Part post-mortem, part vision quest, the Society for Healthcare Epidemiology of America (SHEA) 2023 meeting largely was a look at the pandemic past and what beasts are yet to come.
Nothing about the next pandemic is completely predictable, but there was a general sense that similar challenges will emerge: guideline changes and attendant communication problems, blatant disinformation, vaccine skepticism and hesitancy, and racial and ethnic inequities.
Focused research based on the projected issues in the next pandemic should begin in the near term, Michael Bell, MD, a leading medical epidemiologist at the Centers for Disease Control and Prevention (CDC), said at the SHEA meeting.
“The sorts of things that I think we can predict we’ll want to know include who’s affected and where are they, what is the range of severity, what are the risk factors for severity, do things work — whether they’re therapeutic or preventative,” he said. “Do the interventions to prevent transmission actually do what we hope they will do? Are there long-term impacts [of the infecting agent]?”
Concerning, for example, the issue of inequity in healthcare, preparations can be put in place to track patient populations and get a clear view from the onset.
“If we can have even some of that done in advance, we can be much more nimble during a crisis,” Bell said. “Intentionally include populations — rural and urban, racial ethnicity, socioeconomic categories. If we can prepopulate those fields in advance, we will be ready to collect that information and act appropriately. I think that would be incredibly helpful.”
Another SHEA speaker echoed this idea: Jasmine Marcelin, MD, FACP, FIDSA, said, “We can’t assess or change what we don’t measure. So, in order for us to disrupt these inequities in emerging infections, we first have to start with collecting this information. We’ve got to get the data.”
While COVID-19 revealed the link between social inequities and emerging infections, much the same can be found with other pathogens, antibiotic resistance, and healthcare-associated infections, said Marcelin, an infectious disease physician at the University of Nebraska. “These organisms are not racist,” she said. “Organisms do not discriminate, but people and systems and society can discriminate. And the actions that we engage in, the policies that we enact, those things can have inequitable influences on people. The impact of those policies on people can happen unequally. There are a number of different pathways to inequity in emerging infectious diseases.”
Unequal Exposure
One is “unequal exposure,” she said, giving the example of historical structural racism in dividing communities, towns, and cities with “redlining” and segregation. The Black sections of these racial divisions typically had little access to healthcare, education, and transportation. “Exposure may depend on where you live,” Marcelin said.
And those exposed may have impaired immunity because of a lack of access to diagnostics and treatments, which could lead to hypertension, heart disease, and other chronic conditions.
“Because of structural racism, because of the inequitable access to [medical] drugs that they need to be able to care for their bodies, their susceptibility to disease is higher,” she said. “And then there is unequal treatment. We’ve seen this — the people who need the treatment don’t have access to it and, therefore, they’re more likely to have severe disease, hospitalizations, and mortality.”
Marcelin endorsed the concept of “pharmacoequity,” meaning that every individual — regardless of ethnicity or socioeconomic status — should have access to the highest-quality medications that are warranted for their illness.
“Gone are the days where we say, ‘Oh, OK, well whatever it is that you prescribe, you did the best that you could,’” she said. “We need to ask questions and say, ‘Why did you prescribe this for this patient and not for that patient?’ If we prescribe [a certain] antibiotic, will that patient be able to receive it?”
Clostridium difficile is an interesting example, since white patients are more likely to get it — because of their easier access to antibiotics that can trigger the infection. However, although less often diagnosed, Black patients with C. diff are more likely to develop severe infection and higher mortality, she said.
“Same thing with hospital-onset bloodstream infections,” Marcelin said. “One study showed that Black and Hispanic patients have higher odds of developing multidrug-resistant gram-negative organisms.”1
Although these racial inequities have long been apparent to some, the issue was a blind spot for the healthcare system overall until it was suddenly and widely exposed by the pandemic. It was like a storm raising a shipwreck, and that sea change initially was dismissed by some who rejected the notion of systemic racism in healthcare. Heads rolled after a prominent medical journal aired a tone-deaf podcast on structural racism, questioning its existence and suggesting the subject be dropped from the larger pandemic conversation.2
“Not a lot of folks are really aware of the fact that these disparities are occurring, not only from the antimicrobial prescribing standpoint, but also in the prevalence and incidence of disease in individuals,” Marcelin said. “There has to be something that we can do, as healthcare professionals, something tangible, for us to be able to affect this somehow.”
Healthcare curriculums should address racial equity issues early in training, she recommended, adding that those in the audience should go back to their facility with these questions:
• How can we incorporate equity into our antimicrobial stewardship and hospital epidemiology goals?
• Whose expertise do we need to bring to our team to prioritize equity at our institution?
“We want to develop a culture where people are thinking about every single decision that they make through a lens of equity,” Marcelin said.
Although it admittedly bungled many aspects of the pandemic response, the CDC came down on the right side of history on this subject, with Director Rochelle Walensky, MD, saying “the pandemic illuminated inequities that have existed for generations and revealed for all of America a known, but often unaddressed, epidemic impacting public health: racism.”3 (See “CDC Director Steps Down.”)
Mea Culpa
Last year, the CDC took responsibility for its haphazard response to the COVID-19 pandemic in the United States, admitting to mistakes and miscalculations that included testing, data, and communications. (See Hospital Infection Control and Prevention, October 2022.)
Accordingly, Bell began his SHEA talk with an apology — but not for the reasons suspected.
“The idea of hitting you with [a talk on] preparation for the next pandemic, at this point in this pandemic, seems cruel,” said Bell. “I kind of cringe at the idea of doing this, but at the same time, I think it is an opportune moment.”
For the record, the CDC reported as of May 1, 2023, COVID-19 was causing 1,511 hospital admissions and 88 deaths per day. That is a long drop from its raging peaks and surges, but there is little to celebrate about a continuing rate of more than 30,000 deaths per year.
Given its high mutability and inherent unpredictably, SARS-CoV-2 could resurge, for example, in the fall and winter months. Even so, the coronavirus may be in the process of becoming another endemic, seasonal respiratory pathogen. The larger point is that the forces that drive pandemics still are very much in play.
“If we go back to the 1980s from HIV (human immunodeficiency virus) and move forward, there almost hasn’t been a five-year period without something new coming up — especially if you include multidrug-resistant organisms (MDROs),” Bell said. “It’s been pretty constant that we’ve had to respond to some new emerging threat in the infectious disease, infection prevention and control world.”
Consider that, in a little more than a decade (from 2002 to 2014), severe acute respiratory syndrome-1 (SARS-1) emerged from China, there was a global pandemic of a novel H1N1 influenza strain, methicillin-resistant Staphylococcus aureus began spreading beyond the hospital, a new wave of multidrug-resistant gram-negative bacteria appeared in the United States, the coronavirus Middle East respiratory syndrome surfaced in Saudi Arabia, and a record outbreak of Ebola occurred in Western Africa.
“We will see more and more crowding around the world,” Bell said. “With that, we see potentiation for the creation and dissemination of infectious diseases, certainly with the mobility of populations now. The extremes of age and other chronic or acute conditions create populations that are highly susceptible, have special needs — this is something that we can predict. And then there are the impacts of climate and geopolitics.”
The deputy director of CDC’s Division of Healthcare Quality Promotion, Bell took a shot at the agency, or perhaps himself, in describing the constant revision of the CDC’s COVID-19 guidelines as being like “popcorn popping.”
“It’s chaotic at best,” he said. “Sometimes it’s not avoidable if there’s something urgent that needs to be updated — I get it. But not everything is that urgent.”
Similarly, the CDC needs to be able to say clearly why something was updated, he added: “So that when you’re representing a change, it’s not opaque, but there is transparency on the rationale as well.”
In addition to racial and ethnic inequities, the pandemic brought to stark light how dependent and vulnerable the healthcare system is when it is no longer medicine as usual.
“It showed us how much we are reliant on supply chains, the global marketplace, the connections between long-term care and acute care facilities,” Bell said. “Another factor that I think made this particularly notable is the duration of the crisis. This has been more intense, for longer, than almost anything we’ve seen to date. An exception might be HIV. Still going, but very different.”
A correlation to the duration factor was that new needs evolved rather quickly over the course of the pandemic. “Think about the mpox (monkeypox) outbreak that we’ve seen recently,” Bell said. “That was pretty much a single set of actions related to a single pathogen, and we’re sort of seeing it conclude — I hope. With COVID, there was a new vaccine, a new strain, another new vaccine, another new strain, treatment options that did or didn’t work.”
Again, communication from public health and within individual healthcare systems was an ongoing problem.
“I still see 8.5 x 11-inch sheets of paper pinned to cork boards — that is information delivered to the healthcare workforce,” he said. “That is ridiculous in this age. We have to think about how we can leverage some of the science behind communication and cognitive information sharing in a way that helps staff be able to understand immediately what they need, what they’re supposed to do, and have that be accurate and consistent.”
Lies and Damn Liars
The principal barrier to that goal was an unprecedented level of misinformation about all aspects of the pandemic, from masking to being vaccinated. Once on the fringe, the anti-vaxxers found a whole new audience that not only undermined COVID-19 vaccine uptake but raised conspiratorial questions about immunization shots in general. Coming from all directions and on multiple platforms, a cottage industry of bald opportunists broke out the snake oil. Physicians and nurses told of patients dying of SARS-CoV-2 while still claiming the pandemic was a hoax.
“There was disinformation in the ’80s with HIV, there was disinformation with hemorrhagic fever viruses, with the original SARS, but nothing quite to the extent and expansiveness of what we [saw with COVID-19],” Bell said. “There have been a lot of people on TV saying things that were either absurd or sketchy at best. And I think that is a call to arms for all of us here. We need to have a recognized brand, whether it’s healthcare epidemiology, infection prevention and control, infectious diseases.”
For example, as the pandemic unfolded, it became all too clear how many people were unaware of the long, accomplished history of infectious disease detection and mitigation, infection control in hospitals, and the safety and efficacy of vaccines. Those who acted to save millions upon millions of lives for decades suddenly were viewed with suspicion by people who were constantly getting confirmation bias from disreputable sources.
In addition to raising awareness of the many accomplishments of infection prevention and epidemiology, speaking out now may build back some public trust while preparing the field to seize the narrative. Very early in the next pandemic, “someone will slide in and start talking, and it needs to be us,” Bell said. “It needs to be people who understand the system, understand the science, and can speak to it clearly.”
This should be a point of preparation by organizations such as SHEA, to ensure they have knowledgeable public speakers who can handle media questions and bust the inevitable myths and conspiracies.
The overall fragility of the health system was “very difficult to look at,” but may be exposed again if measures aren’t in place in terms of maintaining staffing and quality of care. To meet these and other threats, the healthcare system must embrace new approaches, such as implementation science and human factors engineering — “the heuristics of figuring out how to error-proof what we do,” he said.
There are some huge issues on the table, and even progress can raise unintended consequences. For example, as diagnostics for all manner of respiratory pathogens come online, they may inform treatment but overwhelm available isolation beds.
“We are increasingly able to do real-time diagnosis of a variety of respiratory pathogens that might, by extension, need [patient] isolation or require [worker] furlough,” Bell said. “What are we going to do about this? I don’t think we are at all prepared for being able to detect all of these potential respiratory pathogens that would be concerning in a healthcare setting.”
REFERENCES
- Evans CT, Jump JL, Krein, SL, et al. Setting a research agenda in prevention of healthcare-associated infections (HAIs) and multidrug-resistant organisms (MDROs) outside of acute care settings. Infect Control Hosp Epidemiol 2018;39:210-213.
- Madara JL. Speaking out against structural racism at JAMA and across health care. American Medical Association. Published March 10, 2021. https://www.ama-assn.org/about/leadership/speaking-out-against-structural-racism-jama-and-across-health-care
- Centers for Disease Control and Prevention. Media statement from CDC Director Rochelle P. Walensky, MD, MPH, on racism and health. Published April 8, 2021. https://www.cdc.gov/media/releases/2021/s0408-racism-health.html
Part post-mortem, part vision quest, the Society for Healthcare Epidemiology of America 2023 meeting largely was a look at the pandemic past and what beasts are yet to come.
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