Public Comment by Andrew Wang, PhD, MPH and Raj Chaklashiya, on behalf of the People’s CDC, submitted to the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) regarding the inadequacy of proposed updated guidelines.
COVID-19 infections injure, harm, and cause mortality among Americans. Based on both case counts and estimates, millions of Americans also are suffering from Long COVID. It is important that everyone in healthcare settings is protected from COVID-19 infections. SARS-CoV-2 is spread via inhalation of aerosol particles with a higher risk at indoor settings compared to outdoor settings. Healthcare settings must employ layers of protection to ensure the highest quality of care and to prevent healthcare acquired conditions. Layers of protection including high quality respirators such as N95s, ventilation, and air filtration have been demonstrated to protect individuals from a COVID-19 infection.
HICPAC’s Work Group on the Isolation Precautions Guidance has proposed a less cautious approach to implementing precautions that lends to minimal protections and allows health care employers an undefined broad discretion to create their infection control plans. The CDC ultimately should establish a high standard for infection control measures. The proposed approach was implemented by the CDC since the start of the COVID-19 pandemic that has enabled health care employers to avoid providing necessary protections for health care personnel and patients, based on cost considerations. As a result, I urge HICPAC and the CDC to establish an approach in the updated guidance explicit about precautions needed to protect health care workers and patients from infectious diseases. This protective approach must include assessments that evaluate the level of exposure, select appropriate control measures (including PPE) for each job, task, and location, resulting in a written exposure control plan following the hierarchy of controls.
The Work Group on the Isolation Precautions Guidance has proposed updated terminology on infectious disease transmission (“air” and “touch”) – but fails to fully recognize the science on aerosol transmission and the role of inhalation of aerosolized pathogens. There are significant errors in the new draft recommended categories of “air” and “touch” as modes of transmission for healthcare-related infections. While CDC/HICPAC proposes the new category of “air” transmission, they fail to recognize the critical role of inhalation and continue to recommend use of surgical/medical masks, which do not provide respiratory protection against inhalation of infectious aerosols. It is also important to update the list of infectious diseases currently classified as transmitted by the airborne or droplet routes to those that can be transmitted via aerosol transmission/inhalation.The Work Group’s proposals ultimately weaken protections for health care personnel even though the Covid-19 pandemic underlined the importance of strong protections for health care personnel and patients.
The current evidence review on N95 respirator and surgical mask effectiveness used for developing the proposed approach is flawed and must incorporate evidence from scientific researchers and experts in respiratory protection, aerosol science, and occupational health. The evidence review focused on findings from a randomized controlled trial that was limited in its generalizability and failed to achieve a conclusion on N95 respirators and surgical masks. The review omitted other applicable data and studies. In particular, it failed to look at extensive evidence on respirator effectiveness from laboratory studies and studies in non-health care workplaces. It is both unethical and unconscionable that HICPAC and the CDC have developed these recommendations that severely impact the lives and health of workers and patients on severely limited review.
CDC/HICPAC inexplicably fails to acknowledge the importance and function of core control measures for infectious aerosols. The large body of evidence on the effectiveness of respirators and the importance of ventilation and air filtration for controlling worker exposure to infectious aerosols have not been considered. There are no recommendations on ventilation. The proposed use of airborne infection isolation rooms (AIIRs), or other approaches to isolation when use of AIIRs is not possible, is significantly limited. In addition, source control (limiting outward emission of infectious aerosols) is not adequately considered in the context of personal protection from inhalation.