Webinar: Evidence Review Presentation on PPE use and TBP for Respiratory Viruses

Hi everyone, welcome. We're going to go ahead and get started. We appreciate everyone taking the time to join us today. I'm Laura Wells with the Division of Healthcare Quality Promotion. Our agenda today is going to start with a 15-minute presentation from Erin Stone on the evidence for gowns and gloves for PPE when caring for patients and residents infected with SARS-CoV-2. Erin is the lead in the division for guidelines and evidence reviews. The second presentation will cover the evidence for the duration of transmission-based precautions and will be presented by Devin Okasako-Schumacher, who is a health scientist in the division. We anticipate having 10 minutes at the end of the call for questions, so please put your questions in the Q&A, and we're going to get to as many as time allows. Please note that the chat function is disabled, so please use the Q&A for all your questions. Lastly, we will not be making the slides for this presentation available, but this session is being recorded and will be shared online. Now, I'd like to introduce Alex Callen, who is the Branch Chief for the Prevention and Response Branch in the Division. Alex? Thanks, Laura. On behalf of the Division of Healthcare Quality Promotion at CDC, thank you for joining us for today's webinar. This call is intended to give healthcare personnel, health departments, and professional associations a better understanding of some of the evidence behind important infection control interventions. Today, our goal will be to provide the results of two systematic evidence reviews looking at select infection control practices used in the care of patients and residents with viral respiratory pathogens. As Laura said, the first will review the evidence for the use of gowns and gloves as part of the PPE ensemble used when caring for someone infected with SARS-CoV-2. The second will review the evidence available on the length of time transmission-based precautions should be instituted when caring for patients infected with a viral respiratory pathogen with a focus on SARS-CoV-2 and influenza. Systematic evidence reviews are the first step in determining if updates to existing recommendations are warranted and what changes are supported by current science. Although these issues are under review at CDC for potential changes to our guidance, it is important to note that there have as yet been no changes to the official CDC recommendations based on these reviews. We hope this information will be valuable to providers, facilities, and organizations as you approach the upcoming respiratory virus season. With that, I'd like to turn it over to Erin Stone for the first presentation. I'd like to start with a disclaimer that the findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency, determination, or policy. Now I'm going to present the draft findings for a rapid review of the use of gowns and gloves for routine care of patients infected with SARS-CoV-2. The recommended PPE ensemble for routine care of patients infected with SARS-CoV-2 includes an N95, eye protection, and a gown and gloves. This is based on a conservative approach to risk assessment used in situations with novel viruses of unknown severity and mode of transmission. Since January 2020, evidence has accumulated on the mode of transmission for SARS-CoV-2, including a CDC scientific brief highlighting the risk of transmission via fomites is generally considered to be low. In a 2022 systematic review, this review concluded that evidence for a chain of transmission of SARS-CoV-2 from fomites to humans was not reported in the 14 healthcare and 9 community studies that were reviewed. Given this evidence, we conducted a rapid review to answer the question, what is the effectiveness of routine gown and glove use for care of patients infected with SARS-CoV-2? To prevent or reduce the transmission of SARS-CoV-2 in healthcare facilities, we developed and ran a literature search in seven databases with results up to June 17th of this year. Two methodologists independently duplicate reviewed all titles and abstracts in full texts using concrete screening criteria detailed on the next slide. The data was then extracted from the relevant studies, independently reviewed, and results were narratively synthesized across outcomes. Our research question and the inclusion and exclusion criteria were developed using PICO's framework and can be seen in this table. We included studies that reported outcomes in healthcare personnel and patients and the use of gowns or gloves for contact precautions compared with no gown, glove, or contact precautions. We included laboratory or clinically confirmed SARS-CoV-2 outcomes, but excluded self-reported infection. For the assessment of adverse events and waste, we included data for outcomes attributed to gown or glove use by healthcare personnel. Importantly, we excluded studies conducted in low- and middle-income country health care settings due to concern for potential confounding by differences in facility policies. Additionally, we excluded studies that used different data collection methods for cases and controls due to concerns for the introduction of additional bias We started with 3,819 references, and after screening, 40 studies met inclusion criteria. Where possible, we limited the analysis to only studies reporting adjusted measures of association, which resulted in the inclusion of 10 studies in the analysis. Four reported SARS-CoV-2 outcomes, three reported adverse event outcomes, and three reported waste outcomes. For the studies reporting glove use in lab-confirmed SARS-CoV-2 outcomes, here are our results. To orient you to this table, the data in each study is represented in the rows. Then from left to right, the columns detail the following data extraction elements. Study identifier, which is the first author and publication year. Then the denominator or study size. The dates of data collection. Data collection methods for PPE use. The diagnostic test used to identify SARS-CoV-2 positive healthcare personnel. And finally, the results. For the results, one quasi-experimental study, SUGIPTO 2025. which is reported in the top row, analyzed SARS-CoV-2 outcomes in healthcare personnel before and after the de-escalation of gown, glove, and face shielding use and reported no difference in lab-confirmed SARS-CoV-2 before and after. Three observational studies reported no protective association between healthcare personnel's SARS-CoV-2 positivity and the self-reported use of gowns or gloves. All three studies adjusted for different variables. An example of these These variables include community SARS-CoV-2 levels. Aerosol-generating procedure frequency and other PPE. Notably, only one study, Mansour 2023, reported testing for SARS-CoV-2 using PCR and using occupational health record data to collect PPE use data. Akinvami and Simbashi retrospectively collected all data using a survey to gather PPE use and a sero survey for infection data. Each of these surveys occurred between one week and four months after the exposure event. These limitations reduce our certainty in the findings of these last two steps. When we narrow these results down only to healthcare personnel exposures during the direct care of patients infected with SARS-CoV-2, only the Simbashi study meets these criteria. This is the smallest study with data collected the furthest from the exposure. Both of these concerns reduce our certainty in the findings. As you can see, the confidence interval for both gowns and gloves crosses one, suggesting no difference. For exposures during direct care and gowns and glove use. Currently, our summary would state that we see no difference in gown and glove use amongst SARS-CoV-2 positive and negative health care personnel. And when we see these results in some of the wide confidence intervals, we wonder if it may be due to study-specific biases. So for context, we reviewed the measure of effect for the routine use of other PPE elements. I'd like to note that this is a post-hoc review, and it was not conducted to analyze the effectiveness of these other elements of routine PPE. It is solely here to provide context on whether any component of routine PPE was associated with a protective effect. The other routine elements recommended for patient care include eye protection and N95s. Mask data is additionally provided. So for this context, for eye protection, the routine use of eye protection, the same evidence reports inconsistent measures of effect and confidence limits. The weight of the evidence suggests no difference in eye protection use among SARS-CoV-2 positive and negative health care personnel, as with Sajipto 2025 and Akinbami 2020. Mansour suggests a higher odds of face protection use among PCR positive health care personnel, while the smallest study suggests a decrease in the odds of self-reported goggle use among positive health care personnel. Again, inconsistent results. For the routine use of face masks, the same evidence suggests there's likely a protective association. The two largest studies, Mansoor and Akinbami, suggest a protective effect from face mask use because they reported lower odds of face mask use among positive health care personnel compared with negative health care personnel. The smallest study reported no difference in face mask use during medical Procedures. Finally, for routine use of N95s, only two studies reported N95 use during routine care. This is Mansoor and Akinbami, and both reported a protective association between N95 or filtering face piece respirators and SARS-CoV-2 positive personnel. Additional context is three other systematic reviews were published in the last five years. All three of them suggested either an unclear benefit to gowns and gloves or conducted meta-analyses of different studies than we included and still reported no difference in gown or glove use. For the harm outcomes, evidence suggests glove use is associated with an observed reduction in hand hygiene adherence. One study, cross-sectional, early in the pandemic, was conducted in 2022. This study conducted observations of hand hygiene and glove use over one week. And they noted with glove use, there was a reduction in hand hygiene compliance. Two studies examined an association between skin symptoms and glove use. They reported inconsistent results. And Dennis, 2023, reported inconsistent results between an association between skin symptoms and glove use. In ER COVID-19 and intermediate care units and the COVID test team where they saw a reduction in skin symptoms. Additionally, Rizzi 2021 reported a decrease in occupational hand dermatitis with more than six hours in gloves. Again, inconsistent results for the skin findings. So to summarize, The draft findings. The routine use of gowns and gloves for patients infected with SARS-CoV-2 may not be associated with healthcare personnel SARS-CoV-2 test results or skin reactions on the hands, but may be associated with increases in waste. Sorry, I am going too far. I missed the waste slide. I apologize. We retrieved three studies suggesting carbon savings and waste reductions will occur. However, the amount will depend on facility policies and waste consciousness. They all reported different measures and different interventions. Two studies went from risk-assessed gown use to single gown use per patient. Waste savings ranged from 1.5 kilograms per patient day in the Segipto 2025 study to 33 grams per patient day with the change in during the pandemic. Changes in the average number of PPE used per patient day for gowns. Ranged from an 84% reduction for Segipto with de-escalation or a 51 to 54% annual reduction with Hamer 2025, which also moved from risk assessed to routine single gowns The mass of carbon savings was approximately 400,000 kilograms per year in Segipto 2025 So this is the summary slide and this is where the waste and decreases come from. Finally, as our limitations, we searched for but did not retrieve data reporting the effect of healthcare personnel use of gowns or gloves on patients' SARS-CoV-2 outcomes, specifically SARS-CoV-2 transmission to patients in healthcare facilities. We also looked for but didn't find mortality outcomes among healthcare personnel, cost effectiveness studies on PPE de-escalation What this review was not designed or intended to assess was the effectiveness of gowns and gloves as part of standard precautions, differences in type of gown or clothing Duration of gown or glove use or extended use, reuse of gowns or gloves, or the effectiveness of other elements of routine PPE. We additionally did not assess basic science outcomes such as contamination of PPE And now I'll turn it over to Erin Thank you, Erin. And I'll be sharing our draft findings for an integrated analysis on the duration of transmission-based precautions for select respiratory viruses. On this slide, we have the current CDC recommendations for the duration of transmission-based precautions for symptomatic patients with COVID, seasonal flu, and RSV. The existing COVID guidance was last updated in 2023 and recommends contact precautions with N95 respirator and eye protection for 10 to 20 days depending on severity of illness and at least 24 hours since last fever without medication with symptom improvement. And the test-based strategy is recommended for immunocompromised patients. For seasonal flu, droplet and standard are recommended for seven days after symptoms begin or 24 hours after resolution of fever and symptoms, whichever is longer, and the duration may be longer for children or immunocompromised patients based on clinical judgment. There isn't a specific recommendation for adults with RSV, so this falls under acute respiratory infectious disease in Appendix A and for children, the recommendation is contact and standard with a mask for the duration of illness. And this can be extended for an unspecified duration for immunocompromised individuals. The healthcare personnel return to work recommendations that were updated last month were supported by a systematic review we conducted on the risk period for transmission among previously healthy adults. Our goal was to identify this risk period for transmission by evaluating the duration of viral shedding, the association between the duration of shedding and symptoms, and the day of symptom onset and secondary cases of transmission pairs And the table below has our findings from the 2026 update of the systematic review, and HCPAC used this data to inform the duration of work restrictions for healthcare personnel. HCPAC decided to use the 70% threshold for the estimated last day of transmission, which is three days for both pathogens, to support work restrictions for three days, and recommended source control through the 90% threshold which is originally day seven, but following the update, day seven became one day beyond the 90% threshold So to identify the risk period of transmission among hospitalized patients, we conducted a similar review focusing on a different population of interest, and our research questions were among patients infected with SARS-CoV-2, influenza virus, or RSV, who are symptomatic and hospitalized, or at increased risk of severe respiratory illness or prolonged shedding, what is the pair-level serial interval defined as the number of days between symptom onset in primary and secondary cases. What is the duration of respiratory viral shedding measured from symptom onset or diagnosis, and what is the association between the resolution of symptoms, specifically fever, and the resolution of respiratory viral shedding? We published our protocol with our screening criteria according to PRISMA guidelines, and the population of interest included infected individuals who are symptomatic and hospitalized or at increased risk for severe illness or prolonged shedding And that included older adults, children, and those with underlying health conditions. So we used CDC's underlying conditions for severe COVID-19 page to help guide us. And for the shedding and symptom research questions, we included any diagnostic tests of any respiratory sample. So those outcomes could be the duration of replication, competent virus measured by culture, RNA shedding measured by qPCR, detectable viral antigen measured by rapid antigen tests, or really whatever was reported. For outcomes, we also included the duration of signs or symptoms and for the research question about pair level data, we wanted serial intervals. Our protocol was pretty broad and we weren't sure about the quality or quantity of the evidence before we began, but we were able to make some post hoc decisions to better prioritize the best available evidence to answer our questions. In going through the shedding and symptom data first, we were able to limit to viral culture only where possible and included qPCR only if there was no culture data available for that particular virus in that population. And for data reported among adults and children, we limited to studies reporting daily sampling or sampled at least multiple times per week. And we also prioritized data that started measuring shedding from symptom onset, diagnosis or admission, and data that measured until negative, discharged, or for at least seven days. We limited to studies that provided enough data to determine when at least some threshold was met. Otherwise, the data would not have been as useful when collapsed across studies. And for the serial interval data, we had a lot of studies reporting intervals with child index cases, so we're able to limit to studies reporting transmissions between lab-confirmed pairs, so excluding studies that identified secondary cases through symptoms alone over people's self-reported test results. Our PRISMA diagram shows the number of studies we looked at for this integrated analysis, and we screened nearly 12,000 titles and abstracts and over 1,000 full texts. We then incorporated studies identified in the earlier systematic review that focused on previously healthy adults, and that added in 31 additional studies, bringing our total to 86 studies that met our post hoc best evidence criteria from the previous slide. And first, I'll walk through the serial interval data. For this review, we define serial interval as the time from symptom onset in a primary case to symptom onset in a secondary case. And this diagram illustrates what this interval represents in relation to the risk period of transmission that we mentioned earlier. And if you look above the summary table, which is in one of the red boxes, you'll see the incubation period for the secondary case. The serial interval includes this incubation period for the secondary case, so if we want to identify the period of contagiousness for the primary case or that risk period for transmission, we could subtract the secondary case's incubation period to identify the time between symptom onset in a primary case and infection in a secondary case, giving us this risk period for transmission in the other red box. And while the primary case's contagious period probably starts during their own incubation period, if they don't have symptoms yet, it is possible they or their providers aren't aware they're sick. So for our purposes, we're most interested in this time period between symptom onset in a primary case and infection in a secondary case in order to estimate the risk period for transmission. And here we have a heat map of the best available evidence for Omicron across populations with data from previously healthy adults added in. We've arranged studies by age and used lines to stratify different age groups, with younger children under two at the top all the way down to older adults age 50 and over at the bottom. The columns provide information on the number of pairs included in each study, the average age of primary cases, the settings in which a study took place, the population of primary cases, the vaccination status of primary cases, and duration of follow-up for each study. If we look at the top row, We have one study with eight transmission pairs where the primary cases were young children under two and the days post-symptom onset in the primary case are listed in the header row on the top right and the numbers below that are the percentages of secondary cases who've experienced symptom onset by the end of each day. The red boxes show when all study all studies in a group report at least 80 percent of secondary cases experiencing symptom onset. So overall, this 80% threshold is reached by day six or seven post-symptom onset in the primary case, with a few exceptions. For children age two to 18, it's around day seven. When previously healthy adults reach the threshold, it's a little earlier on day six, as do most studies in the older adult index cases. So the two exceptions are for young children less than two. Limited data from a single study of only eight transmissions reaches 88% by day eight, and the other one for older adults over 50, a single study with five transmission pairs is pushing that 80% threshold to day eight, and if we excluded just two transmission pairs from the Minnesotan study, we'd see all older adult studies reach the 80% threshold much earlier before even day six. And this really highlights that small studies can impact the results, since we're evaluating these thresholds at the study level. And that arrow at the top represents the incubation period, which for Omicron is approximately two days. So if we subtract two days from day seven, when nearly all age groups have reached 80%, then we get day five as the estimated last day of transmission for nearly 80% of primary cases. And if we use day eight, which is driven by results from small studies, Then the estimated last day of transmission for 80% would be day six. Several concerns for bias in this body of evidence include the potential for misclassification of tertiary cases as secondary cases and potential selection bias due to follow-up durations. And here we have the best available evidence for seasonal flu. Again, the red boxes show that 80% of secondary cases experience symptom onset by day five or six post-symptom onset in the primary case. Flu's incubation period is approximately one day, so if we subtract that from day six, when all age groups have reached the 80% threshold, then we get day five as the estimated last day of transmission for 80% of primary cases. Again, we have similar concerns for potential misclassification and selection bias, and we also have some concerns for potential confounding due to severity of illness of the primary case and infection prevention and control As several of these studies include older adults in acute care hospitals. There was very little data on RSV with nothing retrieved for adults or older children. But we did identify two studies that reported on primary cases who were previously healthy children under age five. And 80% of secondary cases experienced symptom onset by day six. And the RSV incubation period we identified was three days. So if we subtract that, then we get day three as the estimated last day of transmission for 80% of primary cases. But this data is limited to only 62 transmission pairs, and again, we have those same concerns for potential misclassification and potential selection bias. And this table summarizes the heat map data that we showed on the previous three slides and shows the estimated last day of transmission across populations and pathogens for the overall Overall group of adults and children over two. The last likely day of transmission for 80% of pairs is day six for Omicron, which again is driven by small studies, day five for flu, and day three for RSV. And the results for previously healthy adults are about one to two days shorter. There's very limited data for young children under two for Omicron and flu, while children under five is all we have for RSV. Sorry. Next, we'll move on to shedding data. For the shedding data, we made some post-hoc decisions to prioritize the best available evidence and for possible limited respiratory viral shedding to the presence of replication competent infectious virus measured by culture. However, when there was no culture data available for a pathogen or population of interest, we did expand this definition to include the presence of viral RNA measured by quantitative PCR or qPCR. And here we have the best available evidence for Omicron shedding. And similar to the heat maps we already saw, the columns provide information on each study and its population, but for shedding outcomes, we also report the test type, the frequency of testing, and when shedding is measured from and to. The days post-symptom onset, diagnosis, or admission are listed on the right, and the percentage of individuals who stop shedding by the end of each day is listed below for each study. And the red box highlights that 80% of individuals have stopped shedding by the end of day nine post-symptom onset diagnosis or admission, which is a day earlier than the current recommendation. And unfortunately, we didn't retrieve any studies reporting on young children under two, and the studies we do have that report on children under 18 measured the presence of viral RNA by qPCR, so these studies may be overestimating the true duration of shedding. However, the results align with those for previously healthy adults. We do have some concerns for bias in this body of evidence, including the potential for measurement bias due to those qPCR studies, potential selection bias due to different measurement starting points, and confounding due to differences in disease severity and underlying conditions across different populations. For seasonal flu, we were able to limit the data for all populations to culture only, eliminating any concerns for measurement bias. And the red boxes show that similar to Omicron, the adults and children over age two, shedding ends for at least 80% of individuals by day nine, which seems, I think that's actually longer than the current flu rec. And young children under two do seem to continue shedding for four or five more days. We have similar concerns over selection bias and confounding. Plus the potential for misclassification due to non-daily sampling as the majority of these studies report frequencies beyond daily. Again, there was limited data for RSV, but it suggests a longer duration of shedding than Omicron or flu. But there are concerns for bias due to qPCR studies measuring non-infectious virus and non-daily sampling overestimating the duration and different start and end points that could impact results in either direction. There's also potential confounding due to disease severity and underlying conditions. And this table summarizes the shedding data for select viruses with the different days each threshold is met for the different pathogens and populations. For the overall group of adults and children over two, 80% have stopped shedding by day nine for both Omicron and seasonal flu. And that asterisk for flu is for a study that didn't report results beyond 72%, so it never reached the 80% or above thresholds. And for RSV, it's quite a bit longer with 80% having stopped shedding by day 15 for those over two. For children under two, we didn't retrieve data for Omicron, but flu and RSV suggest they may shed longer than others. And now we'll look at the symptom data. So we were interested in the association between the resolution of symptoms, especially fever, and the resolution of viral shedding. We already covered shedding, but symptoms were defined. As the presence of any sign, symptom, or combination during the course of respiratory illness as reported in a study, whether or not was defined, and regardless of how it was collected. So we included both self-reported and provider collected data. And here we have the heat map for shedding and fever. Like the earlier heat maps, the columns are reporting study-specific information with a column specifying if a row reports the resolution of shedding or the resolution of fever. And studies reported data in different ways. So at the top in Section A, we have the resolution of shedding measured from the disappearance of fever. So Jane 2022 and GIA 2011 are telling us the percentage of individuals who resolved shedding each day post-resolution of fever. And the second section, B, reports the resolution of shedding and the resolution of fever stacked together for each study. So RAF 2015 reports the percentage of individuals who stop shedding each day And the percentage of those whose fevers have resolved as well, all measured from treatment administration. And overall, the data suggests that those with fever are likely still shedding, but that fever cessation doesn't necessarily mean that shedding has ended as well. So fever alone may not be a great marker for resolution of shedding. And we have several concerns for bias, including measurement bias for the inclusion of qPCR data. And for those studies in Section B, potential misclassification due to non-daily sampling and indirectness since not all patients may have experienced fever, but they were likely included in the shedding data. And here we have studies reporting signs or symptoms other than fever alone. And overall, data suggests symptom resolution may not be a great marker for shedding resolution since shedding appears to continue after symptoms subside for those with Omicron or RSV. But for flu, data suggests that shedding does end by the time symptoms end. And similar to the last slide, there are concerns due to inclusion of qPCR data, non-daily sampling, and again for those studies in Section B, concerns for indirectness. And next we'll take a look at the peak shedding data. So eight studies reported peak shedding data measured by culture, and the columns report Report study-specific information with a column specifying if a row reports. Peak shedding or the duration of shedding? Data was limited, but across all three pathogens suggests nearly all individuals, at least 98%, have reached their peak by day seven. And if we use that 80% threshold, the studies reach that by day five or six, except for one of two people in the Dave Vincenzo study for RSV. And we have concerns here for bias, which include the non-daily sampling and different measurement starting points. And now we'll take a look at the summary of all our outcomes together. So this table shows our main outcomes for adults and children over two, together in a single table, stratified by pathogen. And overall, the data suggests that at least 80% of transmissions have occurred, and nearly everyone has reached their shedding peak by the end of day seven. And using a 70% threshold, the estimated last day of transmission is day four for flu and day six for Omicron, with peak shedding occurring around day two to five. Shedding resolves by day 8 or 9 for Omicron and flu and day 13 for RSV. If we use the 80% threshold, estimated last day of transmission is day 5 or 6. I remember day 6 for Omicron is driven by a small study with only a few transmissions. Peak shedding occurs by day 3 or 5, and shedding resolution occurs by day 9 for Omicron and flu and day 15 for RSV. As a reminder, HICPAC chose to use the 70% threshold to support a three-day work restriction for HCP. Paired with the use of source control upon returning to work through the end of day seven, which was intended to be the 90% threshold. Sorry. And here we have the stratified results for each population, which shows that the 70 and 80% thresholds that we just walked through on the last slide for the estimated last day of transmission are really driven by results for hospitalized or risk factor adults for the Omicron and children two to 18 for flu. We can also see that younger children may be shedding longer than others, so the data is pretty limited to only a few studies. Thank you, and now I'll turn it back over to Laura for the Q&A. Okay, great. Thank you, Devin. That was great. Okay, so we received one question asking about the p-values. Oh, I'm so sorry. I was going to say that at the end, but that's fine. Yeah. As far as someone did ask about the slides, we're not going to be sharing the slides, but we will be sharing the recording. It will be posted online, hopefully, in the next few weeks. So, I just want to make sure everyone's aware of that. And also, if you have any other questions, please put them in the Q&A. Thank you. So, we received one question about the p-values and confidence intervals for the studies being referenced. How can people review the individual studies that informed these evidence reviews? Alex? Great. Thanks, Laura. Yeah, so I think multiple ways. First, like Laura said, once this gets posted, you will be able to look back at the tables and should be able to find the specific articles. Obviously, there's lots of studies, so I'm not exactly sure which study the question is about, but you should be able to pull the studies yourselves if you wanted to look at the individual studies. Obviously, anytime CDC does these type of reviews, the evidence is published either online or in a journal. We do plan to publish both of these, and hopefully in the relatively near future. So, you would be able to review the evidence that way as well. So, you should be able to find the individual studies as well as the systematic reviews either of those ways. Okay, great. Thanks. Will CDC be updating COVID guidance for nursing homes prior to the start of this respiratory season before the end of this month? What are the next steps for these evidence reviews? Alex? Yeah, great. So that's a very broad question. So let me start. So first of all, these evidence reviews are intended to apply to all healthcare settings, not just nursing homes, but obviously nursing homes would be one of the settings that you could use these for. The second thing I'll say is about a month ago or so, or last month sometime, many of you have probably seen that CDC did update the return to work guidance for respiratory viruses. That, of course, was Evidence that was presented to HiCPAC back in November of 2024, HICPAC is our old Federal Advisory Committee that some of you may be aware of that was terminated a year or so ago. So that was voted on back in 2024, and that has just recently been updated in CDC guidance. So if you're interested in the Return to Work Guidance, that's available in the Healthcare Personnel Guideline on the CDC website, so I encourage you to check there. As part of that update, again, about a month ago, many of you probably saw we also took the opportunity to pull down some of our old guidance, so we archived it, which basically means that the guidance is still available on the website more for historical purposes. It's not being updated any longer, and that it was a couple of guidance, including the mitigating staff shortages. Many remember we had a guidance that was designed to help healthcare facilities that were facing staffing shortages due to work exclusions. That was pulled down, and we also archived the old COVID guidance, so that whole guidance that was for infection control precautions for people with SARS-CoV-2 infection was also archived. We did take the kind of relevant parts of that that were still, you know, applicable and move those over to what we call Appendix Appendix A is in the isolation guideline. So if you're interested in the SARS-CoV-2 PPE recommendations, duration of precautions, patient placement, all those sorts of things that were pulled out of the old SARS-CoV-2 guidance, that is available if you, and it's what's called Appendix A. The isolation guidelines, so usually if you Google Appendix A, it'll be the first thing that comes up. So those were all already done. So if you're referring to the things that we're talking about today, so those things are in the early stages of development. You've seen the evidence reviews and we've had discussions here at CDC about possible changes to recommendations based on those evidence reviews. We've also shared that for feedback with some external groups Oops. to experts to try and get feedback on their thoughts for this. We do at CDC, when we develop guidance, have a very long and formal process, which I think is a good thing and a bad thing. It does allow everybody to provide input and for transparency and those sorts of things, but it doesn't allow things to be done in the most expeditious fashion. So we do anticipate. Once we have that done and we have some feedback formulating some recommendations based on this, that would then, the plan would then, for that to go to public comment, like our old HICPAC guidance were, once that, and, you know, that gives everybody the chance to provide their feedback, even if you weren't in one of the expert groups that we consulted, then once that comes back to We would review the feedback we get from public comments. And then that is where we formulate those recommendations from. So you can see we're still fairly early in this process, and there's probably a fairly long period to go. So I think it's probably fair to say it's definitely unlikely that this will be out before the beginning of respiratory virus season. And I think also probably unlikely that this will be out for most of this respiratory virus season. Great. Thanks. Can we update our recs now based on these reviews? Yeah. So, again, I think, again, the official CDC recommendations are still the things that are posted now for SARS-CoV-2 and flu in Appendix A. So, I think this is evident. I know we know there are groups out there that have formulated their own recommendations, etc. So, we're providing this as a service for folks so that they're able to see what the evidence is to base recommendations on. But again, I think the. The recommendations from CDC are still the recommendations that are posted. These guidance updates that we discussed today are not yet incorporated into official CDC guidance. Okay. Is CDC going to look at use of eye protection and a respirator for SARS-CoV-2? Erin, do you want to take this one? Yes. Right now... We've started a systematic review to answer the question of eye protection, and we're in the early phases of the review, screening titles and abstracts. As a reminder, current CDC PPE recommendations for SARS-CoV-2 infected patients and residents are eye protection and an N95 or higher level respirator. Okay, great. Thank you. Why does CDC have different recs for patients versus healthcare personnel versus the community? Alex, you want to take that one? Yeah, that's a great question. So, again, I think a lot of this has to do with different risks for folks, different risk tolerances for different groups, different potential negative consequences for different groups and long periods of isolation. So, you know, I think whenever we get a request to review evidence and provide recommendations, We, especially those of us who work in the healthcare settings, take a close look at the evidence that's available. I think you saw, at least for the duration of gowns and gloves, that Devin presented that the evidence for, you know, So. Individuals who are either hospitalized or immunocompromised or have other medical conditions is fairly slim. So we take what we gain from that, we add it to the evidence that we have that we use to make the healthcare recommendations, which are obviously, since most healthcare workers are fairly healthy, is more based on otherwise healthy adults. We look at the results that come about the risks of transmission. We look at the... Potential downsides of transmission within healthcare settings based on different patient population groups. We look at the negative consequences of periods of isolation or restriction from work and put all those together to try and make the best possible recommendations. So I think you can see when we look at all those things and we look at the different groups, how different results could come from different different subpopulations. So, you know, again, I think it's a complicated process, but we would love it if there were studies that answered every single question that we have for healthcare. But I think, you know, a lot of times that is impossible and we need to take a lot of these other things into account as well. Okay, great. Will the updated RECs only apply to COVID and flu or will it apply to other respiratory viruses? Aaron, do you want to Yeah. Any updates CDC makes regarding the recommended use of gowns and gloves will only apply to SARS-CoV-2. Any updates made to the duration of transmission-based precautions will apply to SARS-CoV-2 and seasonal influenza. Future work involves a comprehensive review of Appendix A in the isolation guideline, and at that time, this data may be more recognized. It would be valuable to have a pan-respiratory recommendation given the limits of testing. And this option is certainly on the table as we review Appendix A. Okay, great. The long-term care outbreak testing guidelines for staff and residents were also archived. Will updated information be provided? Yeah, so the testing guidance that was in the all SARS-CoV-2 guidance is archived, as it was said, which means it's essentially not being supported by CDC any longer. I think, you know, we all recognize with the testing in these settings for these particular pathogens, it's an incredibly complicated process. And and I think. I think we've all come to realize through the SARS-CoV-2 pandemic that testing is a very useful tool, especially for symptomatic people, but isn't maybe the best first step. We have other tools to use like we've talked about today with patient isolation, with the use of source control, et cetera, that are probably best. you know, first steps in controlling outbreaks in nursing homes, etc. So, to answer your question, there is no plan to update the testing recommendations for SARS-CoV-2 for nursing homes other than our continued recommendation to, you know, low threshold for testing symptomatic individuals. I think you're mainly talking about testing exposed individuals, and that our continued recommendations to use some of the other tools as a first step in controlling transmission, things like... Patient isolation and the use of PPE for healthcare personnel and source control to control spread as a first step. Okay, great. Were data for any other respiratory viruses such as parainfluenza or human metapneumovirus evaluated? Is there any evidence to suggest the duration of shedding transmissibility for those respiratory viruses is substantially different than for flu, RSV, or SARS-CoV-2? Devin, you want to take this one? Sure. So we didn't look at any other respiratory viruses, but this was driven partially by limited resources and time. And we chose to focus on SARS-CoV-2 and seasonal influenza and RSV because these were considered fairly common viruses and important in healthcare settings. Okay, great. Thank you. All right, we're going to do a couple more. We have two more. It sounds like data is limited and there's low confidence for some of these research questions. Is this normal when developing new guidance? Erin? Yeah, this is a great question. It can be normal. It really ultimately depends on the research question and the published data that's available to answer that research question. Really, honestly, like anything in epidemiology, it depends. But it is, unfortunately, in healthcare associated research questions more common than we'd like. Okay. Let's see, one more question. Since there has been so much archived, what is the current guidance for residents who are exposed to someone with COVID? Alex? So again, I think if you have somebody who's, the current recommendations for someone exposed to COVID would generally be to follow them for symptoms. And to test them if they become symptomatic, if you're in, I think testing, like we talked about before, as a first step might not be the best approach as a first step. I think source control is another recommend is another thing you could consider for exposed people, given the risk of asymptomatic transmission or pre symptomatic transmission. And I think the other thing that you could consider if you're going to use testing, again, like I said, it is a useful tool, I think, in a situation where you have an outbreak in a facility or transmission that's ongoing is going on despite. You know, your baseline infection control recommendations, but again, I don't, it may not be your best first step. So, again, I think your options are following for symptoms. I think your use of source control, isolation, if someone becomes infected, isolating infected people to prevent transmission as a first step. And then if things continue to progress, considering that. And considering to. Use other things like testing. And I will also point out, I'm reminded that there is a pretty good toolkit that's available. If you Google long-term care respiratory viral toolkit from CDC that we put out that has basically all the recommendations, not COVID specific, but it is a pretty good resource for interventions that you can use to address respiratory virus transmission in long-term care. Okay, great. Well, that is everything. I want to say, or we all want to say thank you to everyone for attending. Just as a reminder, we're not going to be putting out the actual slide deck, but the webinar has been recorded and we hope to share it online in the coming weeks. So everyone have a great day. Thanks for attending.