Urgent Need for a Paradigm Shift in Infectious Disease Control Amid 2024 Outbreaks

The summer of 2024 is filled with news and scientific reports of expanding threats from infectious diseases. For the most part, there has been little public interest, and the government response directed at the dangers posed by these outbreaks has been muted. We have seen COVID-19 office and ER visits more than double, and hospitalizations almost double compared to last year. The reach of the N1H5 bird flu pandemic is expanding, as is the spread of the Mpox virus which appears to now be airborne.
 
We need a paradigm shift in our approach to infectious diseases. A recent viewpoint in the journal Medicine discussed 5 areas of concern.
 
The first and most important area of concern is a siloed feedback loop.Mostly, the individuals implementing the interventions justify the strategies using governmental advisory panel recommendations, but individuals from the same industry sit on these panels and formulate these recommendations. These concerns were raised by labor unions, public health, and patient and worker advocacy organizations representing over 6 million individuals.

The need to expand the scope of the expertise on these panels was recognized by CDC leadership stating. “…working to expand the scope of technical backgrounds of participants on the HICPAC Isolation Guideline Workgroup and eventually among the committee members through established processes in accordance with the Federal Advisory Committee Act (FACA) regulations and guidance.”

During the August 2024 HICPAC meeting, an Occupational Safety Professional was appointed to HICPAC, and the Isolation Precautions Workgroup now has expertise including “Prevention, Healthcare Epidemiology, Employee Occupational Health, Aerosol Science, Industrial Hygiene, Long-Term Care/Post-Acute Care.“

Implementing enhanced barrier (EB) precautions for nursing homes is a glaring example of this flawed decision-making. The CDC recently released an antibiotic resistance report showing an overall 20% increase in hospital-onset infections and a 5-fold increase in Candida auris infections. However, implementing EB precautions in nursing homes negatively impacts community control of C auris, since patients carrying and sometimes infected with major pathogens, including C auris, are allowed “to participate in group activities.”
 
A second example has been the delayed and almost complete lack of recommendation of optimal strategies to stop the airborne spread of disease by the health care industry. The CDC leadership recognized possible shortcomings in their proposed recommendations and has asked HICPAC to specifically address whether N95 masks should be used for all pathogens that spread through the air (new WHO terminology).

The second area of concern is an overreliance on randomized controlled trials.All too often, the lack of supportive randomized controlled trials (RCTs) is cited as an excuse for not making firm recommendations. Unlike pharmaceutical trials, where the intervention often involves taking a medication once or twice daily, public health interventions are often complex, and subject adherence can be a significant factor. In addition, some RCTs are not ethical to run, and surrogate or related outcomes are used instead.
 
For example, the highly quoted Bangladesh masking study by Jason Abaluck and colleagues was actually a masking education study to encourage masking. This was a massive study with over 342 thousand participants. Both the control and experimental arms wore masks. There was only an 11.6% difference in COVID-19 symptom reduction, but the masking compliance difference was also small 28.8 percentage points, which made the positive results much more impactful.

However, detractors often view this as a negative study even though the subjects did not use N95 masks, and its design made detection of mask effectiveness more difficult. If all patients in one trial arm wore masks and in the other trial arm did not, the reduction in COVID-19 symptoms would be expected to be over 40% and even higher if N95s were used.
 
Significant biases can also exist. For example, a potential bias may have been present in a study by Loren Miller and colleagues that evaluated chlorhexidine bathing and decolonization in nursing homes. The researchers observed a reduction in the study’s primary outcome of hospital transfers due to infections. However, the intervention arm had extensive promotion and encouragement of best practices, which did not occur in the study's control arm. In a similar hospital-based study, the ABATE Study, which promoted best practices in both arms, a reduction in clinical cultures for MRSA or vancomycin-resistant enterococci in general hospital populations was not achieved. Thus, one might assert that a bias created a positive result in Miller and colleagues’ study, and when this bias was not present in the ABATE study, the result was negative.

The third area of concern is the overreliance on hand hygiene. Horizontal interventions must be supplemented with patient screenings and knowledge of carrier states. Although hand hygiene is essential, the US Veterans Health Administration observed marked reductions in methicillin-resistant Staphylococcus aureus (MRSA) compared to methicillin-susceptible Staphylococcus aureus (MSSA) by implementing near-universal surveillance and isolation protocols. Even with SARS-CoV-2, an airborne virus, our initial response was to focus on hand sanitizer rather than masks and upgrading ventilation.

The fourth area of concern is the normalization of deviance or acceptance of the status quo. We must not normalize deviance. This has happened with our approach to MRSA, when we focus on reacting to outbreaks rather than preventing them. It has also happened with COVID-19 with society's apparent acceptance, or at least denial, of the imperative to prevent SARS-CoV-2 infections and the long-term disability from long COVID. This acceptance is illustrated by our referring to “severe disease” only if an illness results in hospitalization or death, thus mitigating the danger of infections in patients who are not hospitalized but who develop life-changing chronic disability (long COVID) after a “mild” infection.

The fifth area of concern is our views of the burden or cost-effectiveness of interventions. Too often, our current view of cost-effectiveness is increasing or maintaining similar profitability levels compared to current services. US Senator Charles Grassley stated, “When it comes to our nation’s hospitals, a business model that prioritizes profits over patient care and safety is unacceptable.” Currently, many health care systems are for-profit, and private equity firms are purchasing health care systems. A recent study has observed a decreased quality with an associated increase in central-line bloodstream infections and falls. We need to remember that the US Government has determined that every year of quality life lost costs society $500,000, and every life lost equates to $9.6 million.

Conclusion: Thus, we must extensively revamp our strategies to provide safe indoor environments and stop the spread of airborne diseases. This includes measuring CO2 levels to check for proper indoor ventilation, HEPA filtration, and installing UVC lighting fixtures. Most importantly, we need to internalize that even breathing and talking can spread airborne diseases. It does not require an aerosolizing procedure. AND N95 masks are required to provide increased protection against contracting airborne diseases. It has recently been demonstrated in human volunteers that N95 masks reduce the exhaled viral load of SARS-CoV-2 by 98%. Thus, 2-way masking is most effective.

In addition, knowledge of the patient’s microbiome should be our long-term goal. However, until this can be accomplished, we should at least screen patients for named pathogens commonly found in the community. If we do not act, the cost of death and disability will be far greater.

Public Health must regain the trust of local governments and the public. Our society must become willing to accept some restrictions (such as universal or 2-way masking in high-risk settings) and make the needed investments in ventilation, N95 masks, and vaccinations. It must also implement an expanded screening system for carriers and report infections caused by major pathogens.