Q&A: Just What Makes COVID So Perplexing

Coronavirus disease 2019 (COVID-19) will continue to change the way infection preventionists do their jobs. So says Maureen Spencer, a Boston-based consultant for infection preventionists. Spencer’s advice and knowledge are in high demand in many quarters, including private industry (where, she says, infection preventionists are already being hired) to the World Health Organization. She recently gave a presentation to the WHO that nudged that organization into determining that SARS-CoV-2 is both a droplet that can cling to surfaces and airborne. “What I talked about is how infection preventionists look at an outbreak investigation,” says Spencer. “We have what’s called the chain of infection.” She recently sat down with Infection Control Today® to provide more details.

Infection Control Today®: Can you give us a gist of what you told the World Health Organization?

Maureen Spencer, RN, M.Ed.: It was a very interesting webinar where clinical engineers and infection preventionists kind of came together and each one of us kind of had a topic to speak about. Mine was on the whole concept of is this airborne transmission. Somebody else was talking about the environment and how disinfectants can work and how to clean equipment. Then there was another gentleman talking about how to take ventilators and make them multi-use. It was really a very fascinating webinar and went out to 40 countries, I think were participating. We got a lot of excitement with it. But my talk was geared toward what we recently within the last month have been dealing with. The WHO being asked by a group of experts—infectious disease doctors, about 239 of them wrote a letter to the WHO on July 6. I had to wait till the last minute to get all my slides finalized because on July 9, the WHO did respond. Primarily, I guess you have to go back to what I talked about is how infection preventionists look at an outbreak investigation. We have what’s called the chain of infection. We start off with what is the agent. So, in this situation, SARS-CoV-2. That’s the virus that causes the condition called COVID-19. How is it transmitted? What’s its portal of exit? It comes out of people through their secretions, either secretions—respiratory—or excretions. We know it can be in stools as well. How did it get around? We have these various modes of transmission. How does it enter a person? In this situation, we’re all concerned about the nose, the mouth, and the eyes. When healthcare workers are wearing masks and 95 respirators and goggles. And we’re trying to get the public to really buy into this everywhere. That if we just would wear the mask for a period of time, we really could stop the transmission. I’ll get back to that moment, why that’s of concern. And where are the reservoirs? Where does this live if it does survive in the environment? We do know that it can last for hours on cardboard, stainless steel, in the air. So, that’s the key is looking at what we call modes of transmission. We have direct transfer like a blood borne pathogen, you directly get in touch with somebody and you get it transmitted to you. You have indirect, where that’s part of our job and infection control is indirect transmission of like, say MRSA, C. difficile, on environmental equipment that gets transmitted indirectly. Then we have droplets. This has been considered a droplet condition. But now we know that we have what are called small particle air transmission. The droplets that come out when you’re speaking, singing, yelling, coughing or sneezing usually typically go out three to six feet drop by gravity to the earth. And so we would put them in a private room and we would all wear masks. For things like influenza, bacterial meningitis, pertussis, and we thought SARS, that this will be a droplet. Well, unfortunately, the clusters that we saw…. Some clusters, a big outbreak among a choir, in churches and restaurants, in homes. We started to see … not in hospitals, interestingly enough. There are no hospital outbreaks of SARS-CoV-2. Some of the healthcare workers got it, but we haven’t had major outbreaks in hospitals. It’s been in small, contained spaces. We’ve had a lot of people and we now know that it’s the asymptomatic in that pre-infectious period, when we don’t even know they have it. And so either mild symptoms or they’re absolutely asymptomatic. That’s when these small particle aerosols are most generated. Once a person is infected, they have found that they really don’t generate those. And many of them are on ventilators. Think of a ventilator that has got everything contained. We’re suctioning them. We’ve taken those secretions out. They’re not coughing in our face. They’re all contained. The World Health Organization did come out and said that they support the concept that this is droplet and airborne. And what that does is it changes our approach for infection prevention. We typically … if somebody had tuberculosis, chickenpox, measles … those are airborne diseases. We would put them in a negative pressure isolation room. We would have the room being sucked out the air so many times per hour, like at least 12. We would all wear N95 respirators. It is a whole different set of engineering controls we do for that kind of a condition. It does help direct some of the infection prevention measures by saying that in some situations, we have to look at better ventilation, maybe the use of HVAC filters, maybe the use of UV lights. That’s what the WHO did finally come out and say. There are some things that we can do, like, prevent overcrowding. Not having people clustered together in bars, or at theaters, or a concert. I mean, that’s kind of where it helps us to say we’ve got to continue not to have big groups of people in a closed space. Because we just don’t know who has it; who’s transmitting. It’s because we have what are called aerosol-generating procedures. You might see that acronym AGP, aerosol-generating procedures like intubation, suctioning, nebulizers, anything that was going to spew secretions around. They already started to work with ventilation and make rooms negative. In an ICU, your air is positive. That’s the other thing we have to look at. Which place needs to be negative; like the decontamination of central processing has to be negative pressure. And then the clean side has to be positive pressure. Well, ICUs were always positive pressure. In some of these situations, they had to bring in these units that would filter the air. Some of them go through a HVAC filter or a UV light. There’s one in particular, a great product, that has been used for orthopedic surgery. But they started to use these to control this virus that’s spread through the air because the whole unit is in positive pressure. And so those are some of the challenges that some of them actually had to convert, with plant operations, the ventilation to be more negative to get the air out. I don’t think in hospitals per se, a lot of this making sure that we have clean indoor air and also get more mix of outdoor air in and not recirculate air as much. That’s created some challenges for hospitals that were very tight. Back in the old days, they made hospitals like that to conserve energy. And unfortunately, I remember this back in the late ’80s, early ’90s, when we had first the blood borne pathogen situation, we use latex gloves, and they were covered with powder. And what was happening is because the air was not circulating the powder out, they were inhaling it and healthcare workers got allergic to latex and some of them lost their careers. I mean, they just would go into anaphylaxis. So that’s the key thing is why we have to work with departments like plant operations and ventilation and making sure that all of that is flowing the right way. I mean, right now they’re all using the PPE and their N95s. Everybody’s wearing masks. I was at a hospital yesterday with my mother and yes, not only you have a mask, we have to have their mask. We had to take our personal mask off and put a clean one on. You can imagine the amount of PPE we’re all going through in healthcare because of that reason. So, it didn’t affect them. Where this is going to have more impact is in the environment outside. And what I said earlier, the justification that we cannot have large groups of people together, at least right now until this thing settles down. SARS-CoV-1 took two years—2002 to 2004—I think were the years. We just don’t know. We don’t know if this is going to peter out like SARS-CoV-1 did, or is this going to be with us like influenza? Time will tell. I think that’s the justification. No bars being opened up and making sure that they have masks on if they are going to a church or having drive-in movie theaters. That’s just life changing.

ICT®: What’s your educated guess on how long this is going to last?

Spencer: We have no idea. That’s what’s so frustrating when you have an outbreak. I mean, I’ve dealt in my career, which has been more than 40 years in this field. It’s been my entire nursing career since I was 20. I’ve done infection control. I’ve been through many outbreaks. Ebola was one thing. That was a very direct contact kind of a disease and devastating. I mean, I say to people, we’re lucky, that this is not Ebola. But we just don’t know whether this is going to establish itself. Because this is a different virus than SARS-CoV-1. The way that this attacks certain proteins in the body—the ACE1 proteins. Most of all your organs are aligned with this. That’s why you’re seeing this virus attacking the brain, the liver, the GI system, not just the lungs. And it causes problems with the blood, the red blood cells. It’s different.

ICT®: Do you see infection preventionists being hired outside the hospital setting?

Spencer: We do know that some companies now are hiring infection preventionists. Big corporations are hiring them so that they can help them put into place their policies. I’ve even consulted for police departments, the hotel industry, two very large global companies. We’ve been doing a lot of work outside the hospital, trying to help guide them and develop policies or write newsletters and do webinars and so forth for their employees. So yeah, there will be more and more infection preventionists out there working with industry.

This interview has been edited for clarity and length.