A shift in consciousness is needed to prevent and control the spread of infection.
The current pandemic has turned the world as we know it upside down. According to the European Centre for Disease Prevention and Control (ECDC), from 31 December 2019 up until 27 July 2020, there have been 16,249,165 reported cases of COVID-19 globally, including 649,208 deaths.
These figures could have been even worse had it not been for the actions taken by governments to reduce infection rates. At the same time, the strategies adopted to fight the virus have varied from country to country, depending on how individual governments have chosen to interpret the science available to them and balance their response to COVID-19 with other socioeconomic factors. The infection rates could have been much lower in many countries where poor decision making led to thousands of unnecessary deaths.
While virologists and vaccinologists race against time to develop some kind of silver bullet in the form of an effective treatment for those already infected or a safe vaccine to neutralise the bite of the virus, another crucial variable in the COVID equation is human behaviour.
A quick scan of any social media platform quickly reveals mixed feelings and a wide range of opinion on the seriousness of the threat of the virus. Everyday perspectives range from believing COVID-19 has been grossly exaggerated as a weapon of control to the idea that the coronavirus is a fake ‘plandemic’ to allow the elites to inject everyone with microchips through the back door…with the help of a well-known billionaire philanthropist, apparently.
Other issues affecting societal attitudes to COVID-19 include questionable figures in relation to mortality rates, which undermine efforts to convince the public through sound scientific data. The sheer volume of misinformation circulated online in the form of YouTube videos, fake news articles, memes and the deeply flawed but easily believed arguments shared in social media posts simply add to the problem. Those who take the virus seriously have differing opinions on how it should be handled. Whether to wear a mask, what kind of lockdown would be more effective, and the pros and cons of social distancing are just some of the bones of contention.
Seemingly contradictory messages from governments in deciding what kinds of activities people can participate in have further weakened efforts to unify public opinion and bring about a useful change in the cultural psyche. Consequently, we see some people doing everything they can to reduce their risk of contracting the virus or spreading it to someone else, while others are ignoring all guidelines. It doesn’t help when issues such as mask-wearing have become politicised in some parts of the world, and we have world leaders making it up as they go along and directly contradicting the available science. Using bleach internally to clean out coronavirus is not going to be recommended by scientists any time soon!
Putting aside efforts to fight COVID-19 biologically, it is easy to see that perhaps the biggest obstacle we face as a global society is a lack of clear understanding on how to minimise the spread of infection. For however long we have to live side by side with this latest coronavirus, the most effective weapon we have is education.
When it comes to the issue of education, there are a number of challenges that need to be tackled. As touched upon already, attitudes towards the virus need to be changed. As lockdown measures were being introduced, many businesses were extremely reluctant to close. Now, as restrictions are being eased here in the UK and elsewhere, some of these businesses are poised to open as soon as they get the green light from government, almost like sprinters listening out for the starting pistol.
Their main concern is not whether their premises are safe but whether they comply with the rules and regulations laid down by government to allow them to trade normally. For those organisations to be truly safe, a shift in consciousness is needed. They need to understand what they are up against and change their internal culture accordingly. When this happens, we are more likely to see organisations implementing measures that go further than government regulations.
Lack of education and training, coupled with a compliance-based attitude, leads to many unintended consequences. Take personal protective equipment for example. How often do we see people wearing face masks incorrectly? At a glance, many people are wearing face masks, however on closer inspection, we find they are wearing them incorrectly or they move them out of the way when speaking to people. This is more likely perhaps where they have been forced to wear them. An easy giveaway is the round-the-neck look, which allows them to say they are wearing a mask (albeit ineffectively) or even to quickly adjust the mask to comply with regulations when the need arises.
Sometimes the heart is in the right place, the attitude is constructive, but the training is lacking. A perfect example of this is the wearing of gloves. Nobody is under any pressure to wear gloves for their weekly shop, so if someone is wearing them, it is a strong indication that they are taking the threat seriously. However, wearing gloves is more likely to increase their risk rather than reducing it. A false sense of security will inevitably lead to cross-contamination to other items on their person, from their bank cards to their mobile phones. This same issue of cross-contamination also crops up with face masks as people fail to recognise that the outside surface of the mask must be assumed to be contaminated with the virus.
Thorough, frequent, and regular handwashing is much more effective than the use of gloves for everyday people going about their daily lives. Again, even for those who are extra vigilant, it is easy to get things wrong. In fact, even some medical professionals fail to wash their hands effectively, so what chance does the average person on the street have when they are simply told to wash with soap and water for 20 seconds?
Previous research into the handwashing habits of health workers in various countries, including the UK, suggest that while the majority of health workers believe they are washing their hands properly, only a small percentage of them actually are. And yet, handwashing is one of the single most effective strategies we can all adopt to minimise the threat of infection from COVID-19, along with a host of other nasty bugs such as the ‘winter sickness bug’, norovirus.
According to the World Health Organization (WHO), up to 50% of all hospital acquired infections (HAIs) could be eliminated with correct handwashing measures in place. It recommends the ‘six-pose’ handwashing method, which ensures all hand surfaces are given thorough attention. Surprisingly, it takes quite a lot of training and practice for people to develop the muscle memory to adopt this technique as a habit. Knowing something academically is one thing. Being able to do it in practice is another. And adopting it as a habit is a different kettle of fish entirely.
Typically, according to one training organisation, it takes between 20 and 30 practice sessions for the six-pose method to become a habit. Once mastered, it should take less than one minute to wash the hands properly!
Without a shadow of a doubt, preventative hygiene has to be one of the essential strategies in learning how to live with COVID-19. Hand hygiene depends on more than handwashing technique. The WHO has highlighted five key moments when health care workers should be washing their hands:
- Before touching a patient;
- Before any clean or aseptic procedures;
- After exposure or risk of exposure to body fluid;
- After touching a patient; and
- After touching patient surroundings.
The WHO’s ‘Clean Care is Safer Care’ campaign focuses on the prevention of infection through best-practice cleaning procedures. By taking a granular look at all processes and applying laser focus to how the risk of transmission can be minimised at every tiny junction, diseases can be prevented and controlled.
It’s a multi-faceted approach that includes every aspect of prevention and control, from personal protective equipment (PPE) and social distancing to personal hygiene and how environments are cleaned.
Just as a lack of training in hand hygiene can expose health workers to the risk of infection, having the right cleaning products does not ensure by itself that an environment is safe. What if the equipment being used in an operation is not sterile or other surfaces are contaminated? This would leave patients and medical staff open to infection?
There are no shortcuts when it comes to safety, hygiene, and infection control. But without detailed and thorough training and education, real risks can be overlooked. For example, when most people think of norovirus outbreaks, they will tend to think of cruise liners. They are unlikely to be aware that one of the most common sources of norovirus infection is the restaurant. If someone is sick in a restaurant, it is wiser to assume the cause to be norovirus rather than the food.
Most people would be shocked to discover that when someone is a sick because of norovirus, while the mess created by their vomiting fit may only extend to a square metre in front of them, viral particles will reach up to 7.62 metres or 25 feet away from them. Furthermore, norovirus is so contagious that it takes fewer than 100 particles to cause illness, but its incredible resilience means that it can remain active and alive on a surface for days and even weeks. Without the appropriate training and education, should we expect people to realise they are at risk from surfaces 25 feet away from a sick person?
The norovirus scenario graphically illustrates why the right training and education is even more important than having the appropriate equipment for cleaning. Simply marketing a product’s features, benefits and capabilities is not enough. That would be like handing over a Formula 1 car to a learner driver. The infection control industry must pay as much attention to showing how its products should be used as it does to show why its products are so good.
Ideally, products should always be supplied with an aftercare package that provides effective training, and this aftercare should be ongoing to ensure best practice is always being observed by users. The WHO believes that infection rates can be reduced by up to 30% through the implementation of effective infection control strategies. Training is a crucial element in any effective infection control strategy. Nowhere is this more important than in medical settings.
Surgical procedures create the perfect conditions for viruses and bacteria to become aerosolised, a process which allows bugs to remain airborne for longer and reach surfaces that are further away from the source. So, following any invasive surgical procedure, it is safe to assume that every millimetre of surface area in the operating theatre is contaminated. Cleaning that environment is no mean feat. If a ball is dropped at any point in the process, the risk of infection rises, not only for patients being operated on and medical team working with them, but for anyone else who enters the theatre and potential spreads infection elsewhere.
From a training perspective, there are many areas to consider, but two of the main ones centre on deciding which product to use and how to use the product effectively.
There are literally millions of bacteria and viruses out there. The vast majority of them are harmless, but there are plenty around that can cause serious harm or even death, and they can’t all be killed in the same way. For example, clostridium difficile (C. difficile) can only be killed with a sporicidal agent, such as peracetic acid, hydrogen peroxide or chlorine.
Sporicidal agents are alkylating agents and oxidising agents. A quaternary ammonium compound (QAC) won’t cut it because QACs are sporostatic, not sporicidal. Just to be clear, sporostatic agents will inhibit spore germination and outgrowth, but they do not kill spores.
Sporicidal agents need to be used correctly to work effectively. When mixing a chlorine-based solution, if the concentration of chlorine is too low, not only will the solution be too weak to kill C. difficile, it will encourage the growth of resistant bugs. However, a solution that is too highly concentrated will give off toxic, carcinogenic fumes and byproducts that will harm people and equipment.
Chlorine-based solutions start breaking down from the moment they are mixed, so they will only be effective for a finite amount of time. ‘Double dipping’ whatever is being used as a cleaning applicator into the solution will accelerate the breaking-down process as dirt and other contaminants are added to the solution.
Even the cloths that are used as applicators can cause a health and safety issue because some materials will absorb the sporicidal agent, and this will mean the solution being wiped on surfaces is too low in concentration. Cloth compatibility is a potential issue whether using a chlorine-based or QAC-based solution.
Some cleaners prefer to use sprays, however using a spray can lead to an inconsistent amount of the active agent reaching the surface. When a dry cloth is added to this scenario, to rub the surface, the viruses and bacteria that have not been killed are spread around. There are several reasons why a spray might not deliver an even concentration of the active agent to surfaces.
Dual action sprays are specifically designed to keep the different elements of the solution separate until the device is used. This prevents the mixture from breaking down and losing its potency. The mixing takes place at the head when the trigger is squeezed. A problem arises because when the spray is held at an angle, this affects the mixing process resulting a suboptimal solution being sprayed onto surfaces.
Not only will this lead to viruses and bacteria not being killed and potentially becoming more resistant to the agent, it also means the product is being wasted. Suboptimal mixing at the head of a dual action spray will cause precipitation to occur and this precipitate blocks the nozzle, which makes suboptimal mixing even more likely. It’s a vicious circle.
Using wet wipes to apply cleaning agents appears to get around many of the problems connected to sprays and other applicators. Wet wipes deliver a consistent mix of product to surfaces, are less likely to produce the fumes, toxins and other byproducts that can be produced by incorrect mixing, and they are less likely to irritate users because the solution is not being sprayed.
Every situation is different, and a thorough risk assessment must be undertaken for any environment before a cleaning strategy is developed. One of the risks that could potentially be overlooked is lack of training.
Cleaners are human beings just like everyone else. They are not machines, and they are just as susceptible to assumptions and exposure to mixed messages and misinformation as anyone else. They depend on their employers to supply them with the right products and training to do their jobs properly. Their own safety, and the safety of the people entering those environments being cleaned, depend on this training being effective. They need appropriate PPE and high quality hygiene products, but without the ongoing training to match, people are being put in harm’s way.
That is why at Reaction 9, we believe the training process should start before a client has even purchased a product. The infection control industry has a responsibility to educate, inform and update the people using their products.
Hygiene professionals must be empowered to make better informed purchasing decisions when buying specialist products that are designed to save lives. Knowledge is not enough. The training must be in place at the point of purchase, and it must be ongoing. Remember, it takes between 20 and 30 practice sessions just to learn the six-pose handwashing method.
Reaction 9 is currently leading the way in this approach to serving its customer base, but there is still a long way to go. There needs to be a real and lasting culture change within the infection control industry, as leaders embrace the philosophy of pre-sale, induction, and post-sale training, and we aim to stay at the front of that.
Learning technology is constantly evolving to engage people more effectively, so they gain deeper understanding and practical ability, and get into the right habits more quickly. From gamification, quizzes, and practice, to the use of AI for helping people learn by themselves, there is something for everyone. Let’s embrace it.
The fight against COVID-19 is far from over, and there are bound to be more disruptive viruses to follow. Our best defence for living with such threats, and our best weapon for fighting them, is training!
This article is from issue 14 of Health Europa. Click here to get your free subscription today.