Public Health

Amid tripledemic, clinicians must redouble infection-control efforts

Jennifer Lubell , Contributing News Writer

COVID-19 continues to claim about 400 lives a day in the U.S. But it’s not acting alone. Many hospital intensive care units are running at 80% capacity due to the “tripledemic” of influenza, COVID-19 and respiratory syncytial virus infection (RSV) brought on by a relaxing of public health mitigation measures. Flu and RSV have appeared much earlier in the season than usual and have posed a major challenge for children’s hospitals and contributed to long wait times in emergency departments.

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It's not a great time for the U.S. health system, noted Michael Bell, MD, deputy director of the Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion. “It’s something that we will get through, but we need to do so by attending to all of the details. … Infection control has to happen every single time we interact with a patient,” Dr. Bell said during a virtual town hall event with the AMA in December.

Read more about Project Firstline, the CDC’s national training collaborative for health care infection control.

The CDC monitors the incidence and prevalence of various respiratory viruses, including SARS-CoV-2influenza, and RSV. However, Dr. Bell noted, “we actually practice in a place that's in a smaller community unit and understanding what's happening in your community is not always easy to do based on national data.” State and sometimes city health departments maintain data that are worthwhile to consult. Additionally, physicians should be in conversations with their networks and health systems. These resources make it easier for clinicians to stay up to date on influenza, RSV and COVID-19 prevalence data which can help guide IPC practices.

Reducing the impact of respiratory infection season for patients doesn’t involve new or revolutionary measures, said Dr. Bell. Optimizing vaccinations and wearing masks remain staples for achieving fewer infections.

Vaccination is still a first-line risk-reduction measure. There is nothing better at reducing the risk of really severe disease than a vaccine. “We don't have a vaccine for RSV yet. Fingers crossed, we'll get there.”

Masking is part of the CDC’s updated core practices for infection control. During periods of higher levels of community respiratory virus transmission, facilities should consider having everyone mask upon entry to the facility to ensure better adherence to respiratory hygiene and cough etiquette for those who might be infectious. When people mask up, they spread less infection. CDC data has shown that simply putting on a plain fabric mask, “not even a fancy, proper year 2023 kind of mask” could reduce the amount of respiratory droplets caused by breathing or talking by over 50%, he added.

Physicians should ask patients and their family members to respect this practice while in the facility. “It’s a reasonable thing to do in this day and age,” he said.

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Dr. Bell also explained why personal protective equipment rules have varied by virus. RSV, for example, may require contact precautions without a mask. With influenza and COVID-19, masks seem more important.

This is in part because infections range in severity from something that is completely asymptomatic to a moderate nuisance to something that's really bad. We think about the risk in a different way. “It's how susceptible we are to a bad outcome. And that's what drives what we're doing,” explained Dr. Bell. Anytime there’s something new. We did it when COVID arrived. “We were very cognizant of the fact that not only can this be severe, we don’t have a vaccine, we don’t have specific treatment.”

The CDC continues to recommend mask use for RSV if someone’s coughing. However, since this infection often targets children that shed a lot of virus, it has traditionally focused on contact isolation due to poor cough etiquette in children, said Dr. Bell.

The reality is “if you contain them in a room using contact isolation, that has much more value than trying to keep a mask on a kid,” he explained.

Dr. Bell also noted that while we now can detect a number of respiratory viruses, such as human metapneumovirus and rhinovirus, we don’t know as much about their modes of transmission as we do with others, such as RSV and SARS-CoV-2.  The CDC is updating Appendix A of their Guideline for Isolation Precautions, and we can anticipate new guidelines in a couple of years.

Environmental hygiene isn’t specific to one respiratory infection, said Dr. Bell. “We do know that if somebody is coughing into their hand and then touching surfaces, they can spread infectious materials. It’s best to maintain high levels of hand hygiene.”

Any cleaning agent should be registered with the Environmental Protection Agency. Most of the hospital disinfectants these days don't need mixing or dilution, said Dr. Bell.

Delegating environmental cleaning tasks to staff isn’t always easy, especially in smaller practices. “It’s worth thinking about what makes the most sense for your practice. How are you going to ensure that everything that needs to be wiped between patients is wiped properly?”

Physician practices should also think about what spaces would benefit from an assessment for improved air handling. “You might want portable HEPA [high efficiency particular air] filter units or you might be able to do an upgrade of your air handling just in the main system,” Dr. Bell suggested.

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Waiting areas are much less crowded than they used to be, as health care systems adapted to COVID-19.

Dr. Bell encouraged physicians to continue this practice. Someone with a fever and cough shouldn’t be allowed into spaces where trauma patients and others are waiting for care. “Divert them in advance,” he said.

Physicians also shouldn’t forget about the value of remote care.

Telehealth doesn't replace direct interactions completely, but it’s another effective way to reduce crowding and opportunities for exposure while providing good care, he said.