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To Mask or Not to Mask as Part of Standard Precautions? · The SHEA Podcast

• 0:09
  SPEAKER_02: Welcome to this rapid response podcast brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the fields of healthcare epidemiology and antimicrobial stewardship.
• 0:25
  SPEAKER_02: I'm Dr.
• 0:26
  SPEAKER_02: Deborah Yokoa, president of the Shay Board of Trustees, and I'll be serving as your moderator.
• 0:32
  SPEAKER_02: Discussion on the podcast does not reflect Shay's perspective, but facilitates communication of multiple perspectives and experiences as we go through these challenging times together.
• 0:43
  SPEAKER_02: Shay is excited to launch this episode, To Mask or Not To Mask, as part of Stanner Precautions, a pro-con discussion.
• 0:50
  SPEAKER_02: Thanks to the availability of COVID-19 vaccines, we're in a much better place than we were early on in the COVID-19 pandemic.
• 0:58
  SPEAKER_02: Now, however, healthcare epidemiologists are being asked to weigh in on a variety of challenging COVID-19 related topics as we see relaxation and rescinding of some of the federal, state, and local public health recommendations and requirements temporally associated with the upcoming expiration of the COVID-19 public health emergency on May 11th, 2023.
• 1:20
  SPEAKER_02: These changes mean that decisions around whether or not to continue a number of strategies that were initially put into place to minimize transmission of COVID-19 in the healthcare setting will be shifting to individual healthcare facilities to make.
• 1:34
  SPEAKER_02: Whether or not healthcare facilities should continue to require masking of healthcare personnel is one of those challenging, very hot button issues at the moment.
• 1:44
  SPEAKER_02: We are so fortunate to have two incredibly accomplished, thoughtful discussants today to talk about this question.
• 1:51
  SPEAKER_02: First, I'll introduce Dr.
• 1:52
  SPEAKER_02: Ibikun Kalu.
• 1:54
  SPEAKER_02: Hello, Dr.
• 1:54
  SPEAKER_02: Kalu, and thank you for joining us today.
• 1:57
  SPEAKER_01: Thank you for having me.
• 1:58
  SPEAKER_02: Dr.
• 1:59
  SPEAKER_02: Kalu is the medical director of pediatric infection prevention and an associate professor in the Division of Pediatric Infectious Diseases at Duke University Hospital.
• 2:08
  SPEAKER_02: We also have Dr.
• 2:09
  SPEAKER_02: Erica Shinoy.
• 2:11
  SPEAKER_02: Hello, Dr.
• 2:11
  SPEAKER_02: Shinoy, and thank you for joining us today.
• 2:14
  SPEAKER_02: Thanks for having me.
• 2:14
  SPEAKER_02: Dr.
• 2:15
  SPEAKER_02: Shinoy is the Medical Director of Infection Control for the Mass General Brigham Healthcare System, a member of the Infectious Diseases Division and Massachusetts General Hospital, and an associate professor of medicine at Harvard Medical School.
• 2:28
  SPEAKER_02: So my first question is going to go to you, Dr.
• 2:30
  SPEAKER_02: Kalu.
• 2:31
  SPEAKER_02: Dr.
• 2:31
  SPEAKER_02: Kalu, you're the first author of a commentary published in Infection Control and Hospital Epidemiology entitled Back to the Future: Redefining Universal Precautions.
• 2:41
  SPEAKER_02: Do you think that we should incorporate masking into the standard precautions that we use for all patient encounters?
• 2:48
  SPEAKER_02: And if so, what are the reasons that you favor this approach?
• 2:52
  SPEAKER_01: Thanks for highlighting our recent commentary and to address the question.
• 2:56
  SPEAKER_01: Yes, my co-authors and I think that we are out of time where we can redefine what our standard precautions look like.
• 3:04
  SPEAKER_01: And I'll just highlight a few things.
• 3:07
  SPEAKER_01: The reason we're making that point is we would like to learn from what has occurred during the pandemic.
• 3:13
  SPEAKER_01: Specifically, we typically have a reactive approach to infection prevention.
• 3:17
  SPEAKER_01: And by redefining the use of masking, we might be a little bit more proactive with emerging pathogens that spread with droplet transmission, with yet undefined outbreaks that occur in our healthcare systems, and even with our equitable approach so that at the point of contact with our first line providers, as they're screening the patient, as they're checking the patient's in, as they're coming into a waiting room and getting vitals, we have at least a barrier of protection to prevent patient-to-staff transmission of some infections and sometimes staff-to-patient transmission.
• 3:52
  SPEAKER_01: So those are some of the reasons why I think we're at a point where we can redefine standard precautions.
• 3:58
  SPEAKER_01: One other thing that specifically ties to SARS-CoV-2 transmission, and I should mention this was not just about SARS-CoV-2.
• 4:05
  SPEAKER_01: It was just to, it started us off on the path, but it's thinking past SARS-CoV-2.
• 4:11
  SPEAKER_01: Initially, when we implemented universal masking, we did see a decline in some of the other respiratory viruses.
• 4:17
  SPEAKER_01: You can assume that the epidemiology of all our viruses changed because we weren't moving around much and our behavior changed, but masking certainly helped.
• 4:26
  SPEAKER_01: And I think in healthcare settings, it may continue to help with reducing the transmission of even non-SARS-CoV-2 viruses.
• 4:34
  SPEAKER_02: That's really excellent.
• 4:34
  SPEAKER_02: Thank you so much.
• 4:36
  SPEAKER_02: Dr.
• 4:36
  SPEAKER_02: Chinoy, similar question for you.
• 4:38
  SPEAKER_02: Do you think that we should incorporate masking into the standard precautions that we use for all patient encounters?
• 4:44
  SPEAKER_02: And if not, why not?
• 4:46
  SPEAKER_00: So I don't.
• 4:47
  SPEAKER_00: And that's actually for a few reasons.
• 4:49
  SPEAKER_00: So I'll lay them out here.
• 4:51
  SPEAKER_00: I think infection prevention strategies need to be commensurate with the risk.
• 4:55
  SPEAKER_00: And we're at a stage where we're transitioning the later phases of the pandemic to an endemic or more predictable time period for COVID-19.
• 5:03
  SPEAKER_00: And we really need to treat COVID-19 the way we do other sorts of endemic respiratory viruses.
• 5:09
  SPEAKER_00: Now, Dr.
• 5:10
  SPEAKER_00: Kalu made the good point that it's not just about COVID.
• 5:12
  SPEAKER_00: And I totally see that.
• 5:14
  SPEAKER_00: And I'm an absolute proponent of standard precautions, but not by wearing a mask when it's not needed.
• 5:19
  SPEAKER_00: So what I would advocate instead is a return or a reinforcement and a re-education around what standard precautions actually means.
• 5:27
  SPEAKER_00: Now, this audience may be mostly infection prevention types, but there may be others we're listening in.
• 5:32
  SPEAKER_00: So I'll just highlight what those really important parts of standard precautions are, which is hopefully everyone knows this, hand hygiene before and after every patient counter and other sorts of encounters and interactions with patients.
• 5:44
  SPEAKER_00: But then there's the addition of personal protective equipment depending on the tasks and what you're encountering.
• 5:50
  SPEAKER_00: So gloves when you're coming in contact with blood or body fluids, secretions or excretions, gowns when your clothes might come into contact with those same sorts of fluids, and then mask and eye protection when you're engaging in activities that might generate splashes and sprays.
• 6:04
  SPEAKER_00: And when I teach this to colleagues and clinicians, I really make the point that you can go into a patient room, into a patient counter.
• 6:13
  SPEAKER_00: There's no signage on the door telling you what you should be wearing, but you could still require all the personal protective equipment that I've mentioned because it's about the test.
• 6:21
  SPEAKER_00: And what I really hope we can do coming out of this pandemic is make these concepts so solid and second nature in the minds of healthcare personnel that they are attuned to it and that they use the personal protective equipment when it's necessary.
• 6:34
  SPEAKER_00: But we also have to make a lot more progress on making it easy for them to do this from a human factors perspective because it's not easy to actually do this.
• 6:42
  SPEAKER_00: If you've gone into the patient room and suddenly you figure out, oh, there's a very large draining wound, I'm going to have to manipulate that wound or examine it.
• 6:51
  SPEAKER_00: You need to then stop what you're doing in a busy hectic day and go get that personal protective equipment.
• 6:56
  SPEAKER_00: So we have a lot of work to do, I think, on the human factors part of this, but by implementing it the way it's meant to be implemented, you can effectively reduce the risk of transmission in healthcare settings.
• 7:08
  SPEAKER_00: And then the last piece I'll just say is that another part of standard precautions is respiratory etiquette and symptom screening.
• 7:14
  SPEAKER_00: And that's really important as well.
• 7:16
  SPEAKER_00: So in a standard sort of way, patients need to be assessed for symptoms.
• 7:20
  SPEAKER_00: If they have symptoms, a mask is put on them.
• 7:24
  SPEAKER_00: And then you take that next step of determining what sort of precautions are necessary.
• 7:29
  SPEAKER_00: And that would tell you what this what sort of PPE you would need to wear.
• 7:33
  SPEAKER_00: So I guess what I would sum this up is it's almost like a back to basics that we need to really, really make sure that people understand what standard precautions are and implement those effectively.
• 7:44
  SPEAKER_02: Thanks so much.
• 7:45
  SPEAKER_02: Really excellent points from both of you.
• 7:47
  SPEAKER_02: My next question goes to you, Dr.
• 7:49
  SPEAKER_02: Kalu.
• 7:50
  SPEAKER_02: Do you think that there will be a time or situation where you would favor discontinuing masking as part of standard precautions for all patient encounters?
• 7:58
  SPEAKER_02: And if so, what would have to change?
• 8:01
  SPEAKER_01: Thanks for the question.
• 8:02
  SPEAKER_01: Dr.
• 8:03
  SPEAKER_01: Shinoi made some really good points there.
• 8:05
  SPEAKER_01: And thankfully, we actually agree with the foundation of infection prevention.
• 8:10
  SPEAKER_01: There should absolutely be a return to basics across the board as it relates to hand hygiene, respiratory etiquette, working while sick, and even some of the basic practices we do to maintain our devices to reduce hospital-associated infections.
• 8:27
  SPEAKER_01: And because we can agree on that, I think we may be able to agree that we have struggled with human factors, with how we manage change in healthcare systems and how we protect our staff and patients, particularly as it comes to respiratory viruses or a lot of other transmissible infections.
• 8:45
  SPEAKER_01: We know that basic standard precautions incorporate the use of barrier protection.
• 8:50
  SPEAKER_01: It might be gloss, it might be something else, to ensure that our staff members are not inadvertently getting splashed or getting contaminated during the period when they're providing regular care.
• 9:02
  SPEAKER_01: I think what we've been more concerned with has been what occurs outside of the room.
• 9:07
  SPEAKER_01: So when our screeners and when our PS workers or nutrition providers are interacting with patients and there's lack of clarity around what's going on with the signs on the door, and they are interacting with patients for a prolonged time, incorporating some level of barrier protection would help in those settings as well.
• 9:28
  SPEAKER_01: But that's not directly answering the question you asked.
• 9:31
  SPEAKER_01: I do think there may be a time where we can favor removal of masking from universal precautions.
• 9:36
  SPEAKER_01: However, it's unclear what would lead to defining that period or when that time would occur.
• 9:42
  SPEAKER_01: We rely a lot on our surveillance techniques to pick up on emergent infections, but we've often learned that we miss the boat.
• 9:48
  SPEAKER_01: By the time we pick up on things, transmission has already started.
• 9:52
  SPEAKER_01: And that's why we have implemented point of contact barrier protection.
• 9:57
  SPEAKER_01: It may be, we may get to a point where, as Dr.
• 10:00
  SPEAKER_01: Shinoi mentioned, we have a better sense of endemic viruses.
• 10:04
  SPEAKER_01: We know that we haven't seen influenza in the last couple of weeks locally, for example.
• 10:10
  SPEAKER_01: Rhinovirus just kind of hangs around.
• 10:13
  SPEAKER_01: Rhinovirus seems to be around for most of the year.
• 10:16
  SPEAKER_01: And at least for us in the last three years, despite the varying rates of COVID-19, we still haven't had a single day where we have not had at least one fresh patient with SARS-CoV-2 in the hospital.
• 10:27
  SPEAKER_01: So I'm not sure that we actually have fully grasped what the epidemiology is at this point.
• 10:33
  SPEAKER_01: But as it changes, perhaps we can use data and evidence to inform a mask-on, mask-off approach and can tie it to a seasonal policy that would fit with the epidemiology.
• 10:46
  SPEAKER_01: If we never get there, I would still revert to the original position where at the point of contact with the patient, particularly for prolonged exposures, as patients are coming to seek care and are receiving care, an additional barrier would be helpful to interrupt transmission between patients and staff.
• 11:05
  SPEAKER_02: Thank you so much, Dr.
• 11:06
  SPEAKER_02: Kalu.
• 11:07
  SPEAKER_02: Dr.
• 11:07
  SPEAKER_02: Shinoi, do you think that there are times or situations where the benefits of masking for all patient encounters might outweigh the downsides?
• 11:16
  SPEAKER_02: And if so, what are some examples of these types of situations?
• 11:20
  SPEAKER_00: Yeah, I think those were those were excellent points.
• 11:23
  SPEAKER_00: So when would I say, since right now I'm advocating that we should not be masking, when when might I say that the downsides are outweighed by the benefits of masking?
• 11:33
  SPEAKER_00: And we haven't actually gotten into the downsides of masking.
• 11:37
  SPEAKER_00: And I think this conversation would be incomplete if we didn't talk a little bit about that.
• 11:41
  SPEAKER_00: So I'll just lay a couple of those out so we're kind of balancing those.
• 11:45
  SPEAKER_00: So we've already discussed the technical infection control reasons why I'm advocating not continuing masking, but some of the downsides are becoming more and more apparent over time.
• 11:55
  SPEAKER_00: We all, I think, will recognize that masking impedes communication.
• 11:59
  SPEAKER_00: That barrier is not equally distributed across patient populations.
• 12:04
  SPEAKER_00: So it's more of an impact in patients for whom English is not their preferred language, those are hard of hearing, those who rely on lip reading and other nonverbal cues.
• 12:14
  SPEAKER_00: There's also good evidence that the increase in listening effort, that's a term I didn't really know very much before the pandemic, but obviously you need to read the literature and learn more about these different uh areas.
• 12:26
  SPEAKER_00: But listening effort, the increase in listening efforts that's required when masks are using clinical counters is associated with increased cognitive load, not only for patients, but also for clinicians.
• 12:36
  SPEAKER_00: And we know that mass obscure facial expression, this can contribute to feelings of isolation both on both sides, patients and clinicians, other healthcare personnel, and negatively impact human connection, trust, and perception of empathy.
• 12:52
  SPEAKER_00: And there are studies that have shown all of this.
• 12:54
  SPEAKER_00: So those are real downsides.
• 12:56
  SPEAKER_00: So that the barrier to the level that we have to go to to be able to counteract those has to be pretty high.
• 13:03
  SPEAKER_00: So the easy situation first, the next respiratory virus pandemic, right?
• 13:08
  SPEAKER_00: There is going to be another one that's just uh, you know, a given.
• 13:12
  SPEAKER_00: And I think we have to be ready to institute not only masking, but other sorts of interventions in that situation.
• 13:19
  SPEAKER_00: I think what's less straightforward is this concept, and and Dr.
• 13:23
  SPEAKER_00: Kahlo is mentioning this of the what do we do in an endemic respiratory virus season?
• 13:28
  SPEAKER_00: Will we get seasonal?
• 13:29
  SPEAKER_00: And I think the the point that was mentioned that there hasn't been a day when we haven't had a patient with COVID in the hospital.
• 13:35
  SPEAKER_00: We have that's where we are the same way in Massachusetts.
• 13:38
  SPEAKER_00: But just because we haven't gotten to that, there will be some low-level virus circulation, whether it's rhinovirus or some of the other endemic coronaviruses that cause the common cold.
• 13:48
  SPEAKER_00: But I think without broad masking in the community, one of the arguments has been workforce preservation, that by instituting masking, we'll preserve the workforce.
• 13:57
  SPEAKER_00: And I think that's really highly unlikely to be effective when there's no masking in the community.
• 14:03
  SPEAKER_00: It may prevent, for example, a cluster in a break room.
• 14:07
  SPEAKER_00: But again, in the break room, people are generally unmasked because they're having a break and eating.
• 14:11
  SPEAKER_00: So it doesn't really jive there that that's going to be working.
• 14:14
  SPEAKER_00: But I think the more likely sort of response would be facilities responding to really hyper-local decisions.
• 14:21
  SPEAKER_00: You know, we have all experienced clusters or outbreaks of influenza or COVID on a unit.
• 14:27
  SPEAKER_00: And that's when we will often implement a variety of sort of interventions to try to break those chains of transmission.
• 14:33
  SPEAKER_00: But those are really hyper-local decisions that are made with infection control based on the totality of circumstances.
• 14:41
  SPEAKER_00: I think what the broad-based masking that's being advocated does is it really removes adaptability and response to local situations.
• 14:50
  SPEAKER_00: And outside of a pandemic, the early and middle stages of the pandemic, it really kind of ties our hands for more targeted interventions.
• 14:58
  SPEAKER_00: But I do agree there's no metric out there.
• 15:01
  SPEAKER_00: There's no metric out there that would say turn on masking.
• 15:04
  SPEAKER_00: And I think a lot of places are and a lot of people are struggling trying to figure out what could that metric be.
• 15:10
  SPEAKER_02: Thank you so much.
• 15:11
  SPEAKER_02: You've both made excellent points about potential benefits and downsides of requiring healthcare personnel masking.
• 15:19
  SPEAKER_02: So this question goes to both of you.
• 15:22
  SPEAKER_02: We've been focused so far during this discussion on healthcare personnel masking, but what about requiring masking for non-healthcare personnel, specifically patients and visitors in the healthcare setting?
• 15:34
  SPEAKER_02: And I'll turn to you first, Dr.
• 15:35
  SPEAKER_02: Kalu.
• 15:36
  SPEAKER_01: Yeah, it's a good point.
• 15:37
  SPEAKER_01: So a lot of our focus has been on healthcare workers and what are the potential risks to the healthcare worker or even to the patient.
• 15:46
  SPEAKER_01: But we know that the healthcare team involves the support system for the patient.
• 15:52
  SPEAKER_01: And quite often that includes a caregiver of some sort or a support person who spends a significant amount of time in the hospital.
• 15:59
  SPEAKER_01: I think we all typically consider the hospital environment a higher risk setting than some of our community settings.
• 16:07
  SPEAKER_01: And we expect that people that are coming in agree, and it might be silently agree, but agree to some precautions around coming into the hospital to ensure they do not get unnecessarily exposed to infections, but they also do not bring in infections that worsen the care of patients, the patients they're visiting or the patients.
• 16:30
  SPEAKER_01: Despite that, I do think that we might have been considered too restrictive with certain policies during the pandemic as it relates to patients and caregivers.
• 16:38
  SPEAKER_01: And as we implement policies, we have to weigh the evidence, also compliance and also burden on the patients and caregivers.
• 16:47
  SPEAKER_01: So if we do have metrics at the local level that we think could inform masking behavior for patients and caregivers, I would encourage people to use those, although I'm not sure that they truly exist.
• 16:59
  SPEAKER_01: Or if there are outbreaks going on in your hospital, that might be a reason to implement more stringent masking guidelines.
• 17:06
  SPEAKER_01: For the most part, a lot of institutions are looking at peeling back masking recommendations for patients and caregivers.
• 17:14
  SPEAKER_01: It does make the impact of retaining masking for healthcare workers likely minimal.
• 17:20
  SPEAKER_01: So it makes it difficult to say the large proportion of people in the hospital, sometimes patients and caregivers, do not have to wear masks during interactions, but staff members do.
• 17:31
  SPEAKER_01: And so it makes it a little bit more difficult to implement that type of policy.
• 17:34
  SPEAKER_01: But I think that could be a reasonable approach.
• 17:37
  SPEAKER_01: On the other hand, going back to my earlier point about potentially including barriers at the highest risk context, so face-to-face interactions with the patient, and if they are able to comply with masking, I think retaining it for patient to provider interactions, say, for example, in a high-risk clinic and even in the hospital setting during transport, for example, when the transporter is riding their face for a prolonged period, might be reasonable.
• 18:04
  SPEAKER_01: I personally struggle with the caregiver approach, just knowing that if we have other policies in the hospital, for example, being in your hand hygiene, being in your family members' room, and limiting interactions with other patients, that may help us prevent transmission as compared to masking.
• 18:21
  SPEAKER_01: So it's a long way of saying I think it depends.
• 18:23
  SPEAKER_01: I don't think it's a yes and no answer.
• 18:25
  SPEAKER_01: And ultimately it might come down to a local decision, but there's evidence to support being less restrictive.
• 18:32
  SPEAKER_01: So not pushing for universal masking for all patients and caregivers for the foreseeable future.
• 18:38
  SPEAKER_02: Thank you so much.
• 18:39
  SPEAKER_02: Excellent answer.
• 18:40
  SPEAKER_02: Dr.
• 18:41
  SPEAKER_02: Chinoy, same question for you.
• 18:42
  SPEAKER_00: Yeah, I would advocate going away from masking for patients and visitors with the caveat, again, that we need to really hone in on the symptom screen and the respiratory etiquette.
• 18:53
  SPEAKER_00: I acknowledge that the points Dr.
• 18:55
  SPEAKER_00: Kalu made were that the impact on these interactions between patients and their loved ones and their caregivers are impacted by the use of masks.
• 19:04
  SPEAKER_00: And I think the reality that we all know in the inpatient settings primarily is that patients are not masking.
• 19:11
  SPEAKER_00: They're not masking, they're not masking with all their visitors who are coming in.
• 19:14
  SPEAKER_00: And that's because there is a clear impulse to have a human connection between the patients and their visitors.
• 19:21
  SPEAKER_00: Now, in a pandemic, early pandemic situation, this was entirely the right thing to do to have patients masking, healthcare personnel masking, and the visitors masking.
• 19:32
  SPEAKER_00: But at this point, where they're in the community, there is really no masking, and we understand the impact it's had.
• 19:40
  SPEAKER_00: And again, the impact, which we haven't actually addressed too much here, of COVID itself has been really mitigated through the use of vaccines and all the medical countermeasures we have in terms of therapeutics, and fortunately, less virulent variants that have come around.
• 19:58
  SPEAKER_00: The impact is less.
• 20:00
  SPEAKER_00: It's not zero, it's not, they're still an impact, but the consequences are far different than they were early in the pandemic.
• 20:07
  SPEAKER_00: Again, I do acknowledge that there could be situations where locally there's a need to implement a temporary, kind of time-limited use of masks, but broad-based masking for patients and visitors does not, to me at this point, seem like the right thing to do.
• 20:25
  SPEAKER_02: Terrific.
• 20:26
  SPEAKER_02: Thank you so much.
• 20:28
  SPEAKER_02: This next question, I think you both touched on a bit.
• 20:31
  SPEAKER_02: So we'll soon be in a situation where we'll no longer be able to use CDC COVID-19 community transmission levels for decision making, since these metrics will soon no longer be available because the CDC will have much more limited access to COVID-19 test result data after lifting of the public health emergency.
• 20:51
  SPEAKER_02: Do you have thoughts about what metrics your healthcare facilities might use to assess COVID-19 transmission risks to help with decision making around dialing up or dialing down COVID-19 prevention strategies?
• 21:05
  SPEAKER_02: And I'll start with you, Dr.
• 21:06
  SPEAKER_02: Shinai.
• 21:07
  SPEAKER_00: This is like not the$64,000 question, the million-dollar question, what are we going to do?
• 21:12
  SPEAKER_00: I think in truth, with the advent of home antigen testing, these levels and metrics have been really not very helpful for a while.
• 21:20
  SPEAKER_00: This is more like the reality because they're just capturing testing that's occurring in healthcare settings or those that are reported.
• 21:27
  SPEAKER_00: And we know that home antigen testing really people are not reporting either the negatives or the positives.
• 21:34
  SPEAKER_00: I think the other part is that even testing in healthcare settings, which drives has driven most of these metrics, is changing.
• 21:41
  SPEAKER_00: Fewer facilities are doing admission or other asymptomatic testing.
• 21:45
  SPEAKER_00: So what we really need are metrics that incorporate more than testing, since there's so many trends out there that are going to influence testing behavior and reporting.
• 21:53
  SPEAKER_00: You know, I think the wastewater data is something that could be useful.
• 21:58
  SPEAKER_00: I am not a wastewater data expert.
• 22:00
  SPEAKER_00: So I can't speak to that, but it's something obviously that's not affected by behavior around testing.
• 22:06
  SPEAKER_00: But I think the other part is that we need some aggregate metric of respiratory viral burden because it's not just COVID out there.
• 22:14
  SPEAKER_00: Dr.
• 22:14
  SPEAKER_00: Kalu made great points.
• 22:15
  SPEAKER_00: There's all this rhinovirus, there's influenza, there's all sorts of other things circulating.
• 22:20
  SPEAKER_00: And when we're honing in just on COVID, we're not seeing the totality of the viral burden that might be out there.
• 22:26
  SPEAKER_00: So some have advocated of thinking about using an ILI metric where it's above a certain threshold that might be an indication that we need to bring out some of our tools.
• 22:36
  SPEAKER_00: And I would just kind of end this part of my comments by saying that it's not all about masking, as we know.
• 22:42
  SPEAKER_00: There's a lot of tools that we have in our toolbox.
• 22:45
  SPEAKER_00: It may not be the on-off switch on masking, it may be an on-off sort of ramp related to other things that we do related to screening or testing changes in addition to masking.
• 22:56
  SPEAKER_02: Excellent points.
• 22:57
  SPEAKER_02: Thank you.
• 22:58
  SPEAKER_02: And Dr.
• 22:59
  SPEAKER_02: Kalu, what are your thoughts?
• 23:01
  SPEAKER_01: I agree with a lot of what Dr.
• 23:02
  SPEAKER_01: Chinois already mentioned.
• 23:04
  SPEAKER_01: As we are approaching a period where some of our surveillance certainly will not and cannot capture the true burden of infection.
• 23:14
  SPEAKER_01: We realize that what has still been challenging has been the symptomatic, pre-symptomatic, asymptomatic people that can still transmit infections, particularly as it relates to SARS-CoV-2, and that we don't, we can't see until maybe we're past the precipice of something and we see a surge or something related to that.
• 23:34
  SPEAKER_01: Because that occurs, it makes it difficult to say we're using our standard surveillance reports that looking at positive tests on the population of people to determine if and when we can implement masking or some other public health approach.
• 23:48
  SPEAKER_01: Quite often we've also realized that even population-based symptom screening or symptom screening at the healthcare facility is largely ineffective, unfortunately.
• 23:59
  SPEAKER_01: And even travel screening is also ineffective.
• 24:01
  SPEAKER_01: And that's because of how people answer questions or even how we as providers ask those questions, where we might lead into, lead them to just say no, just to move through the process.
• 24:12
  SPEAKER_01: And so that means we rely on some level of passive surveillance, wastewater might be one of them, or as Dr.
• 24:19
  SPEAKER_01: Shinoi mentioned, influenza-like illnesses, ILIs.
• 24:23
  SPEAKER_01: Although both as a pediatrician and one that has worked in different community settings, we realized very quickly that ILIs, so influenza-like illnesses, it might be an inadequate screening tool to capture SARS-CoV-2 infections, knowing that some people might present with symptoms that do not fit with ILI, our typical ILI syndromes.
• 24:44
  SPEAKER_01: All of that to say is we will not have one metric.
• 24:47
  SPEAKER_01: We can use what we've learned.
• 24:48
  SPEAKER_01: So, for example, in our institution, we've standardized surveillance tools that look at hospital-associated respiratory viral illnesses.
• 24:57
  SPEAKER_01: That is a very local tool looking at our entire patient population.
• 25:01
  SPEAKER_01: And it's also based on provider decision to test.
• 25:04
  SPEAKER_01: But at least it gives us a trend line over the course of the year and that can tell us if people within our institution, so after they've come in, they've been here for about three to seven days, are now picking up respiratory viral infections.
• 25:16
  SPEAKER_01: And that might be something that people can develop and use at a local level.
• 25:21
  SPEAKER_01: I'm certainly thankful to our public health professionals that have continued to maintain state-level surveillance data.
• 25:26
  SPEAKER_01: While there may be limitations in the data sets, there's still a useful snapshot to what's happening across your state and of course across the country as the CDC continues to provide.
• 25:36
  SPEAKER_01: And I think we've been a little bit better about working with our employee health providers or colleagues, and some of us even function in both roles, but maintaining visibility into staff infections or even just the changes in staff presentation, so being present with symptoms of illness may help because those are some objective measures that we can capture without necessarily waiting for a regulatory organization to give us a transmission level that may or may not directly apply to our local policies.
• 26:08
  SPEAKER_02: Thank you so much.
• 26:10
  SPEAKER_02: Clearly, very challenging issue.
• 26:12
  SPEAKER_02: So really appreciate the thoughtful input from both of you.
• 26:15
  SPEAKER_02: My last question also goes to both of you, and it's a broad one, but appreciate any thoughts that you might have.
• 26:22
  SPEAKER_02: Do you have any concluding words of wisdom about how healthcare facilities can think about transitioning to long-term sustainable strategies that balance the potential benefits and downsides of interventions aimed at preventing transmission of COVID-19 and other respiratory viruses in the healthcare setting?
• 26:42
  SPEAKER_02: And I will turn to you first, Dr.
• 26:44
  SPEAKER_02: Kalu.
• 26:45
  SPEAKER_01: That is a very broad question.
• 26:48
  SPEAKER_01: I will start with a very biased answer of work with your hospital epidemiologist and your infection preventionists.
• 26:55
  SPEAKER_01: We are here to help.
• 26:57
  SPEAKER_01: We are all somewhat learning as we go along, actually as we have different emerging pathogens that may not necessarily fit with our dogma within infection prevention.
• 27:09
  SPEAKER_01: Having flexibility built into approaches, both for the use of PPE, isolation, but also how we screen patients and how we move them within and outside of our institution would help.
• 27:22
  SPEAKER_01: And we've touched on this very briefly, but as we're discussing policies, we think it might be directly helpful to a patient or a staff member.
• 27:30
  SPEAKER_01: Staff morale plays a big part in this.
• 27:33
  SPEAKER_01: And we haven't always emphasized that in some of our approaches to policy, where we might consider patient risk, cost, and staff just overall workforce management.
• 27:46
  SPEAKER_01: But I think prioritizing staff morale early on in the process and all the human factors management, change implementation might help us with sustainability in particular.
• 27:57
  SPEAKER_01: And this goes back to one of my earlier points.
• 28:00
  SPEAKER_01: Part of the reason why it might be difficult to do a mask-on-mask-off approach might be the frustration and the mental health burden that comes with that.
• 28:09
  SPEAKER_01: And so ultimately, if a decision is going to be made around masking, having a long ramp for people to know what to expect.
• 28:17
  SPEAKER_01: And hopefully, without any sudden outbreak or emerging pathogen, any change to that policy should also have a long ramp so people know what to expect when it's coming.
• 28:28
  SPEAKER_01: Flexibility, morale, use and rely on your hospital epidemiologist and infection preventionist as much as you can, and just support for public health professionals as well may help us in the long run.
• 28:39
  SPEAKER_01: We have a lot more work to do.
• 28:40
  SPEAKER_02: Excellent points.
• 28:41
  SPEAKER_02: Thank you.
• 28:42
  SPEAKER_02: And Dr.
• 28:42
  SPEAKER_02: Shannai, same question for you.
• 28:45
  SPEAKER_00: I I agree.
• 28:46
  SPEAKER_00: This is a tough one.
• 28:47
  SPEAKER_00: I think I have two points to make here.
• 28:50
  SPEAKER_00: And one is about basics.
• 28:53
  SPEAKER_00: One of the reasons I love infection prevention control is there are basic things that we can do that are incredibly powerful and they're protective for our patients and for our healthcare personnel.
• 29:03
  SPEAKER_00: But we're coming out of this pandemic very exhausted.
• 29:08
  SPEAKER_00: There's burnout across healthcare, across many sectors.
• 29:12
  SPEAKER_00: So we're not so unique across all of society, but within healthcare, within IPC as well, that could be turned around.
• 29:20
  SPEAKER_00: And if we really get down to the basics that we know are so effective and remind and re-educate and rededicate to them and implement them, I think that is a really important thing to think of in terms of sustainability for the future.
• 29:35
  SPEAKER_00: I think the second point is something that was brought to my attention by a colleague, and it's lessons from implementation science.
• 29:43
  SPEAKER_00: So there are some real experts in implementation science who have proposed what's called the dynamic sustainability framework, which means kind of what we've already talked about, which is that we are continuously learning, we are problem solving, and we have to adapt our interventions to be focusing on the fit between what the intervention is, what the context is of that situation, and that we're constantly improving as opposed to continuing to implement things that have diminishing outcomes over time.
• 30:12
  SPEAKER_00: And I think that sort of approach to healthcare, maybe we've been to infection control policy, maybe we've been inching towards it, is something that we really need to embrace.
• 30:23
  SPEAKER_00: Because whereas Dr.
• 30:24
  SPEAKER_00: Kalu, I hear what you're saying about this, the on and the off ramp and the morale of healthcare personnel, I think the morale is also impacted by the belief in whether or not the intervention is appropriate for the time or the place.
• 30:40
  SPEAKER_00: And so by having an approach that is continuous learning, continuous adaptation, and using the tools that are appropriate and will give us the highest returns over time, I think that we can actually have much more buy-in from our colleagues as to why we're proposing the sorts of interventions we propose.
• 31:01
  SPEAKER_02: Really excellent and truly words of wisdom from both of you.
• 31:06
  SPEAKER_02: So I want to again sincerely thank Drs.
• 31:08
  SPEAKER_02: Kalu and Chinoy for participating in this podcast and for this really, really excellent discussion.
• 31:14
  SPEAKER_02: As healthcare epidemiologists, so many of the decisions that we make are based on very nuanced balancing of potential risks and benefits.
• 31:22
  SPEAKER_02: So having this opportunity to hear these different perspectives so thoughtfully articulated by both of you, I know will be very useful to our listeners as they make decisions around masking requirements at their own healthcare facilities.
• 31:37
  SPEAKER_02: So thanks again to both of you.
• 31:39
  SPEAKER_01: Thank you.
• 31:40
  SPEAKER_02: Thanks so much.
• 31:41
  SPEAKER_02: That was a lot of fun.
• 31:42
  SPEAKER_02: This podcast can be accessed on Shay's Online Education Center, Learning CE under the Rapid Response Program, where you'll also find resources such as the Shea Town Halls.
• 31:54
  SPEAKER_02: This concludes today's episode of the Rapid Response Podcast.
• 31:57
  SPEAKER_02: Thanks so much for tuning in.