By Lambert Strether of Corrente.
Patient readers, after reading this post, you may well decide to throw a flag on a Betteridge’s Law violation, but hear me out. Clearly, one goes to a hospital to be tested, or to be treated and hopefully cured; Caveat Patiens should not be part of the deal. However, for nosocomial infection (also known as Hospital-Acquired Infection, HAI, which at CDC stands for Hospital-Associated infection, neatly removing agency) Caveat Patiens does seem to be part of the deal, at least in the United States, which I find more than a little troubling.
In this post I’ll take a quick look at HAI generally, and then HAI in relation to Covid. Both are troubling. I had hoped to go further, and lay hold of the institutional factors behind our health care system’s failures to recognize aerosol transmission and support universal masking, but — sadly, like the New Yorker writer who entered the swamp on the trail of a thought-to-be-extinct bird, and never found the bird — I’m reduced to mere speculation, and I did try. (That I can’t hold anybody in accountable for demonstrable failure is in itself an interesting data point; perhaps some kind readers will help out with pointers in links, or throw some hospital administrator’s PowerPoint over the transom. Your anonymity is guaranteed. But perhaps all the real decisions are taken out on golf courses, where private equity goons chat among themselves!)
The newest HAI scare — Cordyceps fans, take note — is a fungus. And it is scary. From NBC:
A drug-resistant and potentially deadly fungus has been spreading rapidly through U.S. health care facilities, a new government study finds.
The fungus, a type of yeast called Candida auris, or C. auris, can cause severe illness in people with weakened immune systems. The number of people diagnosed with infections — as well as the number of those who were found through screening to be carrying C. auris — has been rising at an alarming rate since it was first reported in the U.S., researchers from the Centers for Disease Control and Prevention reported Monday.
The absolute numbers, however, are small compared to Covid, which would lead a certain type of mind to conclude that, even though C. auris is nasty, the CDC is trying to change the subject:
Since November, at least 12 people have been infected with C. auris with four “potentially associated deaths,” [MIssissippi’s] epidemiologist Dr. Paul Byers, said in an email. “By its nature it has an extreme ability to survive on surfaces,” he said. “It can colonize walls, cables, bedding, chairs. We clean everything with bleach and UV light.”
The same sort of mind would conclude that CDC is very happy to get back to fomite transmission. More:
It’s important to stop the pathogen so it doesn’t spread beyond hospitals and long-term facilities like the drug-resistant bacteria MRSA did, Snyder said.
So MRSA and CDC have form on HAI. And it’s not good. In fact, things aren’t good with HAI generally. CDC:
Although significant progress has been made in preventing some healthcare-associated infection types, there is much more work to be done. On any given day, about one in 31 hospital patients has at least one healthcare-associated infection…. There were an estimated 687,000 HAIs in U.S. acute care hospitals in 2015. About 72,000 hospital patients with HAIs died during their hospitalizations.
Granted, 72,000 deaths a year isn’t all that big a number — Joe Biden really hit the death ball out of the park at 700,000 and counting — but it’s still a lot. WaPo blames budgets:
The health system faces financial challenges and severe staffing shortages that make infection control more difficult, said Akin Demehin, senior director of policy at the American Hospital Association. “That is why we continue to advocate for needed financial support to hospitals, and for supportive workforce resources and policies across all levels of government,” Demehin said in a statement.
Hospital accreditation organizations and federal regulators require infection-prevention specialists at acute-care hospitals, experts say, but do not set standards for staffing or funding. And the rules are looser in other health-care settings
Frankly, I find AHA crying poor just a wee bit unpersuasive. Stoller writes:
The amount of cash pouring into health care is quite high. In the U.S., we spend about 20% of our GDP on health care, which is between two to three times as much as other countries. But we get worse results. Why? The answer is monopolization and cheating. As one article in 2003 noted, “It’s the Prices, Stupid.” In terms of hospital beds, physicians, and nurses, we provide fewer than most rich countries for our citizens. We pay more, and get less, because of insider skimming.
Naturally, some of the deaths in that 72,000 aggregate are from Covid. From the International Journal of Environmental Research and Public Health:
According to several reports, the SARS-CoV-2 hospital-acquired infection rate is 12–15%. Hospital-acquired COVID-19 represents a serious public health issue, which is a problem that could create reluctance of patients to seek hospital treatment for fear of becoming infected.
(No kidding.) Granted, these figures are from 2021, with different variants and higher transmission, but just to keep on Mr. Spike’s bright side, we’re not tracking anything any more, and we’re relaxing non-pharmaceutical interventions like masking, as we are about to see. So maybe it all evens out!
So our health care system’s performance on HAI is bad, and it’s performance on Covid HAI is also bad. Now let’s turn the specifics of Covid HAI with respect to masking, also bad. Readers of my long-ago ObamaCare coverage may recall a metaphor I often used: “In any system as baroque and Kafaesque as ObamaCare, some citizens will get lucky, and go to HappyVille; others, unlucky, will go to Pain City.” Well, our healthcare system has gone all baroque and Kafaesque on masking in hospitals, too, so whether you are more or less likely to catch Covid as an HAI — less politely, whether your hospital is a death trap — is random.
If we roll the tape back to 2020, we’ll find stories like this: “Frontline healthcare workers are locked in a heated dispute with many infection control specialists and hospital administrators over how the novel coronavirus is spread – and therefore, what level of protective gear is appropriate“:
The topic has been deeply divisive within hospitals, largely because the question of whether an illness spreads by droplets or aerosols drives two conflicting sets of protective practices, touching on everything from airflow within hospital wards to patient isolation to choices of protective gear. Enhanced protections would be expensive and disruptive to a number of industries, but particularly to hospitals, which have fought to keep lower-level “droplet” protections in place.
The hospital administrators and epidemiologists who argue that the virus is mostly droplet-spread cite studies showing it is not as contagious as an illness like the measles and spreads to a small number of people, like a cold or a flu. Therefore, N95 respirators and strict patient isolation practices aren’t necessary for routine care of Covid-19 patients, those officials say. On the other side are occupational safety experts, aerosol scientists, frontline healthcare workers and their unions, who are quick to note that the novel coronavirus is far deadlier than the flu – and argue that the science suggests that high-quality, and costlier, N95 respirators should be required for routine Covid-19 patient care.
Fast forward to 2023. The CDC lifted the federal mandate requiring masks in health care facilities in September 2022. (For the fantastically destructive role the CDC has played in hospital infection control during Covid, see NC here.) This is what happened in the state of New York:
This month, New York became the latest to join the growing list of states that have ended their requirements for routine masking in hospitals and other healthcare settings.
In response, at least one of the state’s largest hospital systems is throwing off the mask despite the continued high level of virus transmission in New York City and most of the rest of the state. NYU’s Langone hospital system decided that — outside of the Emergency Room — patients would generally only be required to mask “if they have fever and cough” (query what percentage of individuals with recent COVID-19 infections did not have this specific combo of symptoms — spoiler: it’s probably high). Similarly, the hospital announced that masking by direct care staff was optional in most situations, with masks required mainly during certain procedures, in particular patient rooms, or — more cryptically — when “there is concern for exposure to infectious aerosols.”
Indeed, even as New York dropped its mask mandate, the state’s Department of Health advised hospitals and other healthcare settings to continue to require masks at this time, and major institutions such as New York City’s public hospital system and Memorial Sloan Kettering announced they would keep masking in place.
So, New York has gone fractal; baroque and Kafka-esque. Ditto Illinois:
Dr. Robert Citronberg, executive medical director of infectious disease and prevention at Advocate Health Care said that the mask-optional policy applies to both visitors and staff members.
Citronberg also said during a press conference this morning that the liberalizing of policies is not in place at Aurora Health Care, the larger system’s facilities in Wisconsin. He said that they use the same metrics as Illinois’ Advocate, but that state-level community transmission is not as low in Wisconsin.
He said that despite other local health systems maintaining more restrictive policies, he does not think the move is premature.
Ditto the state of Washington:
Patients, staffers and visitors will continue to be required to mask up inside many health care clinics and facilities throughout the Puget Sound region, a group of Washington hospital and public health leaders decided Friday.
About 20 public health departments and health care systems around the region made the announcement a couple weeks before the state’s remaining indoor masking requirements are set to come to an end on April 3. Most of the Department of Health’s masking mandates have expired, except those in health care or correctional facilities.
“Many,” but not all. I have not been able to find national data on mask usage in hospitals in the United States. I do see a lot of anecdotes, the first being more representative on my extremely unrepresentative Twitter timeline:
The hospital where I work in OR is ditching masks on Apr 3. Should make for any interesting late Apr/May…WA however is doing the right thing. Seattle & King Co hospitals all still masking.
— AndyAF🎧🔮 (@CactusAndy) March 25, 2023
But the second:
Husband had surgery in Nov ’22 at MUSC in SC….. They have no mask mandate. It was glorious to be able to see most people’s faces from nurses to doctors, to everyone !
— JustWee (@Tinybutfierce1) March 27, 2023
Back to the “heated dispute” in 2020. You will recall that both administrators and hospital infection control epidemiologists were united in favor of droplet dogma and against aerosol transmission (hence against masking). By 2023, the administrators and epidemiologists are split, with the epidemiologists following the science. (There’s plenty of evidence that masking substantially reduces aerosol-borne HAI, including Covid; see here, here, and here). From Infection Control & Hospital Epidemiology, “Hospital approaches to universal masking after public health ‘unmasking’ guidance“:
We surveyed healthcare epidemiologists in the United States following release of the updated CDC healthcare COVID-19 guidance to understand their facilities’ planned approach to universal masking and unmasking outside of patient care areas. The survey also explored the rationale for maintaining universal masking.
Among 44 healthcare epidemiologists invited to participate, the 34 respondents (response rate, 77.3%) represented health systems from diverse US regions. Most worked for health systems with multiple acute-care hospitals (n = 26, 76.5%) or facilities with ≥500 beds (n = 6, 17.6%).
Overall, 33 respondents (97.1%) reported that , and 1 respondent (2.9%) reported their facility had discontinued, or planned to discontinue, universal masking if or when community transmission levels of COVID-19 were not high. No respondents reported that their facility had discontinued or would discontinue universal masking regardless of community transmission levels. Preventing non– SARS-CoV-2 seasonal respiratory viruses (90.9% of respondents) and impact on employee staffing capacity (72.7% of respondents) were the most cited reasons for continuing universal masking regardless of county-specific SARS-CoV-2 transmission levels (Table 1). The “other” reasons described by 7 facilities include several themes: standardizing approach across facilities; the operational challenges of variable or changing masking policies between facilities, within a facility, or as community transmission levels change; and the presence of high-risk individuals (Supplementary Materials online). Also, 7 respondents specifically cited inaccessibility to patients (or visitors) as defining locations where unmasking is permitted in patient care areas.
And from an epidemiologists’ trade association, the Association for Professionals in Infection Control and Epidemiology:
The Association for Professionals in Infection Control and Epidemiology (APIC) is concerned that a recent report questioning the value of masks to prevent COVID-19 could weaken the ability to mitigate future outbreaks of respiratory infectious diseases.
“The benefits of masking have been shown in healthcare and can be critical in preventing the spread of infection – but this depends on proper and consistent use,” said 2023 APIC President Patricia Jackson, RN, BSN, CIC, FAPIC. “The use of respiratory protection – including well-fitting N95s and surgical masks — is a critical public health tool in our arsenal to protect the public and healthcare workers when severe respiratory infections are spreading. APIC will continue to advocate for the value of masks and respirators in reducing transmission of respiratory infections.”
And Jackson specficiallly trashes, as she ought to have done, the “fool’s gold” Cochrane study:
“Despite Cochrane’s reputation for producing credible health reviews, the many factors and details that go into successfully using masks and respirators as a public health intervention weren’t all reflected in this review,” said Jackson.
This makes me happy. I take back everything bad I ever sad about hospital infection control departments; as it turns out, the vile and hegemonic Dr. John M. Conly — corresponding author of the Cochrane study — was an inappropriate proxy or synecdoche for the field.
To conclude, or at least to end, for patients the key point is that masking requirements will vary not merely by state but by hospital. If you are lucky, good health in Happyville. Unlucky, a death trap in Pain City. Such is our health system, the finest in the world!
That said, I am not clear at all where the health care system, taken as a whole, stands on masking in hospitals, or how much masking is still taking place. It is clear that at the Federal level, CDC — cognitively captured, no doubt, by anti-mask elites — would like to do away with masking entirely. It is also clear that many states, though not all, are following CDC’s lead. No doubt our complaisant, superspreading press — who are building the depressing anti-mask narrative I read, after all — follows CDC as well (see under Gridiron club). However, mask policy is ultimately a hospital’s decision. The survey I quoted reported that 97.1% of hospital epidemiologists surveyed reported that their hospital had retained universal masking, so the machinations of the CDC and the states were for nought. If this is true, that means that hospital administrators listened to their epidemiologists. And presumably the hospital owners or boards listened to the administrators. But I’m not sure whether to believe that study or not, not least because at this point I’m very suspicious of good news. And the Twitter say that things are a lot worse than that survey says.
All I can do is throw the matter open to readers. Readers, are hospitals requiring universal masking in your area?
 The methodology: “From participants in an informal e-mail–based list serve, we invited one representative from each US-based, nonfederal, acute-care hospital or health system.” “Informal” seems a little weak.
 And their lawyers? From Harvard Law: “Science, law, and the principle of “do not harm” all concur about the path to keeping patients safe from disease and hospitals safe from liability: at a minimum, continue requiring masks amid the ongoing COVID-19 pandemic. Otherwise, hospitals are proceeding at their own risk — and that of their patients.”