by Robert Haley, MD, at the CDC beginning in 1974.2
“SENIC really solidified the idea that hospitals need an infection control program, and that programs must include a balanced plan of both surveillance and control strategies,” says Haley, now a distinguished teaching professor at Texas Southwest Medical Center in Dallas. “You need to be staying aware by measuring infection rates and then implementing control strategies.”
In a representative sample of U.S. hospitals, Haley and colleagues found that the establishment of infection surveillance and control programs was strongly associated with reductions in rates of urinary tract infection, surgical wound infection, pneumonia, and bacteremia.
The basic principles still apply: If you can find the infection and measure it over time, you can control it. However, the CDC faced early problems convincing hospitals they needed to track what then were called “nosocomial” infections, an intentionally arcane name that was thought to be less stigmatizing.
“When we started SENIC, fewer than half of hospitals had any kind of infection control program and were not even focused on the problem,” Haley tells HIC. “The CDC had recommended that all hospitals have such programs, and it stood in the balance whether they would or not. Most of the hospitals that didn’t have programs thought it was a waste of time, personnel, and money. It wasn’t an issue.”
Early anecdotal evidence suggested HAIs were occurring but were not being addressed at many hospitals, he recalls. When a CDC team showed up to assist in a hospital outbreak, they found many clinicians had not really grasped the concept of finding, measuring, and controlling infection.
“Once we got them set up with surveillance — which was kind of a hallowed word at the time at the CDC — they would measure the infection rates and show that to the doctors and nurses,” Haley says. “They were shocked — they had no idea it was happening — then would say, ‘We’ve got to get control of this.’ They would then address the problem aggressively and bring it under control.”
Although this early evidence pointed to a national problem, the CDC needed hard efficacy data to really make the case for infection control programs in all hospitals.
“SENIC was undertaken to see if this was just anecdotal, something we were seeing due to some bias, or was it universal,” he recalls. “SENIC proved it was a universal phenomenon. If you have a group of people in an infection control program who are tasked with regularly maintaining awareness with surveillance and then using those [data] to intervene, that will minimize the problem. You can’t eliminate [HAIs] completely because some of these are unavoidable.”
The initial SENIC research found about one-third of HAIs could be prevented by having an infection control program in place. This preventability aspect has vacillated over the years, with some saying HAIs largely are the price of conducting increasingly invasive procedures on high-acuity patients. Eventually, the default position shifted to the view that many of these infections are preventable, and there was substantial progress in reductions being made before the pandemic overwhelmed many hospitals in 2020.
In any case, the SENIC project got the Centers for Medicaid and Medicare Services (CMS) involved, and infection control became a regulatory requirement, Haley says, noting that the CMS was “aggressive” early on in getting hospitals to address HAIs.
Although the pandemic led to a rise in infection rates at many hospitals, Haley underscores that the basic principles of infection control proved sound when they could be fully applied. For example, while the primary risk of transmission initially was incoming patients, IPs at several hospitals found that healthcare workers were infecting each other when they removed their masks and took breaks together. “They found transmission wasn’t from the patients, it was in the break rooms,” Haley says. “That is right out of the old playbook — infection control programs identify the risk, give feedback to employees, and modify the risk factors.”
The Harbinger
The event that changed everything in these early days was the CDC report in 1981 that the “occurrence of pneumocystosis in these five previously healthy individuals without a clinically apparent underlying immunodeficiency is unusual.”3 The HIV/acquired immunodeficiency syndrome (AIDS) epidemic had begun. About 40 million people have died of HIV/AIDS since that first report of five hospitalized men in Los Angeles.
There was much fear and stigma, as even healthcare workers were wary of AIDS patients until the routes of transmission were better determined. A young IP at the time, former APIC president Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, recalled the scene. “The panic in healthcare personnel was unlike anything I had ever seen” she told HIC. “It was comparable to the fear of Ebola. It totally changed my career and all the careers of IPs moving forward. We didn’t really know what the route of transmission was originally. We could only presume what kind of precautions we needed. There was so much fear.”
The CDC issued universal (now standard) precautions in response to HIV/AIDS, essentially advising barrier precautions for potential contact with any bodily substance.
Although there are many long-term survivors with access to effective medications that have suppressed HIV enough for them to lead fairly normal lives, others die untreated in a tragedy that has continued. There are about 38 million people living with HIV worldwide, and only about 26 million of them have access to antiviral therapy that first was available in 1996.
That leaves about 12 million people with no access to HIV medication, many of them living in sub-Saharan Africa. Given their untreated HIV and immunodeficient state, an infection with SARS-CoV-2 could linger and mutate, a theory advanced by some when the Omicron variant was discovered in South Africa in 2021.
“I think the HIV epidemic, in a way, was a harbinger of what happened during COVID-19, which was a failure to distribute biomedical advances equitably,” Gandhi says
There was some discussion in the Biden administration in 2021 whether the COVID-19 vaccine patents should be waived so other countries could manufacture their own doses rather than await shipments, she notes. For the record, then top advisor Anthony Fauci, MD, and others were for it, but other advisors and political officials successfully argued “that waiving the patents could backfire, including by handing intellectual property to international rivals [and by creating competition] for scarce vaccine ingredients and expertise.”4
India was among the countries appealing for the patent waiver, as it was being devastated by a surge of the Delta variant. “Heartbreaking scenes in the spring of 2021 from overflowing hospitals turning away dying patients and crematorium pyres burning all night in India were actively playing out against debates on how fast wealthy countries with rapid vaccine rollouts will be getting back to normal life,” Gandhi says. “This is very reminiscent of what happened in HIV, where rigid adherence to patent laws directly led to millions of lives lost to HIV/AIDS in Sub-Saharan Africa, despite the development of highly effective antiretroviral therapies by 1996.”
We now know that HIV can be traced back to a specific chimpanzee reservoir, crossing into humans as they hunted and butchered the animals in central Africa. Some of the same factors that led to the rise of HIV can be seen in the panoply of emerging infections that followed. (See “Timeline: Key Stories and Topics in HIC This Century.”)
“We face a world at risk for more epidemic pathogens due to our treatment of animals, climate change, a global loss in trust in public health, setbacks in routine childhood vaccinations, and declines in overall vaccine confidence post-COVID pandemic,” Gandhi says.5 “I think we have to increase trust in public health and in vaccines in order to effectively prevent the next pandemic.”
The United States and other nations with vaccines failed a “moral test” for not doing more to get people immunized in poor countries, since a pandemic is a global phenomenon that requires a global reaction, she says.
“Although COVID-19 vaccines saved 20 million lives during the first year of their rollout, millions more lives would have been saved in low- and middle-income countries if we had greater global vaccine equity.”
Predecessor of COVID-19
When severe acute respiratory syndrome (SARS) emerged from China and spread globally in 2002-2003, the United States had only eight cases, but nearby Toronto, Canada, was hit very hard. (See “Under-Resourced Public Health Leaves Healthcare Vulnerable.”)
SARS-CoV-1 spread out globally, infecting 8,098 people and resulting in 774 deaths before it faded away with a final few cases in 2004.
The SARS-CoV-1 experience increased infection control funding and certainly informed the COVID-19 response in Toronto hospitals, says Allison McGeer, MD, an infectious disease specialist in the Sinai Health System and a professor at the University of Toronto.
“The funding that went into infection prevention and control in acute care hospitals in Toronto made a huge difference to the ability to get through COVID,” she says. “Unfortunately, kind of the reverse happened in long-term care. But in acute care [post-SARS-CoV-1], there was a real strengthening of our infection prevention and control programs and better relationships with public health.”
That said, there are major epidemiologic and viral differences between these two coronaviruses, including the “serial interval,” which is the time from illness onset in the primary case to transmission to a secondary case.
“The differences between SARS-CoV-1 and SARS-CoV-2 have to do with the incubation period and the pattern of spread,” McGeer says. “We just got lucky with SARS-CoV-1, which had a serial interval of about nine days. We were detecting and identifying contacts in Toronto at 8.5 days — that’s how close we were. Just right at the edge of control of transmission.”
With a tighter window of four to six days, the serial interval for the current pandemic coronavirus has no margin for error. Thus, the interventions effective against its predecessor have not worked as well against SARS-CoV-2.
“You just can’t really do a serial interval of four to six days,” she says. “Also, there wasn’t a lot of asymptomatic infection with SARS-CoV-1. People really didn’t start to transmit significantly until they got sick. And, so, it was possible to eradicate SARS-CoV-1, which is what we did.”
Although SARS-CoV-1 proved to be only a very close shot over the bow for U.S. IPs, they remained vigilant, and it set the tone for the series of epidemic and pandemic pathogens that followed in the 21st century. These included H1N1 pandemic influenza A, Middle East respiratory syndrome (MERS), and Ebola.
McGeer concurs that there are human factors driving infectious disease emergence but is somewhat skeptical about the inevitability that this issue has taken on.
“I do think there are a bunch of things that are making things worse, like globalization, the destruction of habitat, and the increasing exposure of humans and animals,” she says. “But look at MERS — 100 years ago, we may not even have known it existed. Ebola is complicated by changes in society. A big piece of Ebola, from my perspective, is the reaction to it. I think the agony in North America about Ebola is well in excess of the threat.”
The bottom line is that none of these infections are independent from human activity and are in some way uncontrollable and not understandable, McGeer says. “Really, it’s a little bit like cardiac disease, when we all started smoking like chimneys,” she says. “It’s a natural consequence of human activity in the world.”
New and Better Vaccines
If anything became clear in the COVID-19 pandemic it was that research into new and better vaccines may be the most important aspect of preparation for future emerging infections. In that regard, the line of research emerging on vaccines could prove critical in stopping the next pandemic early if there is immunization equity and a true global response, Gandhi says.
“Beyond surveillance for new pathogens and typical forms of outbreak control — isolation of an infected individual — our success in the next pandemic will be dependent on the rapid development of a vaccine, which is now likely,” she says. “The amazing progress in developing and approving COVID-19 vaccines within the same year the World Health Organization declared the virus a pandemic is unprecedented.”
Indeed, lines of research since SARS-CoV-1 in part enabled this, and vaccinologists argue that “if a systematic effort can be sustained, effective interventions for the majority of future pathogens can be developed.”6
In particular, the so-called “plug and play” capabilities of the messenger ribonucleic acid vaccine technology, which has shown efficacy against serious COVID-19 infections, may be able to be produced rapidly against the next emerging pathogen.
“For future pandemics, vaccines will be our first line of defense, and we now have the tools to develop and deploy them quickly,” Gandhi says. “Scientists should patiently explain the known safety of the mRNA vaccine technology, along with other vaccine platforms, and insist on global vaccine equity to combat a pandemic.”
Maximizing global vaccine production and equitable distribution must be the highest priority, she adds, even if innovative mechanisms of financing and licensing production are required.
REFERENCES
- Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: A summary of data reported to the National Healthcare Safety Network. Infect Control Hosp Epidemiol 2022;43:12-25.
- Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121:182-205.
- Centers for Disease Control (CDC). Pneumocystis pneumonia — Los Angeles. MMWR Morb Mortal Wkly Rep 1981;30:250-252.
- Diamond D, Stein J. White House is split over how to vaccinate the world. The Washington Post. Published April 30, 2021. https://www.washingtonpost.com/health/2021/04/30/biden-administration-debates-waiving-vaccine-patents/
- Carlson CJ, Albery GF, Merow C, et al. Climate change increases cross-species viral transmission risk. Nature 2022;607:555-562.
- Graham BS, Sullivan NJ. Emerging viral diseases from a vaccinology perspective: Preparing for the next pandemic. Nat Immunol 2018;19:20-28.
In Hospital Infection Control & Prevention's 50th year of publication, we find ourselves in a perilous world, where the emergence of viral infections and antibiotic-resistant organisms seems to be accelerating.
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