The Emerging Bird Flu Threat: An Infection Preventionist's Perspective

By Phenelle Segal, RN, CIC, FAPIC, Founder, Infection Control Consulting Services (ICCS)

For at least two years, the infection prevention and epidemiology community has been assessing the “pandemic of the century,” COVID-19, and what lessons were learned and how we can apply them to strengthen preparation for a future pandemic. We are also trying to determine whether our COVID-19 experiences have improved confidence in our ability to handle a large outbreak or another pandemic, even if it is on a smaller scale than what we experienced from 2020-2022.

One of the first obstacles to effectively preventing transmission of the deadly respiratory virus in 2020 was the lack of personal protective equipment (PPE) — masks effective enough to prevent healthcare workers from inhaling the highly transmissible virus, becoming ill, and possibly dying from the virus. We did our best to work with the limited supplies we had in our possession and pursued efforts to extend their use, like reprocessing or repurposing N95 masks and reusing disposable gowns. These experiences still haunt me today, and I continue to emphasize the need for facilities to ensure they are adequately prepared for the next pandemic, which is inevitable. We must consider where we experienced shortcomings and what we can learn from those difficult experiences. Doing so will enable us to continue growing and improving our preparedness. We know that complacency leads to potential catastrophe. Yes, we are all burned out and tired of the constant reminder that microorganisms are lurking and can strike at any time, but we must remain alert.

I would be in denial if I said that I’m not in the least bit concerned about the ongoing outbreak of avian influenza, also known as H5N1 or bird flu, among poultry and cattle that has become a daily news item. We are fully aware that what begins in animals (zoonosis) can mutate to infect humans, and that would begin the chain of person-to-person spread, potentially in as virulent if not more virulent manner than COVID-19 spread. Of additional concern is the inability to figure out how soon another pandemic may occur, but we know it is inevitable. Questions include whether it will be respiratory in nature, will it present as it did in 2014 with the hemorrhagic fever illness known as Ebola (five years after the H1N1 swine flu), where will it originate from, and can we contain it without huge consequences, as we were able to do with Ebola?

My concerns with H5N1 were present even before I read a recent Medscape article about the increasing H5N1 cases in North America, whereby the article's author highlighted one individual infected in Western Canada and one in Missouri. Both patients had no history of contact with animals, and the source of the virus is unknown. The most recent case, albeit presumptive at this juncture (as of December 13), is a patient hospitalized in Louisiana who had contact with sick and dead birds.

This is all particularly concerning to me and led me to recommend that all ICCS clients and other facilities should, if they have not done so already, begin putting together or reevaluating and updating their pandemic preparedness plans; educating staff about the emerging threat, particularly emergency department and ICU staff; and, equally as important, pulling the pandemic team back together to discuss mitigation strategies based on lessons learned. A key area to concentrate on besides patient placement and other vital steps is PPE and ensuring that, at a minimum, you have stockpiled enough masks, gowns and gloves to respond when we are faced with another outbreak.

I do not have a crystal ball, and neither do any of us in the infection control and prevention field, but we do know that another respiratory pandemic is not a matter of if but when. With increasing cases of H5N1 among animals, and more human cases reported every week, will this virus remain as a zoonotic outbreak or will it soon begin to mutate and spread from human to human?

HICPAC Draft Infection Control Guidelines: Key Considerations

By Phenelle Segal, RN, CIC, FAPIC

In early March 2020, it became clear that, despite decades of planning for a major pandemic, the United States and most of the world were unprepared for a respiratory virus as powerful and harmful as COVID-19.

The CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC) recently drafted updated guidelines to prevent transmission of pathogens in healthcare settings for CDC to review, and they are being met with concern and pushback by patient and staff safety advocates. While this pushback is necessary and warranted, for reasons explained well in this Medpage Today column, we need to also take into consideration the following:

• These guidelines are a draft and forwarded to CDC for review. They are preliminary at this juncture.  

• Cause for concern is valid. Preliminary guidance can appear convoluted and complex, potentially create confusion and possibly result in a repeat of the chaos experienced in facilities as they worked to respond to shifting guidelines during the pandemic, as seen particularly in acute care hospitals and nursing homes.

• Despite the CDC releasing many sets of guidelines during the acute phase of the pandemic (2020-2022), most providers followed previously instilled infection prevention practices to the best of our ability, just with more limited supplies. These practices were taught to us decades before the COVID-19 pandemic began, but there were still significant challenges we had never faced before.

• We should be optimistic that CDC will go back to HICPAC for further discussion before finalizing the guidelines, as the CDC is fully aware of how confusing their COVID-19 guidance appeared.

• We should be hopeful that, at a minimum, companies manufacturing personal protective equipment (PPE) will never experience another pandemic shortage as they did during the pandemic. We hope they will always be able to produce the PPE needed quickly and proficiently. Lessons learned from COVID-19 will hopefully be significant enough to maintain the changes made and fix the problems found in the supply chain. 

• Healthcare workers are naturally geared towards what’s safest and best for all. We should never deviate from this mindset. We need to trust our instincts, and while it is crucial to follow nationally recognized guidelines and standards, we need flexibility and may have to explain to authorities why we have chosen to interpret guidelines in the best possible way. They are, after all, guidelines and not mandates.

• Finally, it is important to note that the Occupational Safety and Health Administration (OSHA) and National Institute for Occupational Safety and Health (NIOSH) release requirements that are not only guidance, but required by law and must be adhered to. These rules could require more stringent infection prevention requirements than what is finalized in the new CDC guidelines.

In conclusion, we must continue to follow science and take precautions that go beyond what HICPAC is advising as the minimum. Doing so will help ensure we do all we can to keep patients and one another safe.

AAMI Issues New Standard on Water Quality for Medical Device Processing

Water quality is an important aspect of medical device reprocessing because of the critical role it plays in ensuring the effectiveness of the process. Water can be a source of microorganisms and chemicals that can negatively affect reprocessing and thus device safety.

The Association for the Advancement of Medical Instrumentation (AAMI) provides expert guidance for settings such as hospitals and ambulatory surgery centers (ASCs) on issues including the reprocessing of instruments and devices. In October 2023, in response to what the organization said was an "extraordinary amount of interest," AAMI published a new standard that establishes requirements for the quality of water used to process medical devices. The standard, ANSI/AAMI ST108:2023, "Water for the processing of medical devices." This new standard revises and replaces AAMI TIR34:2014/(R)2021, which provided information and guidance on water quality for device reprocessing.

AAMI states its new standard:

• identifies the categories of water quality that should be used during each stage of sterile processing;

• provides a risk analysis and establishes roles and responsibilities for processing facilities;

• assesses water quality based on factors such as pH, microbial level, conductivity and other properties;

• establishes maintenance, monitoring and quality improvement procedures for water treatment systems; and

• addresses emergency circumstances such as service interruptions and boil water advisories.

Infection Control Consulting Services (ICCS) assists central sterile processing departments (CSPDs) in maintaining strict compliance for reprocessing, including following nationally recognized guidelines and standards from the Centers for Medicaid & Medicare Services (CMS); accreditation organizations, including The Joint Commission; and organizations like AAMI. The ICCS team has extensive experience with monitoring the processes for pre-cleaning, high-level disinfection, sterilization, environmental cleaning and much more. ICCS also supports organizations that have undergone a survey that identified deficiencies associated with reprocessing and others in putting together a plan of correction.

Contact ICCS to learn what our team can do for your organization.

Should You Perform Hand Hygiene Before Gloving?

By ICCS Founder Phenelle Segal, RN, CIC, FAPIC

An article recently published in the Journal of the American Medical Association (JAMA) highlights a study intended to assess the value of performing hand hygiene prior to donning non-sterile gloves when compared to donning such gloves without prior hand hygiene.

The Infection Control Consulting Services (ICCS) team visits many facilities in the ambulatory surgery setting, and the most frequent violation of proper practices concerns improper hand hygiene. This violation occurs most frequently prior to healthcare personnel donning gloves.

Performing hand hygiene before donning gloves is a practice that's expected, with the Centers for Disease Control and Prevention (CDC) providing specific guidance in the area. Its guidance includes the expectation that staff will perform hand hygiene immediately before touching a patient, performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices.

CDC specifies the need for hand hygiene “before touching a patient.” Hence, the ICCS team expects to observe this practice before gloving. Donning gloves is an activity required prior to touching a patient, thus it should be preceded by use of hand sanitizer or handwashing to perform hand hygiene.

ICCS will continue to endorse hand hygiene prior to donning gloves until standards change. While this report is receiving significant media attention, it is important that providers of care do not make a change in their practice based upon the conclusion from a single study and article. We hope to see many additional studies on the subject so we can better determine whether standards should change.

ICCS services include observing practices and providing a written report of findings and suggestions for improvement. As noted, shortcomings with hand hygiene is the most common deficiency we observe in ambulatory settings. Ongoing hand hygiene education is required by the Centers for Medicare & Medicaid Services (CMS) as well as accreditation agencies. Our consultants are also able to assist with the development and provision of hand hygiene education that helps with patient safety and maintaining compliance.

Reuse of Single-Use Devices: Why Dental Practices Are Coming Up Short

Infection Control Consulting Services (ICCS) continues to provide a range of services to dental practices, including assistance with remediating deficiencies related to non-compliant practices which violate nationally recognized guidelines and standards.

An ICCS client was recently reported to the state department of health (DOH) and dental board by an employee who was concerned about the reuse of a single use item labeled as disposable. Depending on the type of item being reused, the state DOH will discipline the practice based on the level of risk to patients. The consequences of a visit from authorities include a spectrum of penalties from fines to the dentist(s) losing their license to the worst-case scenario of dental practices being required to notify patients that they may have been exposed to a bloodborne pathogen.

Reuse of single use devices remains a significant issue in the dental community. According to observations conducted onsite and via staff interviews, ICCS consultants report the following as the reasons dental practices fail to adhere to the standards:

• Cost savings

• Lack of recognizing international symbols (e.g., single-use symbol of a 2 with a slash through it)

• Misunderstanding product labels (disposable items are also considered one-time use)

• Unaware of the importance of a manufacturer’s instructions for use (IFU)

• Overall lack of general infection prevention and control education

ICCS reminds the dental community that the Centers for Disease Control and Prevention (CDC) released Guidelines for Infection Control in Dental Health-Care Settings in 2003 and updated in 2016, with an extensive checklist for offices to follow. The American Dental Association references the CDC guidance and encourages all dental practices to strictly adhere to them. Educating and reeducating staff on the importance of following nationally recognized guidance, following manufacturer's IFUs and considering items as single use if IFUs are absent are vital to patient safety.