Infection Prevention: Is Your Facility Ready for the Next Pandemic?

Community virus spread can be unpredictable and sudden.

It’s been more than five years since the COVID-19 pandemic rocked the world of surgery (and the entire planet). Luckily, there’s no indication of a similarly disruptive, world-changing pandemic on the immediate horizon. Still, infection preventionists (IPs) recommend surgery centers stay prepared and ready to act if one does.

IPs have been focused for the last couple years on monitoring the H5N1 virus, popularly known as “avian flu” or “bird flu.” Measles, which was declared eliminated in the U.S. by the World Health Organization in 2000, has returned as vaccination rates have slipped. And COVID-19 doggedly remains in play, particularly with fewer people receiving annual vaccine boosters to protect against the latest variants, and many never receiving the vaccine at all.

The message here is that while a pandemic isn’t currently raging, the potential for one very much exists — and likely always will. With that in mind, pandemic monitoring and prep should be baked into your center’s operations if they aren’t already.

Looming danger of H5N1

Cindy Prins, PhD, MPH, CIC, LTC-CIP, CPH, FSHEA, associate professor, Department of Population Health Sciences at University of Central Florida College of Medicine in Orlando, says H5N1 tops her list in terms of pandemic potential due to observations of increasing spread in different types of animals, including not only birds but also cattle.

“It’s still an evolving thing in that we’ve seen some changes to the virus that we worry could make it more severe in humans,” she says. “Most cases we’ve seen in the U.S. have not been people who got seriously ill, but we had one person die from H5N1 in Louisiana.”

Dr. Prins says it’s not surprising that now that IPs and others are actively searching for H5N1 infections, they’re finding them. “In terms of humans, I think there’s also more awareness and thought toward using personal protective equipment (PPE),” she says. “We worry in particular about people working on farms who may be interacting with poultry who get sick, people milking who have been exposed to splashes with raw milk and been infected.”

Much remains unknown about how H5N1 spreads, however. Dr. Prins cites a recent study at a conference of veterinarians that found a small number who treated cattle possessed H5N1 antibodies, including one in a state with no known cattle cases of H5N1. “You always have something bubbling under the surface that you may not be aware of,” she says. “I’d say that’s where we are right now.”

Healthcare environments are testing for H5N1, which Dr. Prins emphasizes is an influenza virus. “When someone presents with symptoms of influenza, they’re generally going to be tested for the two basic types of flu: flu A and flu B,” she explains. “H5N1 is a flu A, so if the patient is flu A positive, they can be tested further to determine which variant or strain it is. Is it H5N1 or one of our seasonal strains that we know circulates frequently?” These tests, of course, depend on people feeling ill enough to seek medical attention. She says because many people who get flu without serious symptoms tend to “ride it out” without seeking care, H5N1’s rate of asymptomatic or minimal-symptom spread remains largely unknown.

Measles’ unwanted return

Dr. Prins says a lower-than-ideal vaccination rate is fueling measles’ spread. “Because measles is so infectious, if you have a lower-than-95% vaccine immunity level, you’re going to get cases in people who are unvaccinated, especially because people who are unvaccinated often tend to cluster in communities of likeminded people,” she says. “So when one person gets infected, it may spread more quickly within that community.”

While surgery centers can’t control community spread of measles, they can work to prevent the virus’ spread within their walls. “Make sure your employees are actually immune to measles,” says Dr. Prins. “Review employee vaccine records and make sure there’s either evidence of immunity through vaccination or through documented history of disease and antibodies.”

She also encourages surgery centers to talk with patients about their own immunity status. “I’m not necessarily a promoter of saying don’t let them come in if they’re not immune, but have that conversation with people and make plans if someone says they’re not vaccinated,” says Dr. Prins. “Right now, we need to think about what the risk is of them having measles when they come in, making sure they feel well when they’re coming in, that they’re not having symptoms of measles. You might ask them to mask if they’re able and if you’re in a state where you can do that, and also potentially keep them away from other patients.”

“Measles is a big concern,” says Kelly Zabriskie, BS, MLS, CIC, FAPIC, enterprise vice president - infection prevention with Jefferson Health in Philadelphia. “If we see any cases, even in the surrounding areas, even if it’s a state over, we send alerts to our clinicians to be aware.”

COVID-19 continues to lurk

Fear and discussion about COVID has declined, especially after the low level of the virus in the population this past winter compared to preceding years. “There is very low activity in all states right now,” says Dr. Prins, although she raises the possibility of a peak in late summer to early fall.

That doesn’t mean surgery centers shouldn’t continue to watch for COVID. “Right now, it becomes a little bit more, ‘What’s your risk tolerance?’ ” says Dr. Prins, who is encouraged that many people, in particular those who are older or have comorbidities, continue to mask in the community.

“That can help protect them,” she says. “I still keep a mask with me for situations where I just feel I’m potentially getting exposed to someone who’s ill. I still like to wear a mask on an airplane.” However, the great majority of people never mask, and COVID remains highly contagious when it is circulating in a community. As such, she says surgery centers should stay prepared for any future waves or peaks of COVID-19.

Ms. Zabriskie characterizes COVID-19 as an existential issue for IPs. “You’re always in the back of your mind cautiously watching to see if it comes back to a level where it’s becoming an issue,” she says. “We’re always capturing our number of COVID patients and so forth internally. If those numbers start increasing again, what does that look like? How are people responding to it? If we start seeing more issues coming into the hospitals around COVID, that’s where it’ll escalate.”

Advice for surgery centers

H5N1, measles, COVID-19 … these are just the most prominent potential pandemics and outbreaks that healthcare facilities must guard against. The common thread across all of them is to stay prepared and to be proactive in defending your staff and patients from spreading or contracting infectious diseases at your center.

Dr. Prins emphasizes the importance of patient screening phone calls the night before or morning of their surgery: “How are you feeling? Do you have a fever? Have you been exposed to anyone who’s been ill?” she says. “Doing those basic checks will be very helpful in cutting down the likelihood of someone coming into the surgery center who is ill and potentially could spread one of these illnesses.”

She also advises centers to be extra-sensitive about patients who report or display respiratory issues. “By cutting down on people who have any kind of respiratory infections, you’re cutting down on H5N1, but also other types of flu, COVID, respiratory syncytial virus (RSV) and other respiratory viruses that can spread to other patients or workers in the surgery center,” says Dr. Prins. “Do that screening and make sure people are feeling well.” She says that especially in outpatient settings, where procedures are largely elective, a patient’s surgery should be postponed by default if they’re not feeling well.

Ms. Zabriskie likewise advises to be watchful about respiratory illnesses. “The biggest thing for me is something that is a respiratory airborne virus that has the transmissibility of a measles virus and that we don’t have a vaccine for,” she says. “I don’t see it out there just yet, but if that happens, it is going to be difficult and a big concern.”

Dr. Prins advises to designate someone at your center to monitor what’s happening locally and nationally with H5N1, measles, COVID-19 and other emerging infectious diseases and make sure you are well-stocked with PPE. “Have a point person who is your pandemic person to keep you up to date so you can be prepared,” she says. “Attention to hand hygiene is always important, as is cleaning and disinfection. Make sure there’s careful attention paid to that.”

“Try to stay current,” says Ms. Zabriskie. “Internally, we work on how we prepare — making sure we have supplies, that we have alerts in place, grabbing a group of our pandemic and emergency preparedness teams together to raise the concern if anybody is hearing different things or seeing anything changing.”

Dr. Prins acknowledges that pandemic prep and patient screening can have a negative short-term financial impact. “I realize it can be hard for surgery centers because when someone cancels, that affects schedules and bottom lines,” she says. “But it’s much better to postpone a surgery than to have to do contact tracing because you found out someone was in your center who turned out to be sick with measles or COVID-19 or H5N1. It’s going to be a lot less time, effort and money than having to follow up on exposures.” OSM