It’s clear to me that in the next decade we will regret not applying adequate pressure to the CDC to add air precautions to ‘universal precautions’ last week. This is bigger than preventing infectious disease. This has everything to do with the broader right to clean air, and pollution free environmental. It's better for our world and us with it. Pollution doesn't magically stay outside after entering a building closing a door behind. For instance, the link between asthma and living near freeways well documented since the 1990s. As reported by the Children's Health Study in this 2006 peer-reviewed article: https://pmc.ncbi.nlm.nih.gov/articles/PMC1459951/#:~:text=Children%20who%20live%20within%20a,four%20or%20more%20blocks%20away.
Evolution only occurs when adaptation to new conditions occurs. We've successfully accomplished this in the recent past. Mentioned and cited in my letter is how CDC's 'standard precautions' became ‘universal precautions’ when source control guidance broadened to include bloodbourne pathogen specific source control during the earlier days of the HIV/ AIDS pandemic. Latex and nitrile gloves weren't common healthcare before this guidance, yet this small decision not only improved routine point-of-care experiences in healthcare it cascaded to dentistry as well. A small adjustment in standard practice > A large beneficial net impact.
So, with the news from Tuesday, November 19th 2024 that H5 bird flu was detected in Alameda County I’ll share my public statement to the CDCs Healthcare Infection Control Practices Advisory Committee (HICPAC) a few weeks back. This follows another public statement made last year when they sought to do away with significant protection for immunosuppressed peoples in healthcare settings.
Dear HICPAC Members,
I am Giuseppe C. Cavaleri, with 18 years of experience in public health research, direct service work, and advocacy, specializing in infectious disease mitigation including HIV and HCV. I write today as a concerned member of the public regarding HICPAC's proposed guidance on respiratory protection in healthcare settings.
The urgency of strengthening respiratory protection standards cannot be overstated. The WHO reports 8.2 million new tuberculosis cases in 2023—the highest since monitoring began in 1995, with one-third being treatment-resistant. TB remains a leading cause of death among HIV-positive individuals, demonstrating the particular vulnerability of immunocompromised patients. This global trend threatens to reverse 120 years of progress in U.S. TB control.
The threat extends beyond TB. We're seeing alarming increases in RSV, mycoplasma pneumonia, and a five-fold rise in whooping cough cases, while facing potential H5N1 risks. Combined with over 1.2 million U.S. COVID-19 deaths and millions affected by Long COVID, we face compelling evidence that current protection standards are insufficient.
The proposed distinction between "routine" and "special" air precautions is fundamentally flawed. This two-tier approach fails to protect healthcare workers and patients from the reality that respiratory viruses and bacteria require consistent, high-level protection. The success of universal precautions for bloodborne pathogens during the HIV crisis proves that standardized, comprehensive protection measures improved quality of life while saving patient lives. We need similar universal standards for airborne protection.
The United States has a proven track record of successful airborne disease control when comprehensive measures are implemented. Since 1904, when Dr. Edward Livingston Trudeau founded what would become the American Lung Association, innovated medical and public health approaches to effectively control TB transmission. This legacy of comprehensive protection should inform today's standards.
Evidence continues to support this approach. The Texas Center for Infectious Disease (TCID) tuberculosis clinic demonstrates both effectiveness and cost-efficiency of comprehensive respiratory protection. By providing elastomeric respirators with replaceable filters to all 170 employees, they reduced annual costs from $44,000 to $2,000 while maintaining zero TB cases among staff since 1996. This example directly refutes concerns about cost or practicality of universal N95-level protection.
I urge HICPAC to:
Eliminate the proposed two-tier system of air precautions
Require fit-tested N95 respirators or elastomeric respirators as the universal minimum standard for healthcare workers
Include specific guidance for reusable respiratory protection programs to address both cost and sustainability concerns
Recognize that ALL airborne pathogens pose risks requiring consistent, high-level protection
The tools exist. The evidence supports their use. The cost-effective solutions are proven. HICPAC must now show the leadership to implement these protective measures before we face another preventable crisis.
Regards,
Giuseppe C. Cavaleri
On the cutting room floor:
Mentioning this book. Does the hard stuff for 'em National Academies of Sciences, Engineering, and Medicine book published 2019: Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use.
Mentioning Far-UV tech that's been deployed successfully since 1903... and adopted significantly more in the post World War 2 era: https://www.uvtglobal.com/what-is-uv-c/the-history-of-uv-c/
The 2009 the US Department of Labor produced 5-and-a-half-minute video that covers the differences. Titled simply: “The Difference Between Respirators and Surgical Masks.”
For TB rates: WHO report published 2024 covering 2023:
And the 5x whooping cough year over year mentioned in the letter? In 2024, reported cases of pertussis increased across the United States, indicating a return to more typical trends. Preliminary data show that more than five times as many cases have been reported as of week 44, reported on November 2, 2024, compared to the same time in 2023. Table showing this figure is 22,273 in 2024 (preliminary data) vs 4,840 in 2023.
PS: Curious about mammalian adaptation means to you, mammel? It’s the frequency in which we see PB2 E627K in humans that’s the issue. It’s increasing. See comments for extensive citations.
Case Fatality Rate for H5N1 is 52% per this CDC release.
Casual reminder the average adult gets flu 2x a decade. It’s extremely unusual for an adult to acquire it 1x a year or more. Children get flu on average every other year, flu infections became less frequent with age.
The study mentioned in Reuters article linked above: Here
Additional casual reminder we wiped out the B/Yamagata strain in March 2020 through proactive mitigation and prevention for the virus that isn’t a flu (It’d be called a flu). Study from 2022: https://pmc.ncbi.nlm.nih.gov/articles/PMC9524051/
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