CDC's Alex Kallen, MD, MPH, discusses infection prevention and control [Podcast]

In today’s COVID-19 Update, AMA Chief Experience Officer Todd Unger talks with the CDC's Alex Kallen, MD, MPH, chief of the Prevention and Response Branch in the Division of Healthcare Quality Promotion, about the importance of infection prevention and control and what physicians need to know about updated guidance in this area.  

Learn more at the AMA COVID-19 resource center.

CDC infection prevention and control resources for physicians

Infection prevention and control guidance

• Infection control guidance for health care professionals about coronavirus (COVID-19).
  • Interim infection prevention and control recommendations for health care personnel during the Coronavirus Disease 2019 (COVID-19) pandemic.
  • Interim guidance for managing health care personnel with SARS-CoV-2 infection or exposure to SARS-CoV-2.
  • Interim infection prevention and control recommendations to prevent SARS-CoV-2 spread in nursing homes.
  • Additional considerations for nursing homes that apply, in addition to, the other two guidance documents.

COVID-19 data tracker

• CDC’s COVID-19 data tracker can be used to determine the level of SARS-CoV-2 transmission for the county where the healthcare facility is located.
• Some of the IPC measures (e.g., use of source control, screening testing) are influenced by levels of SARS-CoV-2 transmission in the community.

Speaker

• Alex Kallen, MD, MPH, chief, Prevention and Response Branch, Division of Healthcare Quality Promotion, CDC

Unger: Hello. This is the American Medical Association's COVID-19 Update video and podcast. Today we're joined by Dr. Alex Kallen, chief of the Prevention and Response Branch in the Division of Healthcare Quality Promotion at the CDC in Atlanta, about the importance of infection, prevention and control, and what physicians need to know about updated guidance in this area. I'm Todd Unger, AMA's chief experience officer in Chicago. We know that infection prevention and control, or IPC, has always been critical in health care settings but Dr. Kallen, why don't you start by talking about what did the pandemic teach us about new things about IPC?

Dr. Kallen: Right. Well, I think, as we all know, that the pandemic has just put unbelievable stress on the health care system. And I think we've seen how central a role IPC has played and remains necessary to play in preventing the spread of diseases in these health care settings. So for example, we've seen how important it is with regard to HAIs during the pandemic. We've seen huge increases in HAIs and rollbacks of progress that we've made over the last 10 years. We've seen health equity issues with disproportionately affected populations continuing to be affected disproportionately by the pandemic. So I think, again, it just really shows the central role of IPC across the board in preventing transmission of pathogens and protecting health care personnel.

Unger: So in other words, we're going to add this to the list of all the things that the pandemic made worse and more complicated. It's so important, in fact, that last month the administration announced a $2.1 billion investment to improve infection prevention and control activities across U.S. public health and health care sectors. Let's talk about what is that going to enable you to do and what were those gaps that need to be filled?

Dr. Kallen: Right. Really excited about the funding, I think this will really give us a way to move forward to increase capacity, resiliency for IPC both in public health, in health departments and also in individual facilities. The other nice thing we get from this funding is actually the ability to support some clinical activities in nursing homes, which have really been affected by the pandemic. And it really has the potential beyond COVID to allow us to impact some of those HAIs that I talked about that have gotten a lot worse during the pandemic and really kind of reinvigorate our prevention efforts.

Unger: And a big part too, I imagine, is building awareness, engagement with an updated set of IPC guidance for health care settings. Why update this right now at this point in the pandemic?

Dr. Kallen: Right. And I think we've tried to make the IPC guidance kind of a living document during this whole process. I mean, obviously, COVID is new. We didn't know about it a year and a half ago. We've learned a tremendous amount and as we learned things we have to update the guidance. I know that's frustrating for providers, trying to keep track of all the changes, et cetera. So the good news is for this update, not a lot of huge substantial changes. What we're really trying to do is consolidate, simplify the guidance, make it easy to find the things that you need to find, provide the general concepts and let you apply it to your specific setting. So there's also some resiliency built in to try and make it easier for the guidance to change as the situation changes as well. But again, not huge substantial recommendation changes in this guidance.

Unger: I think that is probably one of the things that we've learned through this pandemic is, when it is new, you're learning a lot more along the way and you need a foundation basically to make sure that you can update folks as that learning occurs. What, in your mind, are the most important things that you want physicians to know about this update?

Dr. Kallen: Right. And probably the key, most important thing is, "Where do I find the information that I need?" And during the pandemic we've had probably about 10 or 15 different health care guidance documents. We've rolled that back and scaled it to just down to three. There's our general IPC guidance, where you go if you need to ask general questions about what should I be doing for infection control in my particular setting. It's applicable across all health care settings. The second is what we kind of call our occupational health guidance, so if you have questions about health care worker return to work or exposures or things like that, that's where you go. And then last for folks who work in nursing homes there's a specific nursing home document, that has a few extra recommendations above and beyond what's contained in the IPC guidance. So hopefully that's a lot simpler, more consolidated, easier to find the information you need.

Unger: Where exactly would a physician find these documents?

Dr. Kallen: So all available on cdc.gov. And if you look for the coronavirus section, you click on the section for health care workers. There's a section on clinical and there's a special section just on infection control. It's all right there.

Unger: So you mentioned before not a huge amount of changes but can you summarize what was updated and what wasn't?

Dr. Kallen: So let me quick start with the things that didn't change. So no changes to personal protective equipment recommendations for people caring for people with SARS-CoV-2 or suspected SARS-CoV-2. No huge changes to managing health care personnel exposures, return to work, all that kind of thing. Not any really substantial changes to screening people before they present, either health care workers or visitors or patients when they come to health care settings. So again, the core recommendations pretty much are remaining the same.

Unger: What actually then did change?

Dr. Kallen: Right. So, great question. So there's a couple things that changed slightly. So let me first start with source control because I think that's a thing that's very complicated and confusing and has led to lots of confusion. So when I say source control I mean the use of a face mask or something like that, a device to cover your nose and mouth to prevent the spread of respiratory droplets. There's lots of things that are acceptable for that. Again, the idea is to protect yourself and also to protect the people around you. People can use face masks, they can use N95 respirators. Generally haven't recommended cloth face masks for patient facing health care personnel, just because they're not PPE. And if you need PPE, it's hard to switch back and forth. But again, that's one of the key areas for change.

Unger: Maybe this is moot but let me just ask. Are there any instances where fully vaccinated health care personnel can choose not to use source control?

Dr. Kallen: Yeah. So again, there are. Let me take a step back and just say, for source control we generally recommend it for everybody in a health care setting. That's different than the community and I think that's where a lot of the confusion has come about. When the recommendations got made for community settings about vaccinated people not needing source control, I think people got very confused and thought that applied to health care and it never really did.

Why are they different for health care settings? Well, again, we try to be more conservative in health care settings with much of our guidance just because it's a critical part of our infrastructure. There's lots of patients there at very high risk for severe outcomes so we try to make it generally more conservative. To answer your question, yeah, there are. Generally, they revolve around two things. Vaccinated health care personnel and areas with low to moderate transmission and in those particular circumstances there may be situations where you may not need to use source control for health care personnel.

Unger: So I imagine that that is more detailed or covered in more detail in your guidance?

Dr. Kallen: Yeah, exactly. I can give you one example. I mean I think the specific situation that we often think about is health care personnel who are either not in patient-facing positions, billers or coders or things like that. Or if you're in a break room that patients aren't allowed in, or in a meeting. If people are all vaccinated and you're in an area with low to moderate transmission, health care personnel could choose not to wear a face mask. There's exceptions to that, which I'd refer you to the guidance for but in general that might be an area where it's acceptable. Again, takeaway point is for people in a health care setting, everybody, health care workers, patients, residents, regardless of vaccination status, source control is still recommended.

Unger: Okay. So we've covered source control. Let's turn to the subject of testing. Can you talk about the current recommendations for COVID testing among health care personnel and any updates in that arena?

Dr. Kallen: Yeah. So again key point here, testing is really recommended and prioritized for people with symptoms. Even very mild symptoms, we've been involved in lots of outbreak where the original starting person thought they had allergies for two or three days and turned out to have COVID. So even mild symptoms should be tested. Health care personnel with higher risk exposures or patients or residents with close contacts should be tested. This is another area where we differ slightly from the community, which again for the reasons I mentioned, should be tested immediately and then again five to seven days later.

The one caveat we added there is generally the first test should be two days after the exposure, just to give people a chance to let the test become positive obviously. And then last but not least, there's this thing that we call expanded screening testing, what that is is testing asymptomatic, non-exposed people. Only recommended really right now for nursing homes but again the frequency with which that is recommended has changed slightly and I'd refer you to the guidance for that. Generally that can be applied to other settings but hasn't been for the most part and hasn't generally been something that we've recommended, and continue not to recommend, for patients or residents outside of an outbreak situation.

Unger: How about, beyond the testing part, has anything changed with the rules about quarantining?

Dr. Kallen: Right, yeah. So the only thing that changed there is fairly minor and that's to try and align everybody together. So we've had a recommendation for health care personnel that were vaccinated that they didn't need to quarantine after exposure, and that's obviously consistent with the community guidance, and now we've just added residents and patients to that. So a fully vaccinated resident or patient who hasn't had contact still needs source control, still needs to be tested, doesn't need to quarantine.

Unger: Okay. You mentioned this aspect of community transmission levels and I'd like you to talk a little bit more about the importance of that and how emerging variants, like Delta variant for instance, might impact these recommendations.

Dr. Kallen: Yeah. So this is the flexibility that I mentioned that we've tried to add. So community transmission seems to be a big driver of what happens in health care. So if you have a lot of community transmission, you start to see cases in health care settings. So we've tried to add community transmission levels as a way to tier the recommendation. So if you're in an area with lots of community transmission, the recommendations may be more robust. If you're in areas with lower transmission, you might be able to back those down. And we think, as we've seen with Delta where obviously it came in for whatever reason, increased transmissibility, maybe some vaccine efficacy issues we've seen increased transmission, same would go in the future. New variants could come along that could affect that, could change the situation and you can apply the community transmission levels to your specific setting, your particular area, to be able to tier the recommendations in your specific facility.

Unger: Dr. Kallen, this is important news that you want to get to the medical community. Any other key things you want to leave folks with out there in regard to this news?

Dr. Kallen: Yeah, a couple things. Just first, where do I find the community transmission data? If you actually look on the CDC website under the COVID data tracker, you can actually look it up for your specific community. So I refer you there and you can see what category you are from low to high and tier recommendations. I think the other thing I wanted to emphasize is that the CDC still, despite the updates, continues to stress vaccination, testing, source control and the use of PPE to try and prevent the spread of SARS-CoV-2 in health care settings to protect our patients and our incredibly valuable health care personnel that have just done such incredible work during the pandemic.

Unger: Dr. Kallen, thank you so much for sharing this important information. And again, you can find out more details about the guidance on the CDC website. That's it for today's COVID-19 Update video and podcast. For resources on COVID-19, go to ama-assn.org/COVID-19. Thanks for joining us today. Please take care.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.