Under cloud of scrutiny, CDC advisers meet to revise infection protections for health care workers

Amid scrutiny and protest, the US Centers for Disease Control and Prevention is pushing ahead on its process to update guidelines hospitals use to control the spread of infectious diseases. Some health care workers say they’re worried the changes focus on flexibility for hospitals while putting frontline workers at greater risk.

On Thursday and Friday, the CDC’s Healthcare Infection Control Practices Advisory Committee, known as HICPAC — a group of independent experts that advises the CDC on its recommendations — is meeting and expected to vote on new draft guidelines for hospital infection control practices. The guidelines were last updated in 2007.

Following the guidelines isn’t mandatory, but many hospitals hew to them. They’re also used as the basis of standards made by other agencies such as the Occupational Safety and Health Administration, which defers to CDC when it comes to infectious disease.

A contentious process

In June, the committee stirred controversy and concern from health care workers, aerosol scientists and patients when it released its first-look draft proposals. After an evidence review that included 21 studies, the committee concluded that surgical masks were just as effective at preventing the transmission of respiratory infections in health care settings as more fitted and tightly woven N95 respirator masks. The committee’s draft guideline also appeared to walk back other infection control measures recently deployed for pandemic-causing respiratory viruses, advising that keeping patients in airborne infection isolation rooms was “not routinely recommended.”

National Nurses United drafted a letter to CDC Director Dr. Mandy Cohen in July voicing its concern that, if implemented as drafted, the new guidelines would significantly weaken protections for health care workers. The letter was signed by hundreds of doctors, researchers and others.

“Sometimes people call this the Bible of infection control,” said Jane Thomason, lead industrial hygienist for National Nurses United, which bills itself as the largest union and professional organization of nurses in the United States.

Some health care workers worry what the changes would mean as they come off of hospital-based illnesses during the Covid-19 pandemic. A 2023 study by researchers at Stanford and the University of Southern California at Los Angeles used data from the American Medical Association to determine that more than 4,500 physicians died between the start of the pandemic in 2020 through December 2021. That’s some 600 more physician deaths than would have been expected over the same time frame, the study authors wrote.

Thomason fears if the new guidelines walk back protections for health care workers, the US could see those grim numbers repeated in the next pandemic.

“What they are working on … it’s going to impact patients and health care workers in so many different places. It’s going to determine whether some of them live or die, quite honestly,” Thomason said.

‘This is going backwards’

Dr. David Michaels, an epidemiologist and professor at the George Washington University School of Public Health, said the new guidelines should have benefited from all the knowledge about the transmission of respiratory infections gleaned during the pandemic. Instead, he said, “this is going backwards.”

The conclusion of the evidence review that surgical masks work as well as N95 masks contradicts the findings of a 2022 study by researchers at the University of California at Berkeley and the California Department of Public Health that showed people who said they consistently wore N95 masks in public settings were less likely to test positive for Covid-19 compared with those who wore surgical or cloth masks.

“I think what’s happened here is the members of this committee came to us with prejudgment on how infection control should be applied,” said Michaels, who was part of a group of experts that addressed HICPAC with its concerns about the draft during an October listening session.

“This committee has no members who have expertise in worker protection, or in aerosol science,” said Michaels, who is also the former head of the Occupational Safety and Health Administration. “And so their view of infection control is a hospital-based view and hasn’t changed in decades.”

Asking for greater transparency

Thomason and National Nurses United filed an open records request for the meeting summaries of the work group that’s developing the new guidelines.

“You can see from the very first meeting, there’s this orientation towards flexibility and feasibility, this orientation towards like, what is it going to cost employers really over and above protecting health care workers and patients. They are really focused on kind of those business concerns,” she said.

Three of the CDC committee representatives were among the authors of a June editorial in the Annals of Internal Medicine that argued against universal masking in health care settings to protect against Covid-19. The editorial said masking impedes communication and increases “cognitive load” for health care workers and patients, who have to make an extra effort to listen without the benefit of lip reading or facial expressions.

“We have achieved major advancements in the prevention and management of SARS-CoV-2 since the pathogen was initially identified in 2019,” the editorial said. “In recognition of these achievements, the time has come to deimplement policies that are not appropriate for an endemic pathogen when the expected benefits of such policies are low. Universal masking in health care is a policy whose time has come and gone … for now.”

An updated draft of guidelines posted on Thursday morning said personal protective equipment are a “critical component in healthcare settings,” but the committee’s systemic review of studies found “no difference” in lab-confirmed seasonal viral respiratory infections among health care workers who used N95s compared with those using surgical masks during routine care. In the draft, N95s and other protections were recommended for some situations, such as in cases such as new or emerging respiratory pathogen that spreads through the air or for pathogens known to spread efficiently over long distances and extended time. N95s were not specifically required for routine patient care as a standard practice.

HICPAC was initially expected to vote on several of its contested draft recommendations in August, but that vote was postponed. Votes are expected both Thursday and Friday.

Final guidelines expected in 2024

After HICPAC votes to accept a new draft guideline, it is forwarded to the CDC for approval. The CDC may then sign off on the draft recommendations or return them to the committee with comments for further work and discussion. Following CDC signoff, it is published in the Federal Register and members of the public have 60 days to comment. HICPAC will then review the comments and may tweak its draft guidelines and vote on them again.

Final versions of the guidelines aren’t expected until 2024.

The CDC has already heard some complaints and concerns about the draft guidelines. In October, Dr. Michael Bell, deputy director of CDC’s Division of Healthcare Quality Promotion and Cohen, the CDC director, listened to concerns about the early evidence review from several experts in airborne transmission of infectious disease and worker protections. Bell said because this session was not a public meeting, they couldn’t engage in dialogue with the experts, but he promised to take the comments back to the HICPAC. The minutes of the meeting were posted online.

The committee meetings on Thursday and Friday leave time for public comment, but anyone who wanted to speak up was asked to submit a request at least a week in advance, although a draft of the proposals under consideration weren’t posted until Thursday morning.

“It’s not sufficient engagement,” Thomason said. “The CDC will have made a lot of these decisions already by the time they’ve posted it in the Federal Register.”