There is a dangerous new government policy being proposed which could harm healthcare workers and patients across the country. Instead of strengthening infection control policies in healthcare settings to protect workers and patients from infectious diseases, the CDC is planning future guidance which could lower healthcare infection control standards.

The CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) advises the CDC on infection control policies, but committee meetings are subject to almost no public scrutiny and policies are made with minimal input from patients or healthcare workers. Meanwhile, many HICPAC committee members represent powerful hospitals around the nation. The American Hospital Association recently declared that U.S. hospitals face a “crushing” financial crisis. In a move convenient to their business interests, the HICPAC committee policies plan to create extensive flexibility for health care employers to choose prevention measures.

The proposal ignores the science of airborne virus transmission, flouts decades of advances in aerosol science, and dismisses advances in infection control that have been confirmed in the past three years of the pandemic. HICPAC should incorporate universal masking into standard precautions across healthcare settings and recommend the use of N95 respirators broadly. Instead, the most recent proposal specifically recommended that healthcare workers should only use surgical masks rather than fit-tested N95 respirators when caring for COVID-19 patients. This could endanger healthcare workers and patients, and contribute to outbreaks in healthcare settings.

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Letter:

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Please advocate for increased public oversight of the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC), the committee that oversees policies on the prevention of infectious diseases in healthcare settings. Policies need to be developed with the input of impacted stakeholders, such as health workers and patients. I am concerned that the CDC will soon profoundly weaken its Infection Control guidance which could place health workers and patients at risk of short- and long-term harm and even death from infectious diseases. Universal masking is a simple measure to reduce the risk of infectious disease transmission that has been implemented broadly in healthcare settings for the last three years. HICPAC should codify universal masking as an improvement to standard precautions across healthcare settings and expand the use of N95 respirators. (1) Instead, in June 2023, the CDC HICPAC Isolation Precautions workgroup formally proposed changing CDC guidance to recommend health workers wear loose-fitting surgical masks (2), which are less effective with airborne infectious diseases, to care for patients with COVID and other infectious diseases such as Middle East Respiratory Syndrome (MERS) or Severe Acute Respiratory Syndrome (SARS), rather than fit-tested N95 respirators or more protective equipment, which are much more effective with airborne diseases.

Adopting this policy will endanger millions of workers and patients across the country. Airborne infectious diseases such as COVID-19 are transmitted in the air we all share, which is why wearing high-quality, face fitting respirators is important to prevent transmission, in combination with ventilation and other layers of protection (3). COVID-19 has already caused over 42,000 deaths this year (4), placing it among the top 10 killers in the US in 2023, and 15.8% of U.S. adults have experienced Long COVID (5), a condition that persists after initial recovery from a COVID infection. Similarly, other airborne diseases such as MERS or SARS could also lead to large numbers of hospitalizations and deaths, the 2015 MERS crisis led to 38 deaths among 186 diagnosed cases in South Korea, and the 2002-2004 SARS crisis led to 774 deaths among 8,000 diagnosed cases across several countries in Asia and Canada.

If healthcare workers stop wearing N95 respirators while caring for COVID-19 patients, many more will develop COVID-19. Because over 50% of COVID transmission occurs before people develop symptoms (6), they may pass it to their coworkers or patients in maskless healthcare settings. This could, in turn, fuel further hospital outbreaks and drive health worker shortages.

The recommendations were based upon a widely-critiqued (7), flawed literature review. The guidance even contradicts the CDC’s own data which demonstrated that continuous use of N95 and KN95 respirators cut the odds of infection by 83% compared to 66% with surgical masks (8). Nearly 900 experts and over 1000 members of the public have already signed an open letter urging the CDC to strengthen, rather than to weaken its infection control guidelines, and to open the process of infection control guidelines to include more stakeholders and interdisciplinary experts (9).  

CDC/HICPAC decisions are made undemocratically and developed behind closed doors, without input from nurses unions, healthcare workers, patient, disability and elder advocacy groups or even independent aerosol experts, occupational safety professionals and industrial hygienists. In the last public meeting, CDC/HICPAC voted on a proposal before hearing public comment – an example of lack of inclusion. Even though CDC/HICPAC is part of a Federal agency, they have not made their draft protocols available to the public – unlike other CDC committees. We only have access to a barebones powerpoint from CDC/HICPAC’s last meeting on June 8-9 2023, which outlines the proposed changes (2). The meeting notes are not made available in a timely manner, and are still not available from the June meeting (10). The HICPAC committee is packed with representatives from the hospital industry, and lacks procedures for meaningful public input.

The American Hospital Association has explicitly declared that hospitals are facing a “crushing” financial crisis (11). Given this, I am concerned that the hospitals may be pursuing this short-sighted infection control approach to reduce their expenses by cutting fit-testing programs and limiting access to N95 respirators and other airborne protections. However, increasing rates of health worker COVID infections will further worker shortages and may lead to additional disabilities caused by Long COVID. Ultimately, infection control that ensures the highest protection of healthcare workers and patients based on evidence-based science, and integrates the input of stakeholders is a necessary approach.

References:

(1) Kalu IC, Henderson DK, Weber DJ, Haessler S. Back to the future: Redefining “universal precautions” to include masking for all patient encounters. Infect Control Hosp Epidemiol. Published online February 10, 2023:1-2. doi:10.1017/ice.2023.2 https://pubmed.ncbi.nlm.nih.gov/36762631/

(2) Isolation Precautions Guideline Workgroup - Co-Chairs: Michael Lin, MD, MPH and Sharon Wright, MD, MPH - HICPAC June 8, 2023 https://drive.google.com/file/d/14s40YHjuZxMQ_ZOx2qXIdsPDxD0641_b/view?usp=sharing

(3) EPA - Implementing a Layered Approach to Address COVID-19 in Public Indoor Spaces https://www.epa.gov/coronavirus/implementing-layered-approach-address-covid-19-public-indoor-spaces

(4) COVID Data Tracker - Trends in United States COVID-19 Hospitalizations, Deaths, Emergency Department (ED) Visits, and Test Positivity by Geographic Area https://covid.cdc.gov/covid-data-tracker/#trends_totaldeaths_select_00

(5) CDC - National Center for Health Statistics - Long COVID - Household Pulse Survey https://www.cdc.gov/nchs/covid19/pulse/long-covid.htm

(6) Johansson MA, Quandelacy TM, Kada S, Prasad PV, Steele M, Brooks JT, Slayton RB, Biggerstaff M, Butler JC. SARS-CoV-2 Transmission From People Without COVID-19 Symptoms. JAMA Netw Open. 2021 Jan 4;4(1):e2035057. doi: 10.1001/jamanetworkopen.2020.35057. Erratum in: JAMA Netw Open. 2021 Feb 1;4(2):e211383. PMID: 33410879; PMCID: PMC7791354. https://pubmed.ncbi.nlm.nih.gov/33410879/

(7) Why the CDC’s New Mask Guideline Proposal May Actually Imperil Frontline Workers. “The decisions some of these public health people are making are not getting better. They’re getting worse.” by Katie MacBride, The Daily Beast, Updated Jul. 01, 2023 3:40PM EDT / Published Jun. 30, 2023 11:47PM EDT https://www.thedailybeast.com/new-cdc-mask-guidelines-may-actually-imperil-frontline-workers-experts-say

(8) Andrejko KL, Pry JM, Myers JF, et al. Effectiveness of Face Mask or Respirator Use in Indoor Public Settings for Prevention of SARS-CoV-2 Infection — California, February–December 2021. MMWR Morb Mortal Wkly Rep 2022;71:212–216. DOI: http://dx.doi.org/10.15585/mmwr.mm7106e1

(9) National Nurses United - Urge the CDC and HICPAC to fully recognize aerosol transmission and protect health care workers and patients https://www.nationalnursesunited.org/urge-the-cdc-and-hicpac-to-fully-recognize-aerosol-transmission

(10) CDC - Healthcare Infection Control Practices Advisory Committee (HICPAC) - Meeting Minutes https://www.cdc.gov/hicpac/minutes.html

(11) Becker’s Healthcare - Congress can take action to help healthcare deal with 'crushing' financial challenges, AHA urges - by Nick Thomas - Tuesday, October 25th, 2022 https://www.beckershospitalreview.com/finance/congress-can-take-action-to-help-healthcare-deal-with-crushing-financial-challenges-aha-urges.html

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