Updates on the CDC Advisory Committee’s efforts to weaken infection control guidance for health care

Submitted by ADonahue on
Nurse holds sign "Science Matters, We Are Not Expendable"

The U.S. Centers for Disease Control and Prevention (CDC) has recently initiated work to update foundational infection control guidance for health care settings. CDC has tasked its advisory committee on health care infection control (known as HICPAC) with making these updates. HICPAC voted unanimously on Nov 3, 2023 to send its draft to the CDC, but HICPAC’s draft ignores scientific advancements and proposes to weaken existing practice. NNU called on the CDC to reject HICPAC’s draft.

On January 23, 2024, CDC announced the results of its review of HICPAC’s draft—the CDC officially sent the draft back to HICPAC for revisions! This is a major victory!

The CDC is requiring HICPAC to address some of the core issues that NNU has been raising, including the use of respirators vs. surgical masks to protect health care workers from pathogens that transmit through the air.

The CDC also made a public commitment to expand the scope of technical expertise on HICPAC and its work group, which is an essential step and something that NNU has been calling for since the beginning. HICPAC membership has been dominated by the health care industry. 

In April, 2024, the CDC responded to NNU’s information requests (see documents here). Turns out, the CDC has only added a small number of additional experts but continues to exclude frontline nurses and health care workers, who have essential expertise. There is still no union representative on the work group!

On April 4, 2024, NNU delivered a petition, signed by over 5,600 individuals, commending CDC Director Mandy Cohen for rejecting HICPAC’s problematic draft and urging CDC to ensure all necessary perspectives are added to HICPAC and its workgroup, including frontline health care workers, unions, patients advocates, and other public health experts.

Background information

What is happening at the CDC?

The CDC has an advisory committee called HICPAC, which stands for Healthcare Infection Control Practices Advisory Committee. This committee recently initiated work to update the CDC’s 2007 guidance, Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

On November 3, 2023, HICPAC voted unanimously to finalize its draft 2024 Guideline to Prevent Transmission of Pathogens in Healthcare Settings, sending the draft to CDC for further review. On December 16, 2023, NNU, along with 53 organizational and nearly 5,300 individual signatures, delivered a petition to CDC Director, Mandy Cohen, to reject HICPAC’s 2024 draft and to actively engage the input of frontline health care workers, patients, and public health experts in developing a new draft (including holding public meetings).

Instead of proceeding with posting HICPAC’s draft in the Federal Register for public comment, the CDC has officially returned the draft to HICPAC and requested revisions. The CDC also announced its intention to expand the expertise represented on HICPAC and its work group. This is a major victory!

How does this impact nurses and our patients?

The CDC’s infection control guidance is THE guidance that directs infection control practices in health care settings in the United States. Employers and government agencies in the United States and around the world frequently reference this guidance document.

HICPAC’s 2024 draft guidance fails to recognize updated science on infectious disease transmission and dangerously rolls back current infection control protections in health care settings, which would put nurses, other health care workers and their patients at increased risk of infectious disease exposures and infections. HICPAC’s 2024 draft guidance will exacerbate the current staffing crisis in health care, as more nurses and other health care workers will leave the bedside due to the further erosion of working conditions and health effects from infections.

Who is on HICPAC?

HICPAC members are almost exclusively infection prevention program managers and representatives of health care associations and employers. You can see the full list here.

While the CDC has publicly stated an intention to expand the scope of technical expertise on HICPAC and its work group, they have only added a few additional members and the work group remains dominated by infection prevention and industry perspectives. See more information in updated meeting summaries, obtained from the CDC by NNU via information requests.

What is CDC/HICPAC’s process to update the infection control guidance?

The CDC initially tasked HICPAC to draft updates. HICPAC’s process to develop these updates has not been transparent and has lacked in public input. NNU’s advocacy has resulted in several significant improvements. 

  • HICPAC appointed an Isolation Precautions (IP) Work Group to formulate updated recommendations, whose meetings are closed to the public. Updates from the IP Work Group have not been publicly posted by the CDC. NNU requested and received HICPAC IP Work Group meeting summaries, which indicate the IP Work Group has intended to weaken worker protections since the beginning and has relied on biased and flawed evidence in crafting guidance (read more about the IP Work Group meeting summaries here).
  • While full HICPAC meetings are open to the public, it is only since August 2023 that meeting recordings have been posted. Previously, members of the public had to pre-register and attend the live meeting in order to view proceedings. This change was the result of public advocacy and action by NNU and our allies. 
  • The order of the agenda of full HICPAC meetings has been changed since the August 2023 meeting—previously, voting took place ahead of any public comment. The deadline for written comment has also been extended since August 2023 compared to previous meetings. These changes have come about due to public pressure from NNU and our allies on CDC and HICPAC to improve transparency.
  • However, HICPAC still lacks public input. The public may make short comment (3 minutes per person) during each HICPAC meeting, but this is insufficient time to discuss the complexity of issues under HICPAC’s purview and there are very limited slots provided. There is currently no other mechanism for HICPAC or its working groups to garner input from the frontline health care workers, unions who represent them, experts in addition to infection preventionists who should be consulted, and patients who will be impacted by the updated guidance.
  • The IP Work Group presented its draft to the full HICPAC membership at the Nov. 2-3, 2023 public meeting. HICPAC voted unanimously to send the draft to the CDC for further review. The CDC’s next step is to review HICPAC’s draft, decide whether to accept, reject, or modify it, and to post it in the Federal Register for public comments. NNU called on the CDC to reject HICPAC’s draft and to develop a new draft crafted with input from patients, frontline health care workers, unions, and other public health experts, including industrial hygienists, ventilation engineers, respiratory protection experts, and aerosol scientists.
  • On Jan. 23, 2024, the CDC sent back HICPAC’s draft requesting revisions to address many of the core issues that have been raised by NNU.  

NNU’s concerns with HICPAC’s Draft—and why the CDC should reject it

Health care employers have a legal and moral obligation to provide a safe and healthful workplace for workers. However, HICPAC’s 2024 draft Guideline to Prevent Transmission of Pathogens in Healthcare Settings is explicitly geared toward frontline nurses and health care workers and what they can do to prevent infectious disease transmission, when it should be aimed at health care employers (frontline health care workers should be able to reference it, but do not bear responsibility or authority for many elements of infection prevention). HICPAC’s choice to focus on individual health care workers inappropriately seeks to shift the responsibility, risk, burden, and blame onto individual workers to protect corporate profits—which comes at the expense of protections.

Problems include:

The draft recognizes the hierarchy of controls (i.e., the idea that built engineering controls and administrative controls should be used first and PPE should be a last resort), but then focuses almost exclusively on PPE, sidelining other essential measures, such as ventilation, patient screening, visitor screening, and isolation.

 

Decades of research into aerosol transmission of infectious diseases has shown that respiratory aerosols are a continuum of sizes and can remain suspended in and travel through the air for long periods of time and distances. Transmission depends on multiple factors, including time, distance, dose, air flow/ventilation, and other factors. HICPAC’s draft erroneously maintains the existing, disproven droplet-airborne paradigm in its new Transmission-Based Precautions Categories: routine air precautions (tracks onto existing droplet category), special air precautions (new category that proposes to roll back existing guidance- see below), and extended air precautions (tracks onto existing airborne category).

 

Unlike existing/past CDC guidance whereby airborne infection isolation rooms (AIIR) are recommended for novel pathogens until transmission modes are better understood, HICPAC’s draft recommends against the use of AIIRs as a default precautionary measure.

 

HICPAC’s draft inappropriately and erroneously treats surgical masks as  respiratory protection and PPE for health care workers exposed to infectious diseases transmitted through the air and treats surgical masks as a default level of protection, reserving respirators for only specific “special” circumstances.  

Surgical masks are NOT respiratory protection—FDA, NIOSH, and OSHA are clear on this point, and yet CDC/HICPAC is proceeding to treat surgical masks as a default option for respiratory protection.

 

In the midst of the staffing crisis in health care, and with both patient and health care worker infection rates rising in recent years, HICPAC’s draft omits current language in CDC’s 2007 Isolation Precautions guidance about the importance of bedside nurse staffing.

 

CDC/HICPAC discussed the need to screen for exposure history and to apply Transmission-Based Precautions based on other factors (e.g., travel history, exposure history, risk factors for infection), but appeared to agree to only include a mention in the narrative section, not a full recommendation. An updated draft that includes edits made during the Nov. 2-3, 2023 meeting has not yet been publicly posted.

Spread from people who are asymptomatic or not yet experiencing symptoms is a hallmark of Covid-19 and other common infectious diseases transmitted through the air, such as respiratory syncytial virus (RSV) and influenza. Identification and isolation of all infectious diseases among patients, visitors and health care workers is paramount to preventing transmission whiting health care facilities.

 

The draft proactively embraces Workplace Performance Plus masks (also called enhanced barrier face coverings), even though these masks are not considered respiratory protection, are less protective than N95s (lower filtration and fit testing is not required), and are not yet approved for use in health care settings by the FDA as medical devices. Workplace Performance Plus masks will be used by the CDC and employers to undermine use of N95 respirators in health care.

 

HICPAC limited evidence reviews used to formulate the draft to “clinical studies with infection outcomes” because they are focused on employer feasibility and user adherence under current, existing “real-world” conditions. This approach does not take into account factors that employers could change to improve user adherence, such as providing safe staffing levels, break relief, and fully complying with OSHA’s Respiratory Protection Program Standard. Thus, HICPAC’s 2024 draft seeks to protect corporate profits at the expense of worker and patient safety.

 

More information

Letters and statements

Articles and other media

Video: HICPAC's Process and Proposals to Update the 2007 Isolation Precautions Guidance

Jane Thomason, CIH, Lead Industrial Hygienist for National Nurses United discusses deficiencies in the Centers for Disease Control and Prevention process for formulating infectious disease recommendations.