CDC infection control body rejects the science on airborne transmission

HICPAC continues to stonewall efforts to evolve infection control guidance to match updated information about COVID and other common viruses.

For many disabled and immunocompromised people, hospital settings are a significant threat to health and safety. Since the beginning of the COVID-19 pandemic, nosocomial- or healthcare acquired- SARS-COV-2 infections have been an additional risk for sick and vulnerable people seeking care. As of today, there have still been no updates to national-level guidance to reflect that SARS-COV-2 was determined to be airborne in 2021.

In 2020, such a risk was to be expected; hospitals were overwhelmed with patients, PPE was in short supply, proper isolation wasn’t always possible, and public health guidance about transmission was confusing and, it turns out, incorrect. Early on, the WHO confidently and wrongly asserted that COVID was not airborne; this decision led national health bodies to advise against full airborne precautions in healthcare.

But in the nearly five years since, one might assume that any patient visiting their local hospital could reasonably expect safety from infection with COVID-19. After all, we’ve had five years to study transmission, update guidelines, redesign infrastructure, upgrade ventilation, purchase PPE and train staff, right?

As a matter of fact, the CDC has yet to even issue updated infection control recommendations, much less have we seen implementation. The CDC did ask their infection control advisory body, HICPAC, to update the Guideline to Prevent Transmission of Pathogens in Healthcare Settings, last reviewed and updated in 2007. But when HICPAC submitted a first draft of the updated guidelines in November 2023, it was over loud public objections registering that draft’s inadequacy to control airborne infections.

Now, HICPAC is continuing to insist that surgical-style masks are equivalent to N-95 respirators as it pushes forward with its draft guidelines. This decision is emblematic of its commitment to preserving ineffective droplet-based infection control in spite of new information and evidence. While bizarre from a purely scientific standpoint, it makes more sense from a cultural, political and economic point of view.

I’ve written at length about the political and economic factors that led the WHO to immediately claim that COVID wasn’t airborne without the scientific evidence to do so in Spring 2020. Perhaps just as irresponsible as their early decision to spread this misinformation has been their subsequent reluctance to correct their mistake as loudly as they first made it, and ongoing refusal to unequivocally recommend airborne precautions in the years since.

This year, the WHO released a document that rescinded the previous distinction between “droplet” and “airborne” transmission of viruses. This represents progress, as new data showed that no viruses actually transmit solely via “droplets”- i.e., only via sneezes and coughs.

The evolution of the science was tracked beautifully in this Wired article. It’s astonishing that we had such basic science so wrong, for so long. But it’s critical to note that for decades, there was a large financial incentive against looking too closely at the claim that flus, colds, and other common viral and bacterial infections were being spread only via large “droplets.”

“Droplet” precautions are relatively cheap and easy compared to the more complex and expensive requirements of controlling fully airborne infections. If a virus spreads through coughs and sneezes, how do you prevent transmission? Well, we all remember early pandemic guidance. Loose fitting surgical masks, social distancing and keeping diners (or patients) six feet apart, putting up physical barriers to protect from spit, and simply washing hands and covering coughs and sneezes are all examples of droplet-based infection control measures.

But airborne spread is far more difficult to control. Now we’re talking about viruses spreading well beyond six feet, well beyond the radius of a single cough or sneeze. We’re talking about the virus spreading, not just via coughs and sneezes, but via the simple act of exhaling. And not only that, but because airborne particles are so light, they don’t quickly fall to the ground the way droplets do; instead, they can hang in the air, much like smoke. So now, a waiting room or crowded examining area full of patients with flus, colds and COVID suddenly represents a much more complicated and expensive infection control problem for a hospital.

Proper airborne infection control procedures are expensive, but they are not mysterious. Some changes would be relatively simple; masking with proper respirator-style masks, rather than surgical, is an obvious, necessary upgrade. New ventilation and filtration standards are a simple fix technologically, but require investment. Tools like Far UVC are exciting and could mean drastic leaps forward in both patient outcomes and occupational safety for HCW.

Most likely, in order to save money long term and make airborne infection control sustainable, hospitals themselves would be constructed with airborne infection control, patient isolation, airflow, ventilation, etc. as major priorities in the process of designing the infrastructure.

Airborne infection control would require, rather than tinkering at the edges of existing practices, a top-down rethinking of hospital protocols. How are patients being screened upon entry into the hospital? How can COVID, flu, RSV, etc. positive patients be protected from one another in a waiting room? Why are so many hospitals designed without windows in patient care areas?

Are you beginning to see how the economic incentives align against admitting the need for airborne infection control?

Let’s return to the WHO’s document, the one that rescinded the distinction between airborne and droplet spread. Instead, all viruses which spread through the air are now referred to as “infectious respiratory particles” or IRPs. The document encourages moving “beyond the dichotomy of previous terms known as ‘aerosols’ (generally smaller particles) and ‘droplets’ (generally larger particles).”

But problems arise when the WHO attempts to apply what we’ve learned practically- or rather, doesn’t attempt to apply it. Here, it balks at what would be a massive undertaking. As I reported previously, back in 2020, the WHO had been quick to claim:

“Would there be evidence of significant spread of SARS-CoV-2 as an airborne pathogen outside of the context of AGPs [aerosol-generating procedures], WHO would immediately revise its guidance and extend the recommendation of airborne precautions accordingly”

But in 2024, the WHO, now well aware that SARS-COV-2 is a fully airborne pathogen, adopts a new approach to infection control. It’s one totally unprecedented for any other pathogen in healthcare. They advise:

There is NO suggestion from this consultative process that to mitigate the risk of short-range airborne transmission full ‘airborne precautions’… should be used in all settings, for all pathogens, and by persons with any infection and disease risk levels where this mode of transmission is known or suspected. But conversely, some situations will require ‘airborne precautions’. This would clearly be inappropriate within a risk-based infection prevention approach where the balance of risks, including disease incidence, severity, individual and population immunity and many other factors, need to be considered, inclusive of legal, logistic, operational and financial consequences that have global implications regarding equity and access.

In other words, we shouldn’t always try to control airborne disease. That would be so hard and annoying! The document then goes to state that “risks” have to be balanced and goes on to list a bunch of factors that are never considered when it comes to the spread of other pathogens in healthcare.

When it comes to the spread of norovirus in healthcare, do doctors weigh whether to wash their hands, based on the local levels of diarrhea? When it comes to the spread of bacterial wound infections, do doctors clean surfaces based on how deadly they think the wound will be? I mean, if it’s not going to kill you, why bother, right? When it comes to bloodborne illnesses like HIV, do doctors no longer test for it because it’s now a treatable disease, no longer a death sentence?

Or, when you apply this logic to any other type of infection, is it clear that this is an absurd attempt to continue evading liability for nosocomial airborne infections in healthcare, including SARS-COV-2? People should not be infected with diseases in hospitals. Period. Regardless of disease severity. Of course, SARS-COV-2 is also incredibly severe for hospitalized patients; in Australia, nearly 1 in 10 patients who caught COVID in hospitals in 2022 and 2023 died. And these events are far from rare. Of 206 patients admitted for strokes in a hospital in Japan, 44 were infected with COVID-19. 6 of them - or 13% - died. Globally, we see the same thing over and over again: lack of airborne infection control, high rates of nosocomial infections, high rates of patient death.

The WHO chose to incorporate “balance of risks”, “disease severity”, “immunity,” and the rest of its laundry list of “factors”, not because it expects infection control bodies to do serious risk assessments, but in order to provide cover for them not to do any such thing. Universal airborne infection control would be expensive and disruptive so the WHO simply gives disease control bodies a series of “outs”.

This is the international backdrop against which the US has also been updating infection control guidance. The CDC, like other national public health bodies, does not directly report to the WHO; the WHO does not have enforcement power over the CDC. However, guidance from the WHO is taken seriously at the CDC, and experts at the CDC also influence the WHO.

The WHO’s document constructs a mile-wide loophole for HICPAC to drive through. Although HICPAC provides no evidence whatsoever that the characteristics of SARS-COV-2 (or flu, or RSV for that matter) would justify dropping airborne precautions, the language in the WHO document exists to justify dropping them in the face of the ongoing, global pandemic. Despite SARS-COV-2 being a systemic, multi-organ disease with the potential to cause long-term disability, and highly fatal when contracted by vulnerable patients, culturally and politically, we are treating it like a cold. HICPAC members are not making scientific decisions, but political ones.

The science on disease transmission has advanced tremendously since 2020. In a world that actually wanted to implement what we’ve learned from COVID, this would mean dramatically safer care for patients and healthier workplaces for HCWs. Instead, HICPAC does the opposite, working to ignore the advancements in scientific knowledge and fighting to keep infection control as similar as possible to the outdated droplet model of the pre-pandemic era.

For example, they advise that N95 respirators should be worn for “new and emerging pathogens,” but make an irrational distinction between these and other viruses that are already in circulation. You know, the ones that are actually, currently infecting patients. “Emerging/new” isn’t a type of transmission, so shouldn’t denote a type of infection control.

Even the CDC balked at HICPAC’s initial draft, sending it back with pointed questions about this bizarre distinction and other inadequate protections. It asked for clarification, stating:

Another issue relevant to preventing transmission through air is to make sure that a draft set of recommendations cannot be misread to suggest equivalency between facemasks and NIOSH Approved respirators, which is not scientifically correct nor the intent of the draft language. Although masks can provide some level of filtration, the level of filtration is not comparable to NIOSH Approved respirators.

Why would HICPAC equate surgical masks with respirators? HICPAC’s draft was not designed to protect patients; it was designed to protect the status quo and allow hospitals to continue to infect patients with COVID and other airborne diseases. It’s likely that the CDC’s decision to push back on this claim was influenced by the massive outpouring of public outrage at the draft, which was seen in both the public comments submitted and read at HICPAC’s meetings.

Additionally, both OSHA, the Occupational Safety and Health Administration, and NIOSH, the National Institute for Occupational Safety and Health, agree with both the CDC and patients that surgical masks are not sufficient protection. N95s are required to control airborne infections.

However, despite months of pushback, the tears of suffering and scared patients, the word of the experts who design respirators, as well as the input of occupational safety leaders, HICPAC remains unmoved on the subject.

In a series of votes held last month, HICPAC stuck to their guns. Lisa Baum of the New York State Nurses’ Association was the sole dissenting member of the committee, as reported by Judy Stone of Forbes. She not only voted against the anti-science equating of surgical and N95 masks, but also against allowing COVID positive staff to return to work 3 days after a positive test. The 3-day time frame has absolutely no scientific basis, and return to work should be based on negative tests, not on an arbitrary time window or symptoms. Since a quarter of all COVID cases are asymptomatic, staff should also be asymptomatically screened; they aren’t because hospitals don’t want staff taking time off. Again, these are economic, not scientific, decisions.

Putting these two votes together, HICPAC has voted to allow sick, infectious, COVID+ staff to go to work without proper PPE and infect fellow HCW and patients, in hospitals without proper ventilation and filtration. Patients who are infected in hospitals using outdated droplet precautions will have a 10% risk of death. Coworkers- even if fully vaccinated- will have a significant risk of developing a long-term health condition following their acute infection.

At a time when hospitals remain crushed by the ongoing burden of both COVID and post-COVID health problems, failing to protect workers is a particularly short-sighted decision. Studies have already shown that HCWs suffer unusually high rates of Long COVID, with a recent one in the UK finding a whopping 33.6% reporting symptoms, and 7.4% of respondents reporting an official diagnosis.

These decisions not only mean infected doctors and nurses returning to work actively ill; they also mean that hospitals will continue to reinforce false information about how COVID spreads, purposely miseducating doctors and nurses in their employ to save money.

The members of HICPAC understand that surgical masks aren’t really the equivalent of N95s, they simply believe HCWs are more likely to wear surgicals (they’ve explicitly stated such; this is not, incidentally, how infection control decisions should be made). But this reasoning is not shared with patient-care level HCWs. Instead, HCWs are told that surgical masks are a sufficient infection control measure for COVID-19 when infectious. When an informed patient seeking care tries to correct them, they are greeted with condescension; after all, the doctor’s information comes directly from the CDC.

Disabled and immunocompromised people relate stories of medical professionals who believe COVID spreads via droplets, who wear surgical masks instead of N95s, who draw curtains to prevent the spread of COVID and other viruses; in other words, they are continuing to adhere to outdated precautions. This is unsurprising, because they have never received accurate guidance reflecting our updated technical knowledge about how SARS-COV-2 and other common viruses actually spread.

They’ve never received updated information because the medical system does not want to spend money to protect workers or patients.

At the end of the day, this story is not about droplets and airborne particles as much as it is about dollars and cents. What sounds like an in-the-weeds scientific debate, is no more than a common tale of industry greed. We know- and have known- exactly what it would take to protect patients in healthcare settings. Instead, our leaders sit back and watch as day after day, more unnecessary infections and deaths accumulate. As day after day, more healthcare workers acquire illnesses at work which lead to staff shortages, worse patient outcomes, long-term departures, and the loss of talented, highly trained people from the field.

All of us, patients, doctors, nurses, and other healthcare staff alike, deserve medical leadership that will value our rights to safety in these settings. We deserve medical leadership that won’t actively try to slow scientific progress, and instead will welcome its arrival. We deserve to enter a hospital knowing we won’t be infected and killed because HICPAC would rather allow airborne nosocomial infections to continue on its watch than spend money preventing them.

Right now, the biggest factor protecting hospitals as their negligence rolls on into year five is the ignorance of the public. Most people have no idea how COVID and other viruses spread, have no idea that it’s so dangerous to contract COVID as a vulnerable patient (thanks to years of normalizing propaganda), and may themselves believe that social distancing or curtains prevent infections. This public ignorance is a deliberate tool which enables continued public health negligence on multiple fronts. Continuing to educate ourselves and each other is resistance when the state relies on ignorance to tamp down resistance to policies of mass infection and death.