Editor’s Note: Dr. Theodore Pak is an infectious diseases fellow practicing in Boston, the piece begins with his patient’s story. Dr. Lara Jirmanus is a primary care physician practicing in Cambridge and public health researcher and Clinical Instructor at Harvard Medical School. Dr. Andrew Wang is a health equity researcher at Northwestern University Feinberg School of Medicine. Drs. Jirmanus and Wang are members of the People’s CDC, a public health watchdog organization. The views expressed in this commentary are their own. View more opinion on CNN.
As Covid-19 hospitalizations rise across the country, I (Dr. Pak) think back to my first Covid-19 patient. It was the first time I saw Covid in the hospital — and it wasn’t where it was supposed to be.
It was April 2020. I was an intern on a “non-Covid” floor, admitting an elderly man named John (whose name has been changed to protect his privacy) for bacterial pneumonia and a urinary infection. Per hospital protocol, he tested negative for Covid-19 twice before he was admitted to the hospital. But a week into his stay, despite antibiotics, he had a worsening cough and a fever.
Because John was on a “non-Covid” floor, my colleagues felt Covid-19 was unlikely. But additional testing showed that he was indeed positive and, given the timing of his positive test, he most likely caught the infection in the hospital. John was transferred to a Covid-19 ward where his breathing continued to worsen. He died on his 16th day in the hospital. Hundreds of Covid patients later, I will never forget him — my first.
In 2020, hospitals used universal masks and screening tests to help keep hospital floors safe. But after the US Centers for Disease Control and Prevention (CDC) and the Society for Healthcare Epidemiology of America (SHEA) relaxed infection control guidelines in 2022, many states and hospitals stopped requiring masks and screening tests for symptom-free patients.
Since the beginning of 2023, Covid-19 has steadily killed over 47,000 people in the US. At this rate, it is on track to remain in the top 10 causes of death in the US this year. Even with vaccines and treatments, elderly, disabled, immunocompromised patients and some with major underlying health conditions can still be severely harmed or die from the virus.
Furthermore, we lack effective treatments for long Covid, which can impact anyone, even healthy, vaccinated people. According to government data from July 2023, as many as 23 million US residents have developed long Covid, and 2 to 4 million people in the US are out of work because of it.
Covid spreads in the air like smoke. At least half of Covid transmission happens before people develop symptoms — or even if they never develop symptoms — so people frequently spread the virus without knowing it. That’s why layered protection — the combination of masks, tests and ventilation — is so important.
With hospitals facing what the American Hospital Association calls “crushing financial challenges,” are medical institutions and the CDC really putting patient and worker safety first?
Despite myriad compelling reasons to prevent Covid-19 transmission in hospitals, some hospital infection control leaders pressured public health departments to end Covid protections such as universal masking in health care settings, according to reporting from The Boston Globe. While there are important and legitimate reasons — such as reprioritizing the preventive and elective care that took a back seat during the height of the pandemic — for hospitals to want to move past their Covid priorities, it’s also notable that hospitals stand to lose money from rescheduling elective procedures when patients test positive for Covid-19. But whatever the motive for loosening masking and screening measures, patient and health care worker safety could ultimately suffer.
Because hospitalized patients, like John, are often particularly vulnerable to disease, hospital-acquired Covid-19 is dangerous — with a mortality rate as high as 5-10% in parts of Europe. (That means a 1-in-10 to 1-in-20 risk of dying for patients who catch Covid-19 in the hospital.)
Even in 2020, when most hospitals used masks and screening testing to prevent Covid infections, 12-15% of hospitalized Covid patients caught Covid-19 in the hospital after being admitted for something else, according to research published in the International Journal of Environmental Research and Public Health. One study based in a Boston hospital, and published in the journal Clinical Infectious Diseases, showed that patients may have nearly a 40% chance of passing Covid-19 to their hospital roommate.
Although European data may not be perfectly representative of US hospitals, the CDC’s hospital-onset Covid data lacked sufficient granularity for meaningful research. (We know because we filed a public records request for additional data and were told it was unavailable.)
To top it off, the CDC stopped requiring hospitals to report hospital-onset Covid in May 2023, leaving us without data to evaluate the impact of ending Covid-19 infection control in health care settings. But hospital-acquired cases surged in England and Scotland after hospitals stopped screening all admitted patients for Covid-19 last year.
The Biden administration also reportedly decided to keep the names of hospitals where patients contracted Covid-19 private, according to Politico, meaning that patients cannot look up hospital-onset Covid-19 rates by hospital to assess quality of care.
Instead of withholding this information, the federal government should require its release and financially incentivize hospitals to prevent Covid-19, as it does for other, less fatal infections. The CDC should make hospitals report hospital-acquired Covid-19 and share this information publicly.
Lastly, the CDC should redefine hospital-onset Covid-19 as Covid infections diagnosed in patients after five or more days of hospitalization, as opposed to 14 days, which is the current standard. The Omicron variants take only three to four days to cause infection and most hospital patients are discharged home before 14 days, meaning that, inevitably, many with hospital-onset Covid are not counted.
Most recently, despite a national letter from nearly 900 experts urging the CDC to strengthen health care infection control policies, the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) is poised to further weaken its guidance.
The HICPAC suggested in a draft of updated guidelines for Covid protection in health care setting that surgical masks were just as effective as well-fitting N95 masks. This sparked an outcry from hundreds of health care workers across the country who were concerned about the proposed shift in guidance. Airborne disease-carrying particles can travel through the gaps in loose-fitting surgical masks and infect health care workers, who may then infect their coworkers and patients, leading to more hospital outbreaks. Most voting members of the CDC HICPAC represent large, powerful hospitals, while the “Liaison Representatives” who include some health care worker and consumer groups, including health worker organizations lack voting power. The CDC committee is set to revisit the issue at its November 2023 meeting.
We must push hospitals to put safety first. Public health guidance should be made with transparency and in partnership with impacted patients and health care workers. Vulnerable patients like John should be able to access health care without being exposed to Covid or other serious infections. We should apply our knowledge from the last three years to protect patients and health care workers from Covid-19 and future pandemic pathogens. We all deserve better.