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Re: Letter to the Editor, Regarding the pre-proof of “Implementation of a successful infection prevention and control governance structure and capacity building strategies during COVID-19 pandemic—A brief report”

Published:September 26, 2022DOI:https://doi.org/10.1016/j.ajic.2022.08.009
      To: The Editor, American Journal of Infection Control
      Re: The Pre-Proof of “Implementation of a successful infection prevention and control governance structure and capacity building strategies during COVID-19 pandemic – a brief report” (Dempsey K, 2022).

      Dempsey K, Jain S, Clezy K, Bradd P. Implementation of a successful infection prevention and control governance structure and capacity building strategies during COVID-19 pandemic – a brief report. Am J InfectContr, in press

      As a collective group with expertise in workplace health and safety, occupational hygiene, occupational medicine, emergency medicine, paramedicine, infection prevention and control, and public health, we express our dismay at the suppositions in the article that the New South Wales Clinical Excellence Commission (NSW CEC) has resulted in positive outcomes during the pandemic. While it is noble for the authors to document their work during the pandemic for others to learn from, their conclusions, including that, “the infection prevention and control measures and strategies implemented within health and non-healthcare, proved to be effective…” is not evidence-based and does not stand up to external verification.
      The following statements in the article are overstated:“Since January 2020, the CEC has developed extensive COVID-19 IPAC guidance for healthcare and other settings to build IPAC capacity and capability at a systems level, with a focus on providing timely expert advice on current and emerging problems in HAI impacted by COVID-19. These resources are regularly reviewed and updated in line with new and emerging evidence”. [emphasis added]
      The reluctance of the NSW CEC to recognize the need to protect healthcare workers from airborne transmission of disease has been strong. Early versions of the COVID-19 Infection Prevention and Control Manual in April 2021 restricted the use of airborne precautions (inclusive of P2/N95 respirators) to specific circumstances. That Manual outlined that only contact and droplet precautions were required if healthcare workers were within 1.5 m of patients, which reflects an ignorance of aerosol transmission dynamics as well as the risk of transmission between staff. Airborne precautions were only required in cases of ‘moderate transmission’ where the non–evidence-based “aerosol generating procedures” were taking place, or if multiple patients were cohorted in one area. It was not until May of 2021 that the Manual was updated to include a recommendation that health care workers wear P2/N95 respirators to protect against SARS-CoV-2 based on an assessment of the risk of transmission (Clinical Excellence Commission.

      Clinical Excellence Comission (2021). COVID-19 infection prevention and control manual: Version 1.1.

      This was some 6 months after conclusive evidence was published that SARS-CoV-2 was airborne, including more than 200 scientists calling for it to be recognized as such in a paper providing the evidence for this published in November 2020.
      • Morawska L
      • Milton D
      It is time to address airborne transmission of Coronavirus disease 2019 (COVID-19).
      This is not consistent with the authors claim that their expert advice was “timely” nor up to date with “emerging evidence.”
      Indeed, that same Manual in February 2022 still referred to “aerosol generating procedures” and stated that, “SARS-CoV-2 is mainly spread by direct contact with respiratory droplets and these droplets can be of various sizes and can be aerosolized in some specific conditions.” [emphasis added]
      We note that the NSW CEC only first published their Respiratory Protection Program Manual in December 2021,

      Clinical Excellence Commission (2021). Respiratory protection program manual. Accessed October 7, 2022. https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0004/696712/Respiratory-Protection-Program-Manual.pdf

      9 months into the pandemic, more than a year after the state of Victoria, and more than 8 years after South Australia.
      The NSW CEC has also repeatedly misunderstood the application of basic workplace safety processes such as the hierarchy of control. This is evidenced in the latest version of the Manual published in July 2022, through the following examples. Repeated, incorrect classification of controls artificially elevates their effectiveness, when in fact, they are lower level and prone to human errors.
      • Categorizing “testing and quarantine” and “travel restrictions” as elimination controls, when these are in fact administrative controls;
      • Categorizing “physical distancing” as a substitution control when it is administrative; and
      • Categorizing “registration of all people entering the facility” as an engineering control when this is administrative.
      A repeated failure to recognize the contribution of aerosol transmission was further reflected in the NSW CEC Infection Prevention and Control Manual for Quarantine Hotels which stated that, “Whilst the risk of aerosol transmission requiring airborne precautions is acknowledged it is not the primary mode of spread for COVID-19 and requires a risk assessment approach.”

      Clinical Excellence Commission (2021). COVID-19 infection prevention and control manual: for quarantine hotels.

      As a result, the control measures contained within that document did not adequately control the risk of transmission of COVID-19, due to the absence of control measures to address the risk of airborne/aerosol transmission.
      But above all, the continual failure to recommend appropriate personal protective equipment for healthcare and other workers in high-risk settings was the most telling example of the lack of a multidisciplinary approach from the NSW CEC. P2/N95 respiratory protection is the minimum level of respiratory protection for an airborne virus. Yet such was restricted from workers who were required to be in environments where the potential to breathe ‘shared’ air occurred. This included hotel corridors, saliva screening, hotel entry temperature checking, guest floors, and when in direct contact with a guest (regardless of symptoms). The absence of a specific mention of the need for respiratory PPE fit-testing for use in hotel quarantine per the recognized Australian Standard was also of deep concern.

      Standards Australia (2009) AS/NZS 1715 Selection, use and maintenance of respiratory equipment

      That the authors claim the NSW CEC resources were appropriate, only further speaks to the insular nature and culture against continuous improvement and its failure to heed expert advice from other disciplines, including aerosol science, occupational hygiene, occupational medicine, workplace health and safety, and public health. This paper lacks scientific evidence and providing a platform for these unsubstantiated claims risks the reputation of the journal. To publish this paper unchallenged would promulgate the already insular culture of the Commission and continue to put the lives of Australian health care workers and broader community at ongoing risk.

      References

      1. Dempsey K, Jain S, Clezy K, Bradd P. Implementation of a successful infection prevention and control governance structure and capacity building strategies during COVID-19 pandemic – a brief report. Am J InfectContr, in press

      2. Clinical Excellence Comission (2021). COVID-19 infection prevention and control manual: Version 1.1.

        • Morawska L
        • Milton D
        It is time to address airborne transmission of Coronavirus disease 2019 (COVID-19).
        Clin Infect Dis. 2020; 71: 2311-2313
      3. Clinical Excellence Commission (2021). Respiratory protection program manual. Accessed October 7, 2022. https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0004/696712/Respiratory-Protection-Program-Manual.pdf

      4. Clinical Excellence Commission (2021). COVID-19 infection prevention and control manual: for quarantine hotels.

      5. Standards Australia (2009) AS/NZS 1715 Selection, use and maintenance of respiratory equipment