Guzman-Cottrill, J.A, Henderson, D.K., Babcock, H., Haessler, S. Hayden, M.K., Murthy, A.R., Rock, C., Van Schooneveld, T., Weber, D.J., Wright, S.B., Forde, C.A., Logan, L.K., Malani, A.N., for the SHEA Board of Trustees.

The Board of Trustees of the Society for Healthcare Epidemiology in America expresses our deep gratitude to Dr. Anthony S. Fauci for his tireless and unparalleled leadership of our nation during the COVID-19 pandemic.

As our country moves into the autumn months of 2020, many have described the current COVID-19 pandemic as “unprecedented times.” As we enter what appears to be a third major national surge in infections, hospitalizations and, deaths from COVID-19, this assessment continues to hold true. At the time of this writing, COVID-19 has claimed over 220,000 American lives,1 resulted in record unemployment,2 and has led millions of students at every educational level into a digital school year.3 Projections for the coming winter months suggest that COVID-19 will lead to additional surge capacity pressures on America’s healthcare system. As infectious disease physicians, we are physically and mentally exhausted. As healthcare epidemiologists, we see no end to our pandemic response. Our healthcare institutions continue to face challenges with personal protective equipment supply chains, limited bed capacity, occupational health risk, pandemic fatigue, financial solvency and constant modifications in our guidance as new science emerges. 

These issues are real, and they are indeed challenging. However, perhaps the most unprecedented problem currently facing our country is not SARS-CoV-2 or COVID-19, but rather, a lack of a concerted, coordinated, and strategic public health pandemic response from our nation’s leaders. Much of the leadership responsibility has been abrogated and, instead, delegated to individual states, such that we now have 50 different, and often inconsistent, approaches. Perhaps even more concerning, the nation’s leaders have not consistently relied on scientific facts to guide planning and response.  As has been the case for prior epidemics such as HIV and  Ebola virus disease, from the beginning of the COVID-19 pandemic, the nation has relied on Dr. Anthony S. Fauci for accurate, science-based recommendations and advice.  Dr. Fauci’s non-partisan commentary is consistently guided by science and, as a result, he is often placed in the unenviable position of having to speak truths that are unwelcome to those in power, which he has done unflinchingly throughout his career and continues to do during this pandemic.

As the SHEA Board of Trustees, we are national leaders in infection prevention and healthcare epidemiology, and the work of NIAID directly affects our own work. Our Society would like to publicly thank Dr. Fauci for his calm, consistent reliance on science and for his national leadership during this pandemic. Dr. Fauci is a trusted public health expert who has decades of service.  He is a brilliant scientist and is an unwavering leader during our COVID-19 pandemic response.

Dr. Fauci has served as Director of the NIAID since 1984. He has advised six US Presidents, in both parties, on numerous epidemics, emerging pathogens, and other domestic and international health issues. His contributions to the treatment and prevention of HIV/AIDS, including the President’s Emergency Plan for AIDS Relief (PEPFAR) has saved millions of lives across the world. His expertise and deep dedication to the fields of infectious disease, public health, and epidemiology are unparalleled.

Dr. Fauci remains one of the most trusted infectious diseases physicians and one of the most respected clinical immunologists in the world. From the beginning of the pandemic, he has provided a consistent voice of reason.  As the science of SARS-CoV-2 viral transmission dynamics unfolded, Dr. Fauci’s messaging changed accordingly. He continues to share updates with the general public and provides guidance that is evidence-based and pragmatic.

This year has proven to be one of the most tumultuous times of our lives, and certainly our careers. Despite the current substantial and formidable obstacles to successful public health leadership, Dr. Fauci continues to be a steadfast scientific leader, unwavering in the face of highly visible science denialism. And for that, Dr. Anthony Fauci, we all thank you.

References:

  1. Center for Systems Science and Engineering (CSSE) at Johns Hopkins University, COVID-19 Dashboard. https://systems.jhu.edu/research/public-health/ncov/ Accessed October 20, 2020.
  2. United Stated Department of Labor. News Release, Bureau of Labor Statistics: The Employment Situation – September 2020. https://www.bls.gov/news.release/pdf/empsit.pdf Accessed October 20, 2020.
  3. The New York Times, “Students, Parents, and Teachers Tell Their Stories of Remote Learning.” October 14, 2020.

Ambulatory Management of Neonates Born to SARS-CoV-2 -Infected Mothers

The infection prevention practices for neonates born to women with COVID-19 around the time of delivery, both during the birth hospitalization and in the days to weeks after hospital discharge, is an unresolved issue. In areas with community spread of SARS-CoV-2, hospitals may test all women presenting in labor for SARS-CoV-2 to optimize infection prevention practices. Testing identifies neonates born to women with symptomatic SARS-CoV-2 infection, as well as a larger group born to women with asymptomatic SARS-CoV-2 infection.1 In addition, some hospitals test the father of the infant or other person accompanying the woman during labor.

Available data indicate vertical transmission of SARS-CoV-2 infection is very uncommon, but the risk of infection from transmission in the delivery room or in the days after delivery has not been established.2 The Centers for Disease Control and Prevention (CDC) considers a neonate born to a SARS-CoV-2 PCR-positive woman to be potentially infected.3 As such, these neonates are potentially contagious. Preliminary data suggest 1-3% of infants born to SARS-CoV-2 PCR-positive women will test positive during the first 24-96 hours of life.4

In this white paper, we provide some basic guidance to help primary care and other ambulatory providers decide what infection prevention measures are most appropriate for patient visits. Local practice varies, and clinics and providers should discuss practices with their health system and local infection prevention or public health authorities.

Recommendations:

1.      Newborns of women with symptomatic or asymptomatic SARS-CoV-2 infection at the time of delivery should be considered potentially infected and should remain in quarantine, until at least 14 days of age. They may be at risk for SARS-CoV-2 infection longer because of postnatal exposure from the mother or exposures from close contacts including other members of the household. In healthcare, the need for COVID-19-specific personal protective equipment (PPE) and isolation should be 14 days after the last exposure to an infectious household member/close contact.

2.      Newborns of women with a history of symptomatic or asymptomatic SARS-CoV-2 infection with onset of symptoms or SARS-CoV-2 detection, respectively, longer than 10 days prior to delivery (or 20 days in cases of severe infection or an immunocompromised status) are no longer contagious. Thus, the newborn can be cared for using standard isolation precautions unless there is concern for exposure from other persons in the household/close contacts.  

3.      Birth hospitals should adopt a protocol to ensure the primary pediatrician/provider is informed in a timely manner when a neonate is born to a mother with SARS-CoV-2 infection.

4.      Health supervision visits during the first 2 weeks of life

A.    When scheduling the visit, the family should be informed that the caregiver bringing the infant to the ambulatory visit should be asymptomatic and ideally not in quarantine. Persons who have been exposed to the SARS-CoV-2-positive mother should also remain in quarantine for 14 days after their last exposure to the infectious person. An example of a preferred adult who may bring the infant to the visit is an asymptomatic person who is not a household or close contact of the mother or infant. If no such individual is available, an asymptomatic adult who is in quarantine but is not known to be SARS-CoV-2 infected is acceptable, providing the individual wears a face covering and performs hand hygiene. If no asymptomatic individual is available, the provider should assess the risks of transmission from a symptomatic caregiver with the benefits of an in-person evaluation for patient care. For example, an in-person visit may be necessary for an infant at risk of weight loss and dehydration based on feeding history and maternal breastfeeding status. In such a case, transmission risk can be mitigated by bringing in the infant as the last appointment of the day after all other patient and families have vacated the clinic, and by patient evaluation performed by staff members vaccinated for COVID-19 and with use of PPE. Upon arrival for the visit, the infant and adult should be escorted directly to an examination room and the door should be kept closed. The adult should wear a face covering for the duration of the visit and perform hand hygiene upon entry into the clinic.

B.     All ambulatory healthcare personnel should wear masks. Personnel who will be in the exam room with the neonate should also wear eye protection (i.e., eye shields, face shields, or safety goggles; regular eyeglasses are not sufficient), gown and gloves.5 A surgical mask is sufficient, but per the local health system and department of health guidelines, an N95 respirator or higher level of protection can be used.

C.     If needed, an oropharyngeal/nasopharyngeal swab can be obtained in the ambulatory office setting while wearing PPE recommended by your health system for test collection. Swabbing is not considered to be a procedure at high risk of generating infectious aerosols.5

D.    Few ambulatory offices have negative pressure rooms. The likelihood of viral particles being released and remaining in the air from an asymptomatic neonate is likely to be low unless the infant underwent an aerosol-generating procedure.

E.     Telehealth visits can be considered for 1 or more early visits but an in person visit during the first week of life may provide an opportunity for a more complete evaluation of the infant, particularly if there is a clinical concern that the infant may not be thriving. If an early telehealth visit is contemplated, providing a scale at time of hospital discharge for checking the weight of the infant should be considered.

5.      A SARS-CoV-2-positive mother may directly breast feed provided she is asymptomatic, hand hygiene is performed, and she wears a surgical mask. Symptomatic mothers may pump milk using the same precautions; expressed milk may be fed to the infant by an asymptomatic household member.3,6

6.      The need for SARS-CoV-2 testing of asymptomatic infants born to SARS-CoV-2-positive mothers following hospital discharge has not been established but a second test at 5-14 days of life may identify some infants with SARS-CoV-2 infection and inform infection prevention practices in the infant’s household.7,8

7.      If a neonate develops symptoms, in addition to testing/re-testing for SARS-CoV-2, alternative causes should be sought.

 

Repeat testing and potentially infected person status. CDC3 and the American Academy of Pediatrics (AAP)4,9 have recommended that infants born to women with COVID-19 should be managed like other potentially infected persons.  In the medical office setting this includes use of the appropriate PPE. The AAP recommends that infants be tested for SARS-CoV-2 using a combined oropharyngeal/nasopharyngeal swab (or using separate swabs or only a nasopharyngeal swab) at 24 hours of age and if continued hospitalization, re-test at 48 hours of age. If both tests are negative the AAP states that isolation precautions can be downgraded to standard precautions. However, it is plausible that an infant may acquire SARS-CoV-2 in the delivery room, from the mother while rooming-in, or from another person in the household or close contact following hospital discharge. Therefore, infants should be considered potentially infected until at least 14 days after the last exposure to an infectious household member/close contact.

Advice for handling potentially infected infants at home. Hand hygiene and masking of caretakers when within 6 feet of the infant including when holding or feeding the infant are important to reduce the risk of the baby becoming infected or the baby infecting other close contacts.3,4 As much as is feasible, the mother of the infant and other household members who have COVID-19 should be isolated if they are infectious. Adults, including grandparents, >65 years or those who have a chronic medical condition placing them at increased risk for severe COVID-19, may not be optimal caretakers for the potentially infected infant. In some cases, the mother may be the most appropriate caregiver, provided she uses infection prevention practices such as using a face covering, remaining 6 or more feet away when possible, and practicing diligent hand hygiene and cough etiquette.

References:

1.      Sutton D, Fuchs K, D’Alton M, Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med. 2020 Apr 13: NEJMc2009316. Published online 2020 Apr 13. doi: 10.1056/NEJMc2009316

2.      Elshafeey F, Magdi R, Hindi N, et al. A systematic scoping review of COVID‐19 during pregnancy and childbirth. Int J of Gyn and Obstet 2020;150(1):47-52

3.      Centers for Disease Control and Prevention. Evaluation and management considerations for neonates at risk for COVID-19.https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html (accessed January 16, 2020)

4.      American Academy of Pediatrics. FAQs: Management of infants born to mothers with suspected or confirmed COVID-19. American Academy of Pediatrics, updated 01/19/20  https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/faqs-management-of-infants-born-to-covid-19-mothers/ (accessed 01/16/21)

5.       Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) Pandemic, updated 12/14/20. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html (accessed January 16,2021)

7.      Ronchi A, Pietrasanta C, Zavattoni M, et al. Evaluation of rooming-in practice for neonates born to mothers with severe acute respiratory syndrome coronavirus 2 infection in Italy. JAMA Pediatr. doi:10.1001/jamapediatrics.2020.5086, Published online December 7, 2020

8.      Davanzo R., Moro, G., Sandri, F., Agosti, M., Moretti, C., Mosca, F. Breastfeeding and coronavirus disease-2019: Ad interim indications of the Italian Society of Neonatology endorsed by the Union of European Neonatal & Perinatal Societies. Maternal & Child Nutrition, 2020;49.doi:10.1111/mcn.13010.

9.      Puopolo KM, Hudak ML, Kimberlin DW, Cummings J. Initial guidance: management of infants born to mothers with COVID-19. Published April 2, 2020.  https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf.

The SHEA Advisory Panel includes:

  • Judith Guzman-Cottrill, DO, Chair, Oregon Health & Science University
  • Muhammad Ashraf, MD, East Carolina University
  • Yoko Furuya, MD, NewYork-Presbyterian Hospital (NYP) Columbia University Medical Center
  • Nicole Iovine, MD,  University of Florida
  • Susy Hota, MD, MSc, University Health Network, Toronto, Canada
  • Jesse Jacob, MD, MSc, Emory University
  • Amy Kressel, MD, Indiana University School of Medicine
  • Larissa May, MD, MSPH,  University of California-Davis
  • Rehka Murthy, MD, Cedars-Sinai Medical Center
  • Ann-Christine Nyquist, MD, University of Colorado School of Medicine Children's Hospital Colorado
  • Belinda Ostrowsky, MD, Westchester Co. Department of Health, Montefiore Medical Center & Albert Einstein College of Medicine
  • Nasia Safdar, MD, PhD, University of Wisconsin Health System University of Wisconsin-Madison
  • Heather Young, PhD, MPH, Denver Health Medical Center
  • Kavita K. Trivedi, MD, Content Advisor, Contract Consultant, Trivedi Consults, LLC

The SHEA Education Committee Panel includes:

  • Jennifer Hanrahan, DO, MA, Co-Chair, MetroHealth Medical Center
  • Christopher Pfeiffer, MD, Co-Chair, VA Portland Health Care System
  • Jason Bowling, MD, University of Texas Health Science Center San Antonio
  • Bernard Camins, MD, UAB Health System and University of Alabama at Birmingham
  • Teena Chopra, MD, MPH, Detroit Medical Center/Wayne State University
  • Susan Coffin MD, MPH, Children's Hospital of Philadelphia/UPENN
  • Christina Gagliardo, MD, Maimonides Infants & Children's Hospital of Brooklyn and Albert Einstein College of Medicine
  • Waleed Javaid, MD, SUNY Upstate Medical University
  • Stephen Liang, MD, Washington University School of Medicine/ Barnes-Jewish Hospital
  • Nicholas Moore, MS, MLS, Rush University Medical Center
  • Priya Nori, MD, Montefiore Health System, Albert Einstein College of Medicine
  • Aurora Pop-Vicas, MD, University of Wisconsin Hospitals; University of Wisconsin School of Medicine and Public Health
  • Cindy Prins, PhD, MPH, University of Florida
  • Geeta Sood, MD, Johns Hopkins University
  • Kavita Trivedi, MD, Contract Consultant, Trivedi Consults, LLC
  • Lisa Winston, MD, University of California, San Francisco / Zuckerberg San Francisco General Hospital and Trauma Center

The SHEA Expert Writing Panel includes:

  • David Banach, MD, MPH, MS, Co-Chair, University of Connecticut Health Center
  • Lynn Johnston, MD, Co-Chair, Dalhousie University
  • Duha Al-Zubeidi, MD, Children's Mercy Kansas City
  • Allison Bartlett, MD, MS, University of Chicago Medicine Comer Children’s Hospital
  • Susan Bleasdale, MD, University of Illinois in Chicago
  • Kyle Enfield, MD, University of Virginia
  • Christopher Lowe, MD, MSc, Providence Health Care
  • Luis Ostrosky-Zeichner, MD, McGovern Medical School
  • Kyle Popovich, MD, Rush University Medical Center
  • Payal Patel, MD, Veterans Affairs Ann Arbor Healthcare System
  • Karen Ravin, MD, MS, Nemours/Alfred I. duPont Hospital for Children
  • Theresa Rowe, DO, Northwestern University
  • Erica Shenoy, MD, PhD, Massachusetts General Hospital
  • R Scott Stienecker, MD, Parkview Health System
  • Pritish Tosh, MD, Mayo Clinic
  • Kavita K. Trivedi, MDContent Advisor, Contract Consultant, Trivedi Consults, LLC

SHEA has received a contract from the CDC to create the SHEA/CDC Training Program for Healthcare Epidemiologists to Respond to Infectious Diseases Outbreaks and Public Health Emergencies in United States Hospitals. This SHEA/CDC Outbreak Response Training Program (ORTP) contains several components that will be released from 2016-2018.  Find out more at ortp.shea-online.org.  

SHEA's mission is to prevent and control healthcare-associated infections and advance the field of healthcare epidemiology. Our Topics of Interest page provides a brief overview of a few of SHEA's priority areas to accomplish this mission. Additional information can be found in Infection Control and Hospital Epidemiology, SHEA's scientific journal.

anti-microbial stewardship

Antimicrobial Stewardship

SHEA is committed to fostering strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs. This movement, known as Antimicrobial Stewardship is key to preserving the effectiveness of antibiotics.

influenza

Influenza

SHEA provides guidance on influenza control in healthcare facilities, distribution and use of antiviral drugs, and influenza vaccine of healthcare workers, personal protective equipment, and other topics concerning seasonal and pandemic influenza.

Compendium of Strategies

Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals

These are jointly published these science-based and practical recommendations for acute care hospitals for the prevention of common HAIs in Infection Control and Healthcare Epidemiology.

Emerging Pathogens

SHEA follows several emerging pathogens of interest to our members.

SHEA/CDC Outbreak Response Training Program

SHEA has received a contract from the CDC to create the SHEA/CDC Training Program for Healthcare Epidemiologists to Respond to Infectious Diseases Outbreaks and Public Health Emergencies in United States Hospitals.