By: Megan Meller, MS, MPH / Transcribed & Edited by: Lennard M. Gettz
Months into the global pandemic, we have learned from all state and federal health agencies about the heightened standards of Covid-prevention safety measures in public areas. As a central gathering source for infected people and potential viral transmission, hospitals require the highest level of safety codes and regulated modeling- including the care and treatment of CoronaVirus patients. For this reason, a dedicated department in all health centers is in place to manage and enforce disease prevention protocols within the staff, the patients and the entire hospital environment. Microbiologist and public health practitioner Megan Meller, MS, MPH is a member of this department at the Gundersen Health facilities (La Crosse, WI). Her specialized work provides a significant set of keys in the fight against Covid in the front lines.
A COMMITMENT TO SAFETY EDUCATION
I am the lead infection preventionist for Gundersen Health’s outpatient clinics. My department is focused on the safety of patients and staff, and we do this through education and by carrying out an extensive list of priorities set by regulatory standards. We maintain strict attention to the cleanliness of our work environment and ensure that equipment and instruments used during patient care are cleaned and disinfected according to industry standards. We also help develop patient education as it relates to infectious diseases. Before Covid began, we were focusing on drug resistant bacteria and educating patients about hand hygiene and wound care.
Part of our objectives include ensuring that all safety protocols are being followed through by the nursing staff. An example of this is a group of bacteria called CARBAPENEM RESISTANT ENTEROBACTERIACEAE (CRE) - germs (bacteria) that can cause infections in healthcare settings and they are resistant to many antibiotics (1). Because of the number of CRE cases a few years ago in the U.S., we ensure that all our endoscopes are cleaned and disinfected appropriately as well as setting proper guidelines in handling and storing (2). Knowing about issues like CRE is just one of many hazards in healthcare facilities where a patient’s health can be gravely affected under our care.
Part of our objectives include ensuring that all safety protocols are being followed through by the nursing staff. An example of this is a group of bacteria called CARBAPENEM RESISTANT ENTEROBACTERIACEAE (CRE) - germs (bacteria) that can cause infections in healthcare settings and they are resistant to many antibiotics (1). Because of the number of CRE cases a few years ago in the U.S., we ensure that all our endoscopes are cleaned and disinfected appropriately as well as setting proper guidelines in handling and storing (2). Knowing about issues like CRE is just one of many hazards in healthcare facilities where a patient’s health can be gravely affected under our care.
BURNOUT PREVENTION
To know your capacity is crucial in this job. Staff are trained to look out for this within themselves and each other. In our facility (as with all response units), what we strive to do is WATCH OUT FOR EACH OTHER, especially in a pandemic when we're more focused on trying to stay on top of all the changes and protect patients and protect staff. We also need to remember to put ourselves first - mentally, physically, and emotionally, or else we won’t be any good for everyone else. I need to remember daily to find time for self-care. When I am at my best, I give my best to others.
SINCE THE NEW YORK EPICENTER…
Wisconsin watched New York’s numbers back in March- and we all expected this to come to us and the rest of the country. We all felt it was just a matter of time. Outbreaks happen when people get complacent. When the spike surge hit Florida and Texas, we thought the Midwest got off pretty lucky with lower case numbers and deaths. But what I always try to remind my people is that, “it's just a matter of time” before our own luck runs out. From a public health standpoint, making a difference in this pandemic is about changing behavioral patterns- and the way to do this (until you’re blue in the face) is EDUCATION- pushing to change the minds of the people.
We did not know much about COVID-19 at the beginning of the pandemic, including how long someone remained infectious with COVID. When the CDC published their guidelines on COVID Isolation, this was a breakthrough (3). This guidance shaped our testing criteria, isolation criteria, and quarantine guidance.
Contagious Period
Based off research compiled by the CDC, most people are infectious with COVID-19 up to two days before symptom onset and 10 days after the first appearance of symptoms (4). Scientists showed that in most cases, they were unable to collect replication-competent virus after the 10th day on infection – meaning that an individual was no longer infectious. For patients who are immunocompromised, they may be infectious for up to 20 days. This is important information because in patients with mild illness, they may continue to test positive up to 3 months after their initial infection – even when no longer contagious. We have seen this within our own population. These findings support a symptom-based strategy to isolation discontinuation rather than a test-based strategy.
This kind of information was important in how we developed patient education. It also shaped the way we interacted with providers, because it helped identify when it was safe to bring patients back into the clinic and when to schedule surgeries and procedures.
This kind of information was important in how we developed patient education. It also shaped the way we interacted with providers, because it helped identify when it was safe to bring patients back into the clinic and when to schedule surgeries and procedures.
About MASKS
In July, the CDC published a Morbidity and Mortality Weekly Report (MMWR) about cloth masks that demonstrated their effectiveness in preventing COVID-19 transmission. A CDC investigation showed that in a salon with a universal masking policy, two COVID-positive hair stylists worked while symptomatic but, remarkably, there was no reports of COVID-19 transmission among 139 clients that the stylists worked with (5). Now, other coworkers and their family members of the stylists developed COVID infections, but none of the customers—because they were wearing cloth masks and their clients were also wearing cloth masks during haircut appointments. That to me was powerful data. So to answer a common question about the effectiveness of cloth masks, once I saw that data, it was clear to me that cloth masks work and we need to educate the public to this.
We’ve seen what can happen when we overwhelm a healthcare system, like what happened in New York City and many areas across the world. Overwhelmed healthcare systems often struggle to provide care for all patients due to resource diversion which can result in poor health outcomes. Another concern is how the COVID-19 is impacting chronic disease states since many healthcare systems were redesigning care and limiting services in the wake of COVID-19 (6). In the beginning of the pandemic, Gundersen canceled elective procedures to free up hospital beds and went virtual for many outpatient appointments. Six months into the pandemic, we are fully operational but have modernized patient care. Virtual visits have become common practice at Gundersen Health for health concerns that can be addressed without an in-person appointment.
While we have been successful to date, it is still critical for the community to do their role in COVID-19 prevention through masking and social distancing. It’s hard. I get it. My mom is coming to visit this weekend for the first time since the pandemic was declared. I told her, “okay, we will have to wear a mask around each other while we're inside together”. That kills me to have to set these guidelines, but I don't want to get her or myself sick.
We’ve seen what can happen when we overwhelm a healthcare system, like what happened in New York City and many areas across the world. Overwhelmed healthcare systems often struggle to provide care for all patients due to resource diversion which can result in poor health outcomes. Another concern is how the COVID-19 is impacting chronic disease states since many healthcare systems were redesigning care and limiting services in the wake of COVID-19 (6). In the beginning of the pandemic, Gundersen canceled elective procedures to free up hospital beds and went virtual for many outpatient appointments. Six months into the pandemic, we are fully operational but have modernized patient care. Virtual visits have become common practice at Gundersen Health for health concerns that can be addressed without an in-person appointment.
While we have been successful to date, it is still critical for the community to do their role in COVID-19 prevention through masking and social distancing. It’s hard. I get it. My mom is coming to visit this weekend for the first time since the pandemic was declared. I told her, “okay, we will have to wear a mask around each other while we're inside together”. That kills me to have to set these guidelines, but I don't want to get her or myself sick.
Upgrading Solutions "As We Go"
Fighting a pandemic relies heavily on information sharing. In the beginning, everyone was using ventilators but over time, we’ve backed off from that. Now we're using alternative ventilators like C-PAP (Continuous positive airway pressure) and BiAPS (Bilevel Positive Airway Pressure) because we learned that a COVID infection was causing a wet lung in some severe cases, so intubating someone with a ventilator was not going to typically result in a positive outcome. We found that we can get better outcomes by using less invasive forms of ventilation. What’s more, protocols like MATH+ (use of Methylprednisolone) all ties into this because WE LEARN AS WE GO. The global community of health care professionals all learn what works and what doesn't work and what might be more effective. And the more we publish new findings and the more we share and connect with each other, the faster we're going to get to an antiviral solution whether it's something that's already on the market or a brand-new technology.
One of the questions I get a lot is about a vaccine, and viral dynamics. We know that there is pressure for viruses to evolve in ways that maintain their ability to transmit from person to person. We call it “natural selection.” Some respiratory illness, with time, may evolve to be more contagious but not as deadly. What I hope happens with COVID-19 is that it evolves in this manner to be less severe but only time will tell.
I see COVID-19 eventually becoming more like the flu where it occurs every year. Perhaps 50 years from now or even let's say 10 years from now- COVID may look more like another common cold because it's found its sweet spot where it can keep infecting people without causing the same magnitude of severe illness that we are currently seeing. We're in an incredible age of technology and pandemics encourage innovation. So I do think we will eventually have a vaccine for COVID-19 but it might be one we have to get every single year because the virus is going to keep evolving and we need to just stay on top of it- like we do with the flu.
I see COVID-19 eventually becoming more like the flu where it occurs every year. Perhaps 50 years from now or even let's say 10 years from now- COVID may look more like another common cold because it's found its sweet spot where it can keep infecting people without causing the same magnitude of severe illness that we are currently seeing. We're in an incredible age of technology and pandemics encourage innovation. So I do think we will eventually have a vaccine for COVID-19 but it might be one we have to get every single year because the virus is going to keep evolving and we need to just stay on top of it- like we do with the flu.
REDUCTION IN MORTALITY
A lot of factors are important when it comes to reducing the number of cases (and mortality) linked to COVID-19. I believe masking and social distancing can play a major role in the reduction if enough people adhere to them. The current state of COVID immunity is still being investigated and that too impacts case numbers.
Predicting all this also makes a big difference in prevention. While we're not seeing a surge of deaths and hospitalizations in our area yet, we're seeing other manifestations of COVID-19. In Wisconsin, we are testing more people than we were in the beginning of the pandemic and we are more compliant with masking. COVID-19 has made all of us in healthcare much more attuned to prevention measures like isolation precautions, personal protective equipment, and environmental cleaning. At Gundersen, we stress that where and who you take your lunch break with can increase your risk for getting COVID. In my department, we used to eat lunch together huddled around a table, talking and laughing. Now we eat our lunches separately at our desks because it is safer.
Predicting all this also makes a big difference in prevention. While we're not seeing a surge of deaths and hospitalizations in our area yet, we're seeing other manifestations of COVID-19. In Wisconsin, we are testing more people than we were in the beginning of the pandemic and we are more compliant with masking. COVID-19 has made all of us in healthcare much more attuned to prevention measures like isolation precautions, personal protective equipment, and environmental cleaning. At Gundersen, we stress that where and who you take your lunch break with can increase your risk for getting COVID. In my department, we used to eat lunch together huddled around a table, talking and laughing. Now we eat our lunches separately at our desks because it is safer.
Recent headlines show evidence of Coronavirus pathogens in hospital air supply and air passageways- creating a systemic hazard for the staff and patients under critical care. Substantial controversy about the role played by SARS-CoV-2 in aerosols in disease transmission, due in part to detections of viral RNA but failures to isolate viable virus from clinically generated aerosols. As of March 30, 2020, approximately 750,000 cases of coronavirus disease (COVID-19) had been reported globally since December 2019 (1), severely burdening the healthcare system (2). The extremely fast transmission capability of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has aroused concern about its various transmission routes. This study led to 3 conclusions. (see complete article)
WHAT'S THE DIFFERENCE BETWEEN ASYMPTOMATIC AND PRE-SYMPTOMATIC?
By: Megan Meller, MS, MPH
There has been a lot of news coverage about how COVID-19 is spread. Someone who is asymptomatic has the infection but no symptoms and will not develop them later. Someone who is pre-symptomatic has the infection but don't have any symptoms yet. Both groups can spread the infection. COVID-19 spreads easily and we believe that's because it's spread by those who don't know they're infected. We suspect that individuals who are pre-symptomatic are infectious for two to three days before having symptoms. (see complete article in GundersenHealth.org)
By: Megan Meller, MS, MPH
There has been a lot of news coverage about how COVID-19 is spread. Someone who is asymptomatic has the infection but no symptoms and will not develop them later. Someone who is pre-symptomatic has the infection but don't have any symptoms yet. Both groups can spread the infection. COVID-19 spreads easily and we believe that's because it's spread by those who don't know they're infected. We suspect that individuals who are pre-symptomatic are infectious for two to three days before having symptoms. (see complete article in GundersenHealth.org)
ABOUT THE AUTHOR
MEGAN MELLER, MS, MPH is an Infection Preventionist with Gundersen Health System based in La Crosse, Wisconsin. From a young age, Megan has been passionate about science and the world of infectious diseases. Megan received her Master of Science in Microbiology at Indiana University-Bloomington where she studied alphavirus replication and her Master of Public Health (MPH) from the University of Wisconsin School of Medicine and Public Health. While working on her MPH, Megan worked closely with Infection Control departments and the communicable disease section at the Wisconsin Department of Health Services. In her current role, Megan is the lead Infection Preventionist for Gundersen’s outpatient departments and works closely with infection control partners located at regional hospitals. Megan is also a media consultant for the Infection Control and Infectious Disease departments and serves as an infection control consultant for numerous organizational groups.
REFERENCES
1. CDC Statement: Los Angeles County/UCLA investigation of CRE transmission and duodenoscopes. Centers for Disease Control and Prevention. July 10, 2015. https://www.cdc.gov/hai/outbreaks/cdcstatement-la-cre.html
2. Transmission of multi-drug resistant bacteria via ERCP. American Society for Gastrointestinal Endoscopy. https://www.asge.org/home/about-asge/newsroom/transmission-of-cre-bacteria-via-ercp
3. Sasangophar et al (2020). Provider Burnout and Fatigue During the COVID-19 Pandemic: Lessons Learned From a High-Volume Intensive Care Unit. Anesth Analg.
4. Duration of Isolation and Precautions for Adults with COVID-19. Centers for Disease Control and Prevention. Updated August 16, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html
5. Absence of Apparent Transmission of SARS-CoV-2 from Two Stylists After Exposure at a Hair Salon with a Universal Face Covering Policy – Springfield, Missouri, May 2020. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. July 17, 2020. 69:28.
6. Chudasama et al (2020). Impact of COVID-19 on routine care for chronic diseases: A global survey of views from healthcare professionals. Diabetes and Metabolic Syndrome: Clinical Research and Reviews. 14:965-967.
VIEWPOINTS
COVID-19 changed life as we knew it, highlighting infection prevention (IP) gaps across the spectrum of healthcare settings – especially in long-term care (LTC). IP in acute care has been an emphasis for years. I believe the work that has occurred in acute care can be applied in LTC. While Megan’s article focused on the hospital setting, COVID-19 underscored how the LTC setting was woefully unprepared for the impending tragedy. This article addressed the overwhelmed healthcare system, the demand for ongoing education, and the call for community engagement – all key to preventing transmission regardless of the setting. IP in LTC has not been given the attention it needed or deserved. The infection preventionist in LTC usually wears multiple hats and is forced to juggle priorities. I believe the new normal will change IP across all settings as IP outside acute care directly impacts the acute care setting. (www.ipstrategies.org)
RODNEY CHENG, MD - Los Angeles, CACOVID-19 has been responsible for a lot of economic hardships, disrupted a lot of lives, and killed a lot of people. Despite this- we can take away some positives from the pandemic and this article touches on them. There is an overdue emphasis on safety and personal protection. Who knows what the new normal will be, but at the very least, if we learn to wear masks when we are sick and wash hands often, this will have been an invaluable lesson. This article does a great job of explaining why this virus is effective as a disease vector. Lastly, it’s amazing to see scientists and health experts race to characterize the disease, and base protocols on good data. Given that virus shed from patients after 10 days are no longer replication competent, it’s reasonable and important to proceed with critical health services if asymptomatic.
KATELYN HARMS, MPH, CIC - Madison, WIInfection Prevention’s response to COVID has evolved as rapidly as the data is published. Unlike most science and research, the general public has been along for the journey- as everyone has been updated through media about each research breakthrough, failed trial, and vaccine development phase. The ebbs and flows of scientific discovery are challenging to translate, as success is not always linear. As this article points out, healthcare has made tremendous progress in understanding the virus and how to prevent transmission. But maintaining the public’s engagement with prevention measures will continue to be challenging. It’s important for science communicators to continue spreading facts and translating complex concepts into relatable and clear guidance. Infection Preventionists will continue to support the safety of our patients and healthcare workers. But managing this pandemic relies on support from everyone both inside and outside the healthcare setting.
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SUMAN RADHAKRISHNA, MD FACP - Los Angeles, CA
COVID continues to disrupt societal structure and our lifestyle this fall. Schools, colleges, nonessential workers are still learning and working from home. Zoom, common to comic book readers, is now a household word. Social distancing is now becoming physically and emotionally isolating. Small and large gatherings are epicenters for community outbreaks. How do we proactively work to control the spread of this disease? This is a good time to update our vaccination status and receive the influenza vaccine. Pharmacies and clinics can schedule appointments for vaccination. Vaccines for COVID are in clinical trials. Wearing a mask, washing/sanitizing hands, and social distancing reduces respiratory viral infections in addition to COVID. When transmission is controlled, restrictions ease allowing resumption of work and social activities. All of us have a crucial role to play in this process. Let us commit to proactively control COVID transmission.
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