COVID-19 Experience Suggests Need for National Reporting System for Dangerous Pathogens

After decades of reluctance to implement a national reporting system in the United States, we witnessed almost overnight the formulation of case definitions and comprehensive national reporting from all healthcare facilities. The onslaught of COVID-19 brought about this much-needed improvement. Now, we must ask: Why has this not been done for other dangerous pathogens?

The healthcare industry cites the burden of reporting and lack of resources as justification for its inaction. Infection preventionists (IPs) are stretched to the limit with both reporting and patient responsibilities with an unwillingness of facilities to prioritize infectious disease prevention in their operating budgets. In addition to financial concerns, accountability was also at the heart of the inertia in implementing the infrastructure needed for a comprehensive national reporting system for dangerous pathogens.

Intense concern has been focused on nursing homes. On May 6, 2020, the US Centers for Medicaid and Medicare Services (CMS) issued an interim final rule regarding COVID-19 cases among residents in nursing homes. Nursing homes are now required to report COVID-19 residents and staff infections to the US Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) and to the other facility residents along with their families and/or representatives. The regulation states: “Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or 3 or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.”

Of the CDC’s 5 urgent bacterial threats only 1, Clostridioides difficile has required reporting, but participation is only mandated for hospitals, and only those which participate in Medicare’s prospective payment system. Thus, critical access hospitals are not included. Carbapenem-resistant enterobacteriaceae (CRE) is not required to be reported on a national basis, even though their bloodstream infections have close to a 50% fatality rate. Candida auris and carbapenem-resistant Acinetobacter are also not required to be reported. Of the CDC’s 11 Serious Threats only methicillin-resistant Staphylococcus aureus (MRSA) is required to be reported, and only in hospitals. Nursing homes, surgery centers, dialysis centers, critical access hospitals, along with private physician offices are not required to report in a national system.

Deborah Birx, MD, the White House’s Coronavirus Response Coordinator, called for testing all nursing home residents and staff in the immediate term. The CDC’s Anthony Fauci, MD, agreed with Brix and took the recommendation a step further.

“.. In the long range we will have to have infection control capabilities in nursing homes that are really pristine and really unassailable. We have to do the kind of surveillances and have to have the capability of when you identify someone you get them out of that particular environment so that they don’t spread the infection throughout. General testing for all I think is a good start, but you look where are you going to go in the future there has to be a considerable degree of surveillance capability.”

It is of utmost importance to screen healthcare staff and patients for dangerous pathogens along with the establishment of a national tracking system. In addition, an economic and healthcare safety net for healthcare workers needs to be established. 

A dangerous pathogen is a dangerous pathogen, we should not discriminate on our approach to COVID-19. The frequency of an outbreak should not be used to deter a policy that an outbreak of a dangerous contagious pathogen should be publicly reported in real time. The nursing home reporting policies for COVID-19 need to be adopted system wide for all dangerous pathogens and our infrastructure permanently enhanced. 

One may think that enhancement is a forgone conclusion. But we did not learn these lessons from the 1918 Spanish flu or from the Ebola, SARS or MERS outbreaks. Six months or six years after this epidemic our resolve may wane. IPs need to document their experiences and keep telling their stories so our memories of this horrific ordeal do not fade.