COVID-19: fear, explanation, action, unity and ingenuity and World Hand Hygiene Day

At the time of writing (31 March 2020) the COVID-19 emergency is beginning to take hold and many of you have been working flat out for the past six weeks in preparation for this. It is difficult to write an editorial that will have relevance in two months when, if the epidemiological modellers are correct in their forecast, we will hopefully be on our way out of the other side of the UK epidemic. All those working in the health service will have been giving their absolute best at considerable cost to themselves and their families, but many lives will also have been lost.

In the March Editorial I wrote about Strong’s psychology of epidemics (1990) in which he describes three phenomena or “epidemics” that accompany the emergence of novel infections: fear, explanation and the need for action. Since the pandemic spread of HIV starting in the 1980s, the UK has been relatively untouched by novel infections. Severe Acute Respiratory Syndrome (SARS) in 2003 resulted in four confirmed cases and Middle Eastern Respiratory Syndrome (MERS) in 2012 in five confirmed cases and the UK did not experience the epidemics that Strong described. However, COVID-19 is a different matter. The daily press conferences in the middle weeks of March saw a slow and stealthy number of measures being put in place that impacted our daily lives and resulted in behaviour changes associated with self-preservation and taking the last opportunities to be “normal”. The need for strict social distancing, self-isolation, the suspension of normal everyday activity and liberties, and the constant media and social media focus on the lack of testing, personal protective equipment, ventilators and intensive-care beds is frightening. The increasing number of new cases and deaths in the UK coupled with similar coverage from around the world is sobering and individual stories of people fighting for their lives and dying without the comfort of loved ones is heart breaking: the epidemic of fear is well and truly with us.

We have also seen the epidemic of explanation take hold of the nation. As a society we don’t deal well with uncertainty or the messages coming from experts that we are learning about COVID-19 as we go along. Experts differ in their opinions about what may and may not work in the UK, and the suggestion that what has been done in other countries may not work here for a range of complicated cultural and scientific reasons is perplexing. The language of epidemiologists, that we are trying to “flatten the curve” and not conducting an experiment in herd immunity is also quite alien. I find mathematical modelling a difficult science to understand, although I can grasp the principle that a model is only as good as the data you put into it, but that too is difficult for the public to understand. Forecasts are not facts or even pretty good predictions when you are learning as you go along, but they are helpful in helping you to consider what might happen given a specific set of parameters. Our admiration for the government advisers across the UK, who have supported and advised central and devolved governments is immense. They have been calm and consistent in their advice against a changing epidemiological landscape and an often-fractious media audience.

Understanding and communicating risk is similarly fraught with missteps. Rowlands et al. (2015) indicate that 43% of people aged between 16 and 65 years find health information too complex, and when the information also requires maths skills this rises to 61%. There are 34.1 million adults in England aged 16–65 years, so this means that between 15 and 21 million people of working age across the country may not be able to understand and use the information they need to look after their health. Much of the information being provided about COVID-19 is available from internet sources and supposes that everyone has access and is able to negotiate web sites. However, we know that computer and internet literacy skills are lower among older adults when compared with the general population resulting in a “grey” digital divide, with many older people missing out on the benefits that computers and the Internet can provide. The mainstream television and print media have so far provided extensive coverage of the global outbreak, with numbers and graphics to support the public information campaign and some of these are excellent. The infographic is certainly helpful in communicating key messages such as COVID-19 signs and symptoms, steps in hand hygiene and social distancing.

The epidemic of action is also being played out. Calls for the government to make decisions about limiting the movement of people or “lock down” were heeded, to be followed by the imperative to “act” to support people’s incomes through both business and individual state packages of measures. The issues of procuring, distributing and making available COVID-19 antibody testing, personal protective equipment and ventilators have become the keystones of calls to action. It is also easy to understand how lack of action in these areas feed into a vicious cycle of fear and need for explanation.

A considerable amount of the attention directed at strategies to protect healthcare workers has been focused demands for personal protective equipment. Healthcare workers are consumers of the media in the same way as the rest of the population and their direct experience of patients who are severely ill or dying of COVID-19 heightens their sense of fear and anxiety about their risk of exposure to this infection. The fear of contagion is not a new phenomenon and the early, uncertain days of the AIDS pandemic were also associated with high levels of anxiety and irrational behaviour (Walsh, 1992). The infection control practitioners in the 1990s faced similar problems around implementing rational, evidenced-based infection control measures in the context of a highly anxious workforce.

Even in non-pandemic circumstances, healthcare workers use of protective clothing is often driven by their desire for self-protection rather than a recognition of the requirement to reduce cross-infection. The reliance on clinical gloves to protect the wearer from infection has been shown to have a significant impact on compliance with hand hygiene (Loveday et al, 2014). This is alarming in the current context of COVID-19 where there is a danger that the same gloves are worn for prolonged periods, touching patients, the environment and a wide range of shared equipment and, with gloved hands, facilitating the spread of the virus through contact with contaminated surfaces. In a time when gloves have become paramount, there has never been a more important time to focus on hand hygiene and to re-iterate the critical importance of changing gloves and decontaminating hands between procedure and between patients.

On a more positive note, World Hand Hygiene Day has never before been accompanied by such a high profile and world-wide emphasis on the importance of hand hygiene in preventing the transmission of infection. The message about hand hygiene is being promoted to all corners of society, to the wider public as well as healthcare workers. Getting this message out in such a powerful and relevant way can only be a good thing and infection prevention and control practitioners should capitalise on this unprecedented focus on their core message.

The patient is often overlooked in the messaging about the importance of hand hygiene. Observation of almost any clinical environment will demonstrate that patients are rarely encouraged or supported to decontaminate their hands. In the context of COVID-19 it is critical that all patients are enabled to do this and, if access to soap and water is not feasible, then alternatives such as hand wipes should be made available (Burnett, 2009; Chadwick, 2019; Loveday and Wilson, 2018).

In the past two weeks amongst the fear, need for explanation and calls to “do something more” we would suggest that there is a fourth “epidemic” as Stong (1990) would term it and it is more positive than those above: the epidemic of unity and ingenuity is beginning to take hold. The past week has seen the NHS Nightingale facility in London emerge from the EXCEL conference venue in London Docklands, with similar facilities being planned in Birmingham, Harrogate, Manchester and Scotland. While one could term this “action” it is also a coming together of human ingenuity and a feeling that we need to work together to tackle the challenges that face us. The call for recently retired healthcare professionals, medical students and student nurses, midwives, other allied health professionals including clinical scientists to make themselves available to support the NHS workforce has resulted in thousands of practitioners coming forward. A nation request for volunteers to help to support the most vulnerable among us was preceded by local initiatives to meet the needs of the elderly and other vulnerable groups. The need for ventilators and facial protection has led to engineers from Medtech and other industries across the country, such as Formula 1, using their skills to design scalable alternatives using new technology such as 3D printing to meet the needs of the NHS. The campaign to get people to clean their hands regularly to prevent the transmission of COVID-19 led to a shopping spree that seriously hit stocks of hand sanitiser across the country. The response to this shortage came from the gin and whisky distillers in all the countries of the UK, who indicated that they could switch production from spirits to isopropyl alcohol. In the month of World Hand Hygiene Day could infection prevention ask for a better juxtaposition that gin and hand hygiene?

COVID-19 is likely to be with us for many more months, maybe years, and we need to grasp this opportunity to focus attention on the one single intervention that is critical to preventing the transmission of infection.