Amy Maxmen | KFF Health News (TNS)
Sonya Stokes, an emergency physician, is still disturbed by the unpreparedness and wrong guidance of the American health system during the surge of COVID-19 patients in New York City four years ago.
In the early months of 2020, hospital leadership instructed health workers not to use protective N95 masks, despite the increasing number of COVID cases. Stokes mentioned that they witnessed patients dying and were told not to use high level of protection by people who were not exposed to these risks.
Droves of front-line workers became ill trying to save lives without proper face masks and protective measures, and more than 3,600 died in the first year. Stokes recalled how nurses unintentionally transmitted COVID to their families, including their elderly parents, when returning home.
Hospital leadership across the country relied on advice from the Centers for Disease Control and Prevention regarding the limitations of airborne transmission. The agency's early statements supported employers' insistence that N95 masks were necessary only during specific medical procedures at very close distances.
These policies conflicted with the observations of doctors and with advice from scientists who study the transmission of viruses through the air. Research indicated that people could contract COVID by inhaling SARS-CoV-2 viruses suspended in minuscule droplets in the air as infected patients exhaled.
However, this research was inconvenient when N95s were scarce and costly.
Now, Stokes and many others are concerned that the CDC is repeating past errors as it develops a vital set of guidelines that will be applied by hospitals, nursing homes, prisons, and other healthcare facilities to control the spread of infectious diseases. The guidelines will update those established nearly two decades ago and will be used to develop protocols and procedures for years to come.
Peg Seminario, an occupational health expert and a former director at the American Federation of Labor and Congress of Industrial Organizations, which represents approximately 12 million active and retired workers, stated, “This is the foundational document. It becomes gospel for dealing with infectious pathogens.”
Towards the end of last year, the committee advising the CDC on the guidelines submitted its final draft for the agency's consideration. Unions, aerosol scientists, and workplace safety experts cautioned that it allowed employers to make unsafe decisions regarding protection against airborne infections.
Seminario remarked, “If we had applied these draft guidelines at the beginning of the pandemic, there would have been even less protection than there is now — and it's already pretty bad.
In a rare move in January, the CDC addressed the public outcry and sent the controversial draft back to its committee to clarify points on airborne transmission. The director of the CDC's National Institute for Occupational Safety and Health requested the group to ensure that a draft set of recommendations cannot be misinterpreted to imply equivalence between facemasks and NIOSH Approved respirators, which is not scientifically accurate.
The CDC said it would involve a wider range of experts in their decision-making process. Some people criticized the committee from last year for mainly representing large hospital systems. They were also concerned about some members publishing articles against mask-wearing in certain situations. For instance, Erica Shenoy, a committee member from Massachusetts General Hospital, wrote in May 2020 that wearing masks outside of healthcare facilities does not provide much protection from infection. wrote in May 2020, “We know that wearing a mask outside health care facilities offers little, if any, protection from infection.”
Those who criticized the previous draft are happy to see it being reconsidered but still have concerns. Jane Thomason, the lead industrial hygienist at the union National Nurses United, said, “The CDC needs to make sure that this guidance doesn’t give employers leeway to prioritize profits over protection.
She’s part of a growing coalition of experts from unions, the American Public Health Association, and other organizations putting together an outside statement on elements that ought to be included in the CDC’s guidelines, such as the importance of air filtration and N95 masks.
But the feedback from these experts may not be considered.
The CDC has not publicly announced the names of experts it added this year. It also hasn’t said whether those experts will be able to vote on the committee’s next draft — or just provide advice. While the group has met this year, members are not allowed to discuss the proceedings. The CDC did not respond to questions and interview requests from KFF Health News.
One main issue in the draft guidance is that it suggests different approaches for airborne viruses that “spread predominantly over short distances” versus those that “spread efficiently over long distances.” This approach in 2020 allowed employers to not provide protective gear to many workers. draft guidance is that it recommends different approaches for airborne viruses that “spread predominantly over short distances” versus those that “spread efficiently over long distances. logic allowed employers to withhold protective gear from many workers.
As an example, medical assistants at a large hospital system in California, Sutter Health, were not given N95 masks when they were with patients who seemed to have COVID in clinics. After California’s occupational safety and health agency cited Sutter, they appealed by referring to the CDC’s statements indicating that the virus mainly spreads over short distances.
The differentiation based on distance shows a lack of scientific understanding, according to Don Milton, a University of Maryland researcher specializing in the aerobiology of respiratory viruses. In general, people may get infected by viruses in someone’s saliva, snot, or sweat — within droplets that are too heavy to go far. But people can also inhale viruses carried on very small, lighter droplets that travel a longer distance. What matters is which route infects people the most, the concentration of virus-laden droplets, and the impact of being exposed to them, Milton explained. “By focusing on distance, the CDC will obscure what is known and make bad decisions.”
Front-line workers were well aware that they were being exposed to high levels of the coronavirus in hospitals and nursing homes. Some have filed lawsuits, claiming that employers caused illness, distress, and death by not providing personal protective equipment.
One lawsuit filed by employees was against Soldiers’ Home, a state-owned veterans’ center in Holyoke, Massachusetts, where a minimum of 76 veterans died from COVID and 83 workers were affected by the coronavirus in early 2020.
“Even at the end of March, when the Home was averaging five deaths a day, the Soldiers’ Home Defendants were still discouraging employees from wearing PPE,” according to the complaint.
It describes the experiences of workers, including a nursing assistant who said six veterans died in her arms. “She remembers that during this time in late March, she always smelled like death. When she went home, she would vomit continuously.”
Researchers have frequently criticized the CDC for its reluctance to address airborne transmission during the pandemic. According to a new analysis, “The CDC has only used the words ‘COVID’ and ‘airborne’ together in one tweet, in October 2020, which mentioned the potential for airborne spread.’”
It’s unclear why infection control specialists on the CDC’s committee take a less cautious position on airborne transmission than other experts, industrial hygienist Deborah Gold said. “I think these may be honest beliefs,” she suggested, “reinforced by the fact that respirators triple in price whenever they’re needed.”
Critics fear that if the final guidelines don’t clearly state a need for N95 masks, hospitals won’t adequately stockpile them, paving the way for shortages in a future health emergency. And if the document isn’t revised to emphasize ventilation and air filtration, health facilities won’t invest in upgrades.
“If the CDC doesn’t prioritize the safety of health providers, health systems will err on the side of doing less, especially in an economic downturn,” Stokes said. “The people in charge of these decisions should be the ones forced to take those risks.”
(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)
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