The Healthcare Infection Control Advisory Committee met on November 3 and, to no one’s surprise, voted unanimously to accept their widely criticized draft guidelines, which weakens infection prevention precautions. The guidelines now go to Mandy Cohen, the CDC director, for approval.
ProMed-mail, an early warning network from the International Society for Infectious Diseases, issued a warning of a widespread outbreak of respiratory infections and clusters of pneumonia in children in China. The World Health Organization followed with a global alert on Nov 22. Some hypothesize that the infections are due to “immunity debt,” others that it is “immunity theft,” from immune systems weakened by prior Covid19. Even if this outbreak does not prove to be due to a novel pathogen, this serves as a warning for the future.
We have been facing new infectious disease threats at a steady pace, as avian influenza, fungal meningitis, and mpox (formerly monkeypox), just in the past two years. Covid19 caused a global pandemic in 2020. Do we really want to weaken measures to prevent the spread of infectious diseases now?
Criticisms of HICPAC fall into three general areas. First, their guidelines themselves water down infection control protection for all. In particular, the new proposal suggests that surgical masks (aka “baggy blues”) are equivalent to N95s in protectiveness and will be the new standard.
Peg Seminario, a retired safety and health director for the AFL-CIO, said the proposed guidelines “don’t protect healthcare workers and patients. They (HICPAC) certainly have not responded to any of the comments that have been made by the public or by experts both to HICPAC and the CDC.”
Seminario cited the recent report, “Employer-Reported Workplace Injuries and Illnesses,” that shows that the number of respiratory illnesses in the private health care and social assistance sector increased from 145,300 in 2021 to 199,700 cases in 2022, an increase of 37.5 percent.
Even though illnesses went up, HICPAC is recommending weakening protections. Seminario didn’t hold back in her criticism: The healthcare industry “failed. They failed healthcare workers, they failed patients, and they continue to do so. And so the idea that any government agency would let the industry write their own standards—I think it’s just wrong. And that’s essentially what CDC is doing.” She added, “The fox is running the hen house” now.
As an industrial hygienist, Seminario was extremely critical that there were no experts in respiratory protection on the committee nor did it include engineers who developed ventilation guidelines. She believes that the HICPAC committee members are likely so opposed to respirators “because once you are into recommending respiratory protection, with that comes a full respiratory protection program from OSHA,” with penalties for violations.
An epidemiologist and consultant, Michael Olesen, echoed this, believing the changes reflect “pressure to remove liability from hospitals.” He added, “I take a very clear position that we should be having respiratory protection mandates in all healthcare settings right now.”
Regarding the efficacy of surgical masks, Olesen said the Cochrane Review, a systematic literature review, “should be retracted.” He said, “The conclusions they reached were really bad” because of “cherry picking and misrepresentation of some of the studies.”
Roselie Bright, a retired FDA epidemiologist concurred. She added that HICPAC should consider that “the harm from wearing an N95 or better respirator is much much much lower than the harm of being wrong and wearing a surgical mask and getting infected.” Bright had many criticisms of the study design comparing N95s and surgical masks; the bottom line was that they were heavily “biased towards finding no difference between respirators and anything else.”
Aerosol researcher Jose-Luis Jimenez added, “The Cochrane Review is scientific garbage.” He continued, “There is high-quality evidence from many angles that shows that, of course, N95 masks are better.”
Jimenez, was also critical that HICPAC is “ignoring the huge body of evidence coming out of the pandemic” that most respiratory viruses have airborne transmission. “They don’t mention ventilation at all. They don’t address all the measures that you can do to remove the virus from room air.”
Each expert I spoke with is also concerned about HICPAC and the CDC’s secrecy. Jimenez said that NIOSH experts he’s spoken with agree with him but “are basically forbidden from talking to the press.” This is because “if they talked freely about the science, it will contradict the policies of the CDC,” he added.
The second recurrent area of criticism is about the procedures of the committee. It is emblematic that they only released the draft guideline to the public on the morning of their meeting. They have operated in secrecy and not published detailed minutes of meetings nor opened up documents for review. Further infuriating many, HICPAC severely restricted public comment. It seemed as though the committee allowed a few brief comments to appear in compliance but did not actually take them into consideration.
Finally, the membership of the HICPAC committee is narrow. “It doesn’t represent the full range of expertise needed,” Seminario said. “They just kept it as the small, internal club that it has been for many years.”
The World Health Network filed a complaint with the Office of the Inspector General early in November that the HICPAC is illegally constituted by having too few members. They also noted that the Federal Advisory Committee Act requires that committee memberships be “fairly balanced in terms of the points of view represented and the functions to be performed.” HICPAC is neither.
What Happens Now?
The draft recommendations have gone to the CDC for approval. The guidelines will be posted to the Federal Register for public comment.
“CDC and HICPAC review and respond to the public comments. The guidelines are revised to reflect public input.” Since HICPAC has not yet responded to the comments nor modified its recommendations, there is little reason to think that it will be different in the next round.
Nosocomial Covid-19
A recent study noted that “up to 10% of hospitalized patients with SARS-CoV-2 and other respiratory viruses may have acquired their infection in the hospital.” The death rate with Delta was 20% and has dropped to 10% with Omicron.
These articles only talk about death—and not the toll of long Covid, which we know affects 15-20% of people who become infected with Covid-19, even if they have a mild case.
Many patients who spoke at the HICPAC meetings said they had gotten Covid-19 when they went to the hospital and that the new policies were keeping them from getting care.
Given that, Dr. Art Caplan, professor of medical ethics at New York University’s Grossman School of Medicine, previously told me that dropping masking requirements in hospitals is “utterly, completely, irresponsible.” Similarly, staff refusing to mask, even when a patient requests it, is a moral failure. “The first principle is, you must do what is in the best interest of your patient,” he said.
Rationale
Several people were asked why they believe HICPAC is determined to water down protections. Consistently, respondents say, “to reduce liability.” Earlier in the pandemic, hospitals regularly tested patients and staff for Covid-19, and you could often tell where and how you became infected. Since staff are no longer masking and continue working when ill, and patients are not being tested on admission, you can no longer prove who infected you. Hospitals are the only ones who win in this scenario, absolving themselves of responsibility and liability.
What Are The Next Steps?
Asked what the public and practitioners can do now to object to HICPAC’s recommendations, Seminario suggested people “ask Congress to weigh in” to tell the CDC director to reject this draft and start from scratch to “develop guidelines that actually protect health care workers and the public.”
Under the current design, Jimenez said, “the hospitals and health care industry gets the benefit, and the cost is passed on to the patients and the healthcare workers in terms of disease costs.” This will also result in a “scarcity of healthcare workers,” so it will not be sustainable.
Per OSHA requirements, if an employee thinks a place is unsafe to work, the employer has to address the problem. The employee can file a confidential complaint, prompting an OSHA inspection. So, “employee safety is probably going to be the strongest lever we have,” Olesen noted.
The World Health Network urges people to call the Office of the Inspector General: (202) 619-3148, and complain the committee is illegally made up. National Nurses United has a petition urging CDC Director Cohen to reject HICPAC’s draft. They, and Seminario, among others, believe the process should start from scratch and emphasize broader stakeholder input emphasizing protection. Given the threat of new outbreaks, this seems reasonable.
The CDC is expected to decide whether to accept the HICPAC recommendations next month.
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