Why Americans are tiring of social distancing and hand-washing – 2 behavioral scientists explain

States are beginning to open up their economies after successfully slowing the spread of the coronavirus. Much of the credit for that goes to Americans dutifully following prescribed behavior.

People have been washing their hands frequently, maintaining physical distance from others, wearing face masks, sanitizing door knobs and even disinfecting food and packages brought into the house.

But in order to continue to contain the spread of the virus, we’ll still need to sustain these behaviors for weeks and maybe months to come. Will people be able to maintain their vigilance over time?

As scholars who study health-related behavior change, we’re skeptical. While continuing to wash your hands and stay six feet away from others doesn’t seem so hard for an individual, the problem is that people are unable to “see” the benefits of their actions – and thus often don’t recognize just how important they are.

As a result, adherence to these protective behaviors could wane over time without policies designed to sustain them.

Intangible benefits

It is, in fact, remarkable to us that efforts to promote hygiene measures have been as successful as they have been. That’s because they are almost the embodiment of the types of protective measures that people are especially bad at taking.

The most obvious reasons are that maintaining physical distances and constantly washing hands are inconvenient and require constant vigilance. The costs of these behaviors are immediate, but the benefits are delayed.

A more subtle and equally important reason, however, is that the benefits are intangible: You can’t touch, taste, feel or see the benefits of, for example, wiping off your door knob.

One reason the benefits are intangible is that people tend to be insensitive to even dramatic changes in probabilities – such as from one-in-a-thousand chance to one-in-a-million chance – when it comes to small probability events such as the chance of contracting coronavirus.

This is true unless the change in probability leads to certainty that the event will not occur, which is why people are not eager to engage in preventive behaviors unless they completely eliminate the risk, as research by psychologists has shown.

For example, one study found that people were willing to pay much more to reduce a pesticide risk from 5 in 10,000 to 0 in 10,000 than from 15 in 10,000 to 10 in 10,000, even though the actual reduction in risk was identical. A similar study concluded that people were more attracted to a vaccine said to entirely eliminate a 10% risk for a disease than to one that reduced the risk from 20% to 10%. And a third one found that a vaccine described as 100% effective in preventing 70% of known cases of a disease was more appealing than one that was 70% effective in preventing all cases even though both would have the same net effect.

Even if we follow all recommendations about sheltering in place, washing hands, wearing masks and disinfecting grocery deliveries, we can only reduce and not eliminate the chance of catching COVID-19.

Will people continue to feel that it’s really worth it to sanitize all those plastic bags from the supermarket if the only effect is to reduce the odds from, say, 1 in 2,000 to 1 in 3,000?

Invisible impact

Another reason the benefits of prevention seem intangible is that we don’t get useful feedback about the effects of our actions.

The microbes are invisible, so we have no idea whether we had them before we washed our hands or have gotten rid of them after we have done so.

In addition, we get no feedback about how a particular protective action has changed our probability of getting infected. If all of our actions work, the outcome is that we don’t get sick. But not being sick was the state we were in before we took those actions. Thus, it seems as if the preventive actions caused nothing to happen because we can’t see the negative outcome that might have happened if we hadn’t been so vigilant.

Documenting such a pattern, studies of treatment for depression have found that many patients skip or discontinue taking antidepressants as soon as their symptoms improve, leading to relapse.

The same is likely true at a societal level. If all the sacrifices people are making pay off in the form of lower infection rates, people will point to those low rates as evidence that the sacrifices weren’t actually necessary. Such a pattern has been documented among anti-vaxxers, who claim that low rates of diseases that are vaccinated against are evidence that the vaccine wasn’t needed in the first place.

When one is healthy, it is very difficult to imagine being sick – even when one has been sick in the past. This probably has something to do with low rates of adherence to lifesaving medications.

For example, one year after hospitalization for a heart attack, nearly half of patients prescribed statins stop taking them. And rates of medication adherence for acute diabetics are similarly dismal.

In both cases, people who are healthy – or even those who are sick but not experiencing immediate symptoms – don’t appear to appreciate the risks of failing to protect themselves.

Constant vigilance

So how can we sustain vigilance in the face of pervasive intangibility?

We could remind ourselves that life rarely offers certainty, and behaviors that reduce risk significantly are worth continuing even if they don’t eliminate it altogether. Or we could try to keep in mind those who have been hospitalized or even killed by COVID-19 – a fate that could befall any of us.

Realistically, however, neither of these approaches is likely to have much traction due to the intangibility of the effects of preventive behaviors. And so the best policies are those that eliminate the need for individual decision-making altogether, such as when stores ensure grocery carts and public spaces are kept well sanitized.

As for policymakers, they could compel companies to maintain these measures as a condition of being open. And they could design regulations that require people to continue to wear face masks in public or don gloves when entering public buildings, while lightly punishing those who don’t comply. Small penalties can have a huge impact on behavior.

The longer these behaviors are maintained, the more likely it is that they’ll become habitual, overcoming the problem of their benefits being intangible. And society will be able to get back to some semblance of normal while keeping the lid on the coronavirus.

By Mr. Edwyne Fernandes
Published May 31, 2020

This is an updated version of an article originally published on April 20, 2020.
https://theconversation.com


How better home hygiene could curb antibiotic resistance

Pharmacologists and infectious disease specialists say there is an urgent need to promote good hygiene in the home and in community settings. They believe that this will be essential in reducing antibiotic use and preventing the spread of drug-resistant bacteria in the coming years.

Rates of resistance to commonly used antibiotics have already reached 40–60% in some countries outside the Organisation for Economic Co-operation and Development (OECD) and are set to continue rising fast.

In OECD countries, rates of resistance could reach nearly 1 in 5 (or 18%) by 2030 for eight different bacterium-antibiotic combinations.

By 2050, about 10 million people could die each year as a result of resistance to antimicrobial agents.

While policymakers usually focus on hygiene in healthcare settings, such as hospitals, a group of pharmacology and infectious disease experts believes that improved hygiene in homes and community settings is just as important.

The scientists have published a position paper in the American Journal of Infection Control on behalf of the Global Hygiene Council.

“Although global and national [antimicrobial resistance] action plans are in place,” they write, “infection prevention and control is primarily discussed in the context of healthcare facilities with home and everyday life settings barely addressed.”

They have also launched a manifesto that calls on health policymakers to recognize the importance of this topic.

‘More urgent than ever’

Simple hygiene measures, such as hand washing, can help reduce infections and antibiotic use, the authors argue. In turn, this will minimize the development of resistance.

“In light of the current COVID-19 pandemic and evidence presented in this paper, it is more urgent than ever for policymakers to recognize the role of community hygiene to minimize the spread of infections, which, in turn, will help in reducing the consumption of antibiotics and help the fight against [antimicrobial resistance],” says lead author Prof. Jean-Yves Maillard from the School of Pharmacy and Pharmaceutical Sciences at Cardiff University in the United Kingdom.

The World Health Organization (WHO) estimate that 35% of common infections are already resistant to currently available medicines, with this figure rising to 80–90% in some low and middle income countries.

Overuse of the drugs accelerates the development of resistance. In the United States, for example, the Centers for Disease Control and Prevention (CDC) estimate that of the 80–90% of antibiotic use that occurs outside hospitals, about half is inappropriate or unnecessary.

The authors point out that while the majority of bacteria that are multidrug-resistant (resistant to at least one agent in three or more antimicrobial classes) get picked up in hospitals, some have become prevalent in the community.

Patients leaving the hospital can carry methicillin-resistant Staphylococcus aureus (MRSA) on their skin, for example, or resistant strains of enterobacteria in their gut. Resistant bacteria can then pass to other family members.

The authors write:

“Although the precise impact of hygiene on transmission of infection between community and healthcare settings needs further investigation, it is important to recognize that reducing the need for antibiotic prescribing and the circulation of [antimicrobial-resistant] strains in healthcare settings cannot be achieved without also reducing circulation of infections and [resistant] strains in the community. We cannot allow hygiene in home and everyday life settings to become the weak link in the chain.”

 

Hand washing is a crucial measure

They argue that better hand hygiene would prevent many infections in the home and in community settings, such as schools, nurseries, and workplaces.

Only about 19% of people wash their hands after using the toilet, according to a review of research that the paper cites. The same review found that hand washing reduces the risk of diarrhea by nearly one-quarter (23%) in studies with good methodological design.

Educating people to wash their hands with ordinary soap is one of the best ways to reduce infections, according to experts. Overall, research has shown that improvements in hand hygiene lead to a 21% reduction in respiratory illnesses and a 31% reduction in gastrointestinal illnesses.

In addition, the position paper highlights the problem of foodborne pathogens, including Salmonella, Campylobacter, and Escherichia coli. These affect millions of people globally every year, causing diarrhea and other debilitating symptoms.

A 2014 study in Mexico found Salmonella in almost all cleaning cloths. Soaking these dish clothes in a 2% solution of bleach twice a day reduced the bacteria by 98%.

Key risks and strategies

The authors identify key risk moments for transmitting infections in the home. These are:

• food handling, including contaminated chopping boards and kitchen sponges
• using the toilet
• changing a baby’s diaper
• coughing, sneezing, and nose blowing
• touching surfaces that others frequently touch
• handling and laundering clothing and household linen
caring for domestic animals
• disposing of refuse
• caring for an infected family member

As key strategies to combat infection in the home, they recommend:

• soap or detergent-based cleaning together with adequate rinsing
• alcohol-based hand sanitizer
• inactivation or eradication using a disinfectant on hard surfaces
• mechanical removal using dry wiping
• heating to at least 60°C (140°F)
• UV treatment
• a combination of the above

However, they note that further research is necessary to evaluate the extent to which these practices might contribute to preventing the transmission of antimicrobial-resistant bacteria.

____________________________________

Written by James Kingsland on May 25, 2020 – Fact checked by Hilary Guite, FFPH, MRCGP

Published: https://www.medicalnewstoday.com


Handwashing is saving lives - but for too many people, it remains a luxury

Despite its prominence today, handwashing is still out of reach for many people.
Water and sanitation can act as a firebreak for any infectious diseases to come, as well as for COVID-19.
Here are three ways we can all help increase access to this most basic of resources.

Sorry to say, “We told you so.” But, we told you so. While our two water-focused organizations, Water For People and IRC, have been diligently working for a collective 81 years to ensure the world’s most vulnerable communities have reliable access to safe water, it has taken a global pandemic to raise the world’s awareness of the importance of handwashing and access to clean water – basic services that more than 2 billion people in the world still lack.

Indeed, humble handwashing has gone mainstream because it is the first defence against COVID-19. It literally saves lives. But, the simple act of handwashing is unachievable for far too many people. For the more than one-in-three on the planet who lack basic water access, handwashing is not just a lifesaver, it is a privilege.
Have you read?

This infographic highlights how effective washing your hands can be in an outbreak
Coronavirus: Why drying your hands is just as important as washing them
How people without running water can wash their hands

This was always our fear – that one day, a virus as contagious as this new strain would spread insidiously across the globe. We said: “Communities must have water to protect themselves. Rural health clinics must have the ability to practice proper hygiene in the event of a pandemic. We must work faster and do more!” And we were right. It’s happening. COVID-19 is creeping steadily into Latin America, India and Africa.

When COVID-19 reaches the world’s most vulnerable populations— those without water, let alone those without the luxury of social distancing or working from home – the results could be devastating. The lack of sufficient testing in much of the southern hemisphere belies the true level of infection.

Our organizations are dedicated to improving the quality of life for people in low and middle-income countries through the development of water and sanitation services and hygiene education. This is our everyday work – to ensure people living on less than $2 a day can prepare for, and become resilient to, threats like COVID-19. And it works. Knowing you have access to safe water and a clean toilet changes everything. The way of life for millions of people has improved in thousands of villages and low-income urban areas through the dedication of our global teams. Water and sanitation aren’t rocket science – they are simpler than vaccine development – yet they aren’t sexy enough to attract the necessary funding. Perhaps that will now change with COVID-19.

Water and sanitation face an estimated $114 billion annual funding need over the next decade – and the gap is around $85 billion per year. National governments don’t give enough priority – or sufficient funding – to this work. Funds collected by system users (domestic and industrial) are insufficient to cover the operational costs while continuing to invest in the new infrastructure required to meet Sustainable Development Goal 6 – water and sanitation for all – by 2030. Our voices in the water, sanitation and hygiene (WASH) sector are not loud enough to break through the noise and political chatter in the daily news. Instead, we piece together government allocations, user fees, philanthropic donations and aid dollars to reach as many people as we can with improved services. But it isn’t enough. And because it isn’t enough, the quiet, recurring mortality rates never stop. As of writing, more than 350,000 people worldwide have died from COVID-19. We are riveted to the daily reporting and have no way of knowing where these numbers will eventually stop.

But what we do know is that, according to the World Health Organization, 829,000 people die every single year from a lack of safe drinking water, inadequate sanitation and poor hygiene. Why isn’t this daily headline news?

Thanks to COVID-19 awareness, many people now realize that disease transmission can be slowed or stopped by having access to water and soap, by doing a good job of washing their hands, and by not touching their faces. These are the basic tenets of hygiene education that we teach around the world every day. Because of COVID-19, our message of making handwashing an important part of everyday life has been amplified. It has become mainstream. Yet in the urgency of mobilizing a global response, with the world fixated on ventilators and personal protective equipment, we still struggle to get across this most basic message: where there is no medical treatment available, a fundamental health response is access to water and sanitation.

Deaths due to inadequate water and sanitation services are almost entirely preventable, and water and sanitation can act as a firebreak to new diseases for which we have no cure. Yet to do so, they need attention and investment.

Here are three ways you can help:

1. Influence your lawmakers to support global health programs for COVID-19. In the United States, this means contacting your representatives and senators to support robust international affairs allocations, especially for water, sanitation and hygiene. We are a member of the Millennium Water Alliance and the alliance advocates Congress on our behalf.

2. Support organizations like Water For People and IRC that are part of Agenda For Change – a coalition of sector partners who are collectively taking action to drive systemic change around sustainable water, sanitation and hygiene services.

3. Spread the word and share the facts about the still far-too-great need for this most basic resource: safe, reliable water!

Hopefully the spike of interest in hygiene and handwashing that came with COVID-19 will help water and sanitation be seen as the fundamental public health interventions that they are. Hopefully proper funding will follow. Hopefully the rising visibility of WASH is a permanent trend and not a blip. And hopefully, finally, the world will wake up and realize that we already have the solution to deliver basic water and sanitation services to everyone on our planet. We can make ourselves more resilient to pandemics. Now we just need the financial commitment to get it done.

So, may our next “We told you so” be one of positive proclamation. When all people across the globe have the humble privilege of washing their hands, let us say, “We told you it was possible. We told you so!”

By Eleanor Allen
Chief Executive Officer, Water For People

Published 28 May 2020
https://www.weforum.org/


Hygiene reduces the need for antibiotics by up to 30%

Everyday hygiene reduces the need for antibiotics by up to 30%, helping to prevent daily deaths from antimicrobial resistance (AMR), new paper reveals.

According to a new Position Paper published in the American Journal of Infection Control (AJIC) online, improved everyday hygiene practices, such as hand-washing, reduces the risk of common infections by up to 50%, reducing the need for antibiotics, by up to 30%. Global public health experts responsible for the Position Paper, are now calling for home and community hygiene to become part of strategic plans to reduce hundreds of thousands of deaths from AMR globally each year.

As witnessed during the recent global efforts to delay the spread of COVID-19, hygiene practices, including hand-washing, have become an essential part of everyone’s daily routine and are considered to be the first line of defence in reducing the spread of common infections. However, national and international AMR strategies, while focussing on the important role of hygiene in the healthcare setting, fail to recognise the key role that home and community hygiene plays.

This Position Paper, developed on behalf of the Global Hygiene Council (GHC), and published online in AJIC, explores the role of targeted hygiene in the home and everyday life settings to reduce antibiotic prescribing and its likely impact on antibiotic resistance. It provides evidence that practising hand hygiene in homes and community settings can prevent infections and therefore reduce the need for antibiotics. One intervention study demonstrated a 30% reduction of antibiotic prescriptions for common respiratory infections in a group who used hand sanitisers compared with a control group.

The Position Paper, also demonstrates the increasing prevalence of multidrug-resistant bacteria in the home and community. It is considered that 35% of common infections occurring in healthcare and the community are already resistant to antibiotics, and that in some low-and middle-income countries, resistance to antibiotics is as high as 90%,4 causing 2,000 people to die every day globally.

According to the lead author, Jean-Yves Maillard, Professor of Pharmaceutical Microbiology at the School of Pharmacy and Pharmaceutical Sciences, at Cardiff University; “In light of the current COVID-19 pandemic and evidence presented in this Paper, it is more urgent than ever for policy makers to recognise the role of community hygiene to minimise the spread of infections, which in turn will help in reducing the consumption of antibiotics and help the fight against AMR.

To coincide with the publication of the Paper, the GHC has launched a Manifesto calling upon national and international policy makers, health agencies and healthcare professionals to further recognise the importance of hygiene in the home and everyday life settings and acknowledge the following:

1/ IPC committees, responsible for implementing national AMR plans, should recognise that improved hand and surface hygiene in the home and community are key to minimise the spread of infections and as a consequence the consumption of antibiotics, which will then help in the fight against AMR. To achieve this, recommendations for improved hygiene in the wider community should be included in global AMR action plans by 2022 and in all national plans by 2025.

2/ IPC advice, guidance and education for HCPs on hand and surface hygiene and its relation to AMR should not be limited to healthcare settings, but also include recommendations to influence the wider community with immediate effect.

3/ Relevant medical associations should ensure messaging around home and community hygiene is cascaded to members through amending on-going and existing AMR training and education.

With evidence to show that home and community hygiene urgently needs to be taken more seriously, it is time for the global community to collaborate and recognise that reducing the need for antibiotic prescribing and the circulation of AMR strains in healthcare settings cannot be achieved without also reducing the circulation of infections and AMR strains in the community.

The Position Paper ‘Reducing antibiotic prescribing and addressing the global problem of antibiotic resistance by targeted hygiene in the home and everyday life settings,’ was developed on behalf of the Global Hygiene Council, following a scientific meeting in London 2019 with global hygiene, AMR and public health experts.

Published by: https://www.eurekalert.org/

References:

Curtis V, Cairncross S. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis. May 2003; 3 (5): 275-81

Azor-Martinez E, Yui-Hifume R. Effectiveness of a hand hygiene program at child care centers: a cluster randomized trial. Pediatrics. November 2018;142 (5). Available from:ncbi.nlm.nih.gov/pubmed/30297500 (Accessed 15 April 2020)

amr-review.org/

Interagency Coordination Group on Antimicrobial Resistance. No Time to Wait. Securing the Future from Drug-Resistant Infections. April 2019. Available from: https://www.who.int/antimicrobial-resistance/interagency-coordination-group/IACG_final_report_EN.pdf?ua=1. (Accessed April 15, 2020.)

Review on Antimicrobial Resistance: Tackling Drug-resistant Infections Globally. 2014. Available from: https://amr-review.org/Publications.html. Accessed July 3, 2019.


Hand hygiene a key defence in Europe’s fight against antibiotic resistance

Antimicrobial resistance (AMR), and resistance to antibiotics in particular, continues to grow in the WHO European Region and hundreds of thousands of patients die or are considerably affected each year by health care-associated infections (HAI) and diseases caused by germs that are resistant to antimicrobial medicines.

This year’s SAVE LIVES: Clean Your Hands campaign on 5 May uses the slogan “Fight antibiotic resistance – it’s in your hands” to highlight the fact that health-care workers and the public have a responsibility to prevent and control AMR and HAI, in turn helping to prevent related complications and deaths.

It is estimated that 7–10% of patients will acquire at least one HAI at any given time under treatment. A large percentage of these are preventable by improving hand hygiene practices and other infection prevention and control measures.

Taking action from many sides

HAI, including those resistant to antibiotics, are among the most common adverse events in health care delivery. Such infections can impact quality of life and lead to serious disease or even death. Action across all sectors of society is required to effectively prevent AMR. The following key recommendations will help prevent the spread of AMR and protect people in the Region from HAI:

• Health workers must clean their hands at the right times (see below).
• Chief executive officers and managers of health facilities need to support hand hygiene campaigning and infection prevention and control (IPC) programmes.
• IPC leaders should champion hand hygiene campaigns and comply with WHO’s “core components” for IPC.
• Policy-makers should stop the spread of AMR by demonstrating national support for and commitment to infection prevention programmes.

Cleaning hands at the right times

Protecting patients against HAI can be achieved by improving hand hygiene at five key moments, preferably by using an alcohol-based rub or by hand washing with soap and water if hands are visibly dirty. The “five moments” for hand hygiene comprise:

• before patient contact
• before preparing and administering injections
• after contact with body fluids
• after patient contact
• after touching patient surroundings.

Reinforcing the importance of hand hygiene through policy-making

Making infection prevention and hand hygiene a national policy priority by aligning and strengthening existing programmes will go far in combating AMR and protecting patients from resistant infections.

National authorities should implement or reinvigorate any or all of the following options according to the new WHO recommendations on core components for IPC programmes:

• establish a national IPC programme linked with other relevant national programmes and professional organizations;
• ensure that any national IPC programme supports the education and training of the health workforce as one of its core functions;
• establish an HAI surveillance programme and networks that include mechanisms for timely data feedback;
• consider hand hygiene as a key national performance indicator providing vital feedback data on health-care practices;
• have a system in place to ensure patient care activities are undertaken in a clean and/or hygienic, well-equipped environment to prevent and control HAI.

 

Building momentum in the fight against antibiotic resistance

This year’s campaign builds important momentum ahead of World Antibiotic Awareness Week (WAAW), which takes place on 13–19 November 2017. WAAW encourages all countries, health partners and the public to help raise awareness of AMR and to emphasize that we all have a part to play in preserving the effectiveness of antimicrobial medicines.

 

By WHO Europe
Publihed May 4th 2017
http://www.euro.who.int


Slowing down transmission of COVID-1

One of the most important contributions we can make to slowing down transmission of COVID-19 and keeping ourselves and our communities safe is to wash our hands. Global COVID-19 Prevention.

This short animated video from Stanford Medicine illustrates how the novel coronavirus — the virus that causes the respiratory disease COVID-19 — is transmitted among people and how transmission can be prevented.

For more information, please visit https://med.stanford.edu/covid19.html


“The very sight of her hands did almost turn my stomach”: a brief history of hand-washing

As the disease known as coronavirus spreads around the world, the public has received one key piece of advice: hand-washing is our best defence. But what would our ancestors have made of this tactic? Katherine Harvey explores for HistoryExtra…

Contrary to the popular belief that people in the Middle Ages were disgustingly smelly and dirty, medieval people frequently washed their hands, usually on rising and before and after meals. This was not just a case of good manners; they were well aware of the link between dirt and illness. Consequently, the 14th-century surgeon John of Arderne required prospective apprentices to have “clene handes and wele shapen nailes…clensed fro all blaknes and filthe”. Hand-washing mattered because it was seen to remove both external dirt and harmful bodily excretions.

This dual concern with dirt and bodily excrement continued into the Renaissance. Italian physician Tommaso Rangone (1493–1577) advised that hands must regularly “be cleaned of superfluities, sweat and grime that nature often deposits in those places”. Other medical writers also recognised that hands could transmit disease, although their concerns focused on skin diseases such as scabies, rather than the more well-known plague. Therefore, hand-washing was thought to be necessary for good health.

Hands must regularly ‘be cleaned of superfluities, sweat and grime that nature often deposits in those places’

Early modern concerns about hand hygiene often focused on meals, so most people washed before and after eating. Some advice books insisted that even clean hands must be rewashed at the table, using a basin and ewer, so that everyone else would feel reassured about sharing food. As such, poor hygiene could provoke real repugnance: after dining with his Uncle Wight in 1663, Samuel Pepys recorded that “the very sight of my aunt’s hands…did almost turn my stomach”.

17th-century diarist Samuel Pepys.

 

Georgian polite society fretted a great deal about servants’ hands, particularly in relation to food preparation and table service. The 18th-century author Eliza Haywood required her maids to wash their hands regularly, and other employers made serving staff keep their hands “in open view, neat and clean”, according to a conduct book of the day. Jonathan Swift’s Directions to Servants (1745) specifically criticised domestic helpers who prepared salads with unwashed hands after handling meat or visiting the lavatory.

In the 19th century, scientists such as Louis Pasteur and Joseph Lister made significant advances in germ theory and its practical applications, which explained why hand-washing works in curbing the spread of disease. Though perhaps lesser known, another important pioneer was the Vienna-based Hungarian obstetrician Ignaz Semmelweis (1818–65), who realised that labouring women caught puerperal fever from doctors who went straight from the morgue to the delivery room. He proved that maternal mortality could be drastically cut by routine hand-washing with a chlorine solution.

This revolutionary new knowledge had surprisingly little immediate impact, partly due to resistance from physicians who resented being blamed for their patients’ deaths. Nevertheless, the following decades saw frequent attempts to persuade the wider public of the value of hand hygiene, the motivations for which were sometimes concerned as much with reaping profits as promoting public health. In the 1920s, the soap manufacturing company Lever Brothers ran a Clean Hands Campaign that urged children to wash their hands “before breakfast, before dinner and after school”. Their Lifebuoy soap was marketed as the best way to tackle germs, as in a 1927 advert in which a father advises his son that “Dirty hands are dangerous”. This wise parent practises what he preaches, using the product several times each day.

Adverts such as this had considerable impact, but their message still bears repeating. Despite centuries of advice, many of us are no better than the “plaine people in the countrie” who riled the Tudor physician William Bullein – because they would not clean their filthy hands.

Katherine Harvey is a historian of medieval Europe based at Birkbeck, University of London.

By Katherine Harvey

Published at HistoryExtra; The official website for BBC History Magazine, BBC History Revealed and BBC World Histories Magazine
March 5, 2020 at 1:08 pm

https://www.historyextra.com


UNICEF: Novel coronavirus (COVID-19) outbreak: What you should know

UNICEF:
– It’s important to remember that key prevention measures are the same – frequent hand washing, and respiratory hygiene (cover your cough or sneeze with a flexed elbow or tissue, then throw away the tissue into a closed bin).

– Continue to follow good hand and respiratory hygiene practices like regular handwashing, and keep your child up to date with vaccinations – so that your child is protected against other viruses and bacteria causing diseases.

– Instead of keeping children out of school, teach them good hand and respiratory hygiene practices for school and elsewhere, like frequent handwashing, covering cough or sneeze with a flexed elbow or tissue, then throwing away the tissue into a closed bin, not touching their eyes, mouths or noses if they haven’t properly washed their hands.

– On 17 February, UNICEF appealed for US$42.3 million to scale up support for efforts to contain the novel coronavirus outbreak. The preliminary funds will support UNICEF’s work to reduce the transmission of the virus including by strengthening risk communication and tackling misinformation so that children, pregnant women and their families know how to prevent COVID-19 spread and where to seek assistance.

https://www.who.int/docs/default-source/coronaviruse


What to do next to control the 2019-nCoV epidemic?

The 2019 novel coronavirus (2019-nCoV) infection can lead to acute resolved or fatal pneumonia. On the basis of knowledge of other coronaviruses, the main route of human-to-human transmission of 2019-nCoV is probably through respiratory droplets. As of Feb 4, 2020, statistical data show that the outbreak constitutes an epidemic threat in China, where the exponential increase in patients has reached 20438 confirmed cases, with 2788 (13·64%) patients in critical condition and 425 (2·08%) deaths; 23214 additional suspected cases have also been identified so far. The most affected city, Wuhan, and related regions in Hubei province of China have reported 13522 confirmed patients (66·16% of total cases) and 414 deaths from 2019 nCoV infection (97·41%of total deaths in China). 632 patients with confirmed infection have recovered and have been discharged from hospital. However, the downward turning point for new cases of infection has not been observed yet (figure). Notably, 159 confirmed cases have been reported in 23 other countries beyond China, including Japan, Thailand, Singapore, South Korea, Australia, the USA, Malaysia, and Germany. Because of the seriousness of this outbreak, WHO declared it a public health emergency of international concern on Jan 30, 2020, followed by the USA announcing a public health emergency on Jan 31, 2020.

During the epidemic, rapid and robust research is important to help guide clinical practices and public health policies. Zhu and colleagues sampled bronchoalveolar-lavage fluid from three patients and used next-generation sequencing and PCR to characterise the virus, and they identified the pathogen of this outbreak as a novel coronavirus that falls within the subgenus Sarbecovirus of the genus Betacoronavirus and confirmed the cytopathic effects (structural changes in host cells) of this virus.1 Their achievement not only improves methods of diagnosis confirmation in clinics but also promotes the study of the underlying mechanisms of viral infection.2 Subsequently, collaborations between Chinese and international scientists have rapidly unmasked some additional virological features of 2019-nCoV. A specific viral nucleic acid assay using RT-PCR was quickly developed for the diagnosis of 2019-nCoV infection.3,4Additionally, human angiotensin-converting enzyme 2 has been shown to be the putative receptor for the entry into host cells by use of bioinformatic prediction methods and in-vitro testing.2,5,6 Furthermore, bats are speculated to be the original host of this zoonotic virus, but whether an intermediate host facilitated the viral infection in humans is still unknown.7 Lastly, evidence of person-to-person transmission is accumulating,8,9 with an estimated R0 of 2·2 (95% CI 1·4–3·9),10 and the assessment of the full extent of this mode of transmission is urgently needed.

In The Lancet, two retrospective studies from Wuhan Jin Yin-tan Hospital have recently provided the first-hand evidence of epidemiological, clinical, laboratory, radiological imaging, and outcomes among 41 patients11 and 99 patients.12 Of 99 patients with 2019-nCoV pneumonia,12 the average age was 55·5 years (SD 13·1) and 50 (51%) patients had chronic diseases. Clinical manifestations were fever (82 [83%] patients), cough (81 [82%] patients), shortness of breath (31 [31%] patients), muscle ache (11 [11%] patients), confusion (nine [9%] patients), headache (eight [8%] patients), sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and vomiting (one [1%] patient). In view of the findings from both studies, as well as accumulated clinical experience, the next crucial step would be to identify the proper treatment for patients infected with 2019-nCoV.

No fully proven and specific antiviral treatment for the coronavirus exists. Guidance from China’s National Health Commission suggests taking an anti-HIV drug combination of lopinavir and ritonavir and inhaling a dose of nebulised interferon α for the antiviral therapy.13Many efforts, including several clinical trials, such as NCT04246242 and NCT04252664, are in progress to screen existing antiviral drugs to identify those that could be specific and efficient against 2019-nCoV. Notably, the first reported use of remdesivir, in the first diagnosed patient with 2019-nCoV infection in the USA,14 has encouraged additional clinical study of this medication.

More importantly, patients in critical conditions often develop serious complications, such as acute respiratory distress syndrome (17 [17%] of 99 patients),12and thus medical groups should include physicians with expertise in both infectious diseases and critical care. It is noteworthy that patients in critical condition often show a reduction in peripheral blood lymphocytes.11,12 Whether immune cells infiltrate into the lungs and then cause serious lung lesions (as occurred in patients with severe acute respiratory syndrome [SARS])15 is not clear. Therefore, it is important to understand the lung microenvironment and the map of immune responses against 2019-nCoV infection, which might help to define clinical stages and uncover the pathogenesis of the disease. Recent data showed that mostdeaths were due to respiratory failure;11,12 however, no reports of lung pathology in patients who died from 2019-nCoV infection have been reported so far. Notably, elderly men with 2019-nCoV infection and other underlying diseases often have a higher fatality rate than that of elderly women or younger and more healthy patients;11,12more studies are needed to determine the associated influencing factors underlying this finding.

The development of more efficient and quicker methods for the detection of viral nucleic acids is needed to ensure the accuracy of diagnosis. Several challenges remain for basic research, including viral mutation rateand transmission, infectivity dynamics, and viral infection-associated pathogenicity in vivo. Some evidence has suggested that the virus can spread during the incubation period9,16 and is detectable during the convalescent period.16 Notably, the virus was found in the loose stool of a patient in the USA,14 suggesting potential transmission through the faecal–oral route. It is of high priority to ascertain whether persistent asymptomatic carriers of 2019-nCoV exist and to reach an accurate definition of when a patient can be considered cured. Moreover, no certainty exists about the source of the outbreak, and a prophylactic vaccine is still under development.

WHO has acknowledged the efforts made by the Chinese Government to investigate and contain the outbreak.17 For example, authorities rapidly initiated the first measures to isolate Wuhan, which were then extended to the whole Hubei province, stranding 35 million residents during the heavy-travel Chinese Spring Festival holidays. At the same time, the two new-built hospitals in Wuhan have been put into use, with 2600 beds for the confirmed and suspected patients with pneumonia. The decision makers also extended the holiday period and postponed school openings. Additionally, at least 68 medical teams, including more than 8000 physicians and nurses, from other provinces and cities went to the most affected Hubei province to fight against the disease side by side with the local medical staff.18 The Chinese Government has initiated at least 13 research programmes as an emergency measure to study the different aspects of the outbreak such as the diagnosis, treatment, and prevention of 2019-nCoV-associated disease.19 Novel therapeutic approaches, including treatment with allogeneic mesenchymal stem cells, are expected to progress to clinical trials involving patients with 2019-nCoV infection in a critical condition when the projects meet both ethical requirements and the principle of informed consent (eg, NCT04252118). Furthermore, therapeutic drugs, protective equipment, and charitable funds from inside and outside of China are transported to the epidemic area to support the response. All these measures are aimed to maximise prevention and minimise the occurrence of new infections, which will help the in-time diagnosis and treatment of patients and protect the healthy population against viral infection not only in China but also in the rest of the world. China also faces other challenges, including asymptomatic carriers with 2019-nCoV might be a new potential source of infection; there will be a huge increase in people returning from trips after the Chinese Spring Festival vacation; and it may be difficult to control the outbreak due to the lack of adequate medical resources in epidemic communities and rural areas of Hubei province.

First-line medical staff and scientists in China have had a leading role in fighting the outbreak of 2019-nCoV-associated pneumonia. The basic and essential strategies that we should stick to remain the early detection, early diagnosis, early isolation, and early treatment of the disease. With the huge efforts from medical professionals to treat patients, substantial public health prevention measures, and accelerated research, we hope the downward turning points for both new cases of 2019-nCoV and the resulting fatal events might come soon.

We declare no competing interests.

*Fu-Sheng Wang, Chao Zhang
fswang302@163.com

www.thelancet.comVol 395 February 8, 2020

Treatment and Research Center for Infectious Diseases, The Fifth Medical Center of PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing 100039, China

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Hand Hygiene Day: It’s in your hands – prevent sepsis in health care

Sepsis is a life-threatening complication from infection that arises when an infection alters the body’s normal response, causing injury to tissues and organs. Each year, sepsis can cause up to 6 million deaths globally – most of which are preventable.

Sepsis is the most preventable cause of death and disability in Europe. According to the Global Sepsis Alliance, more than 3.4 million individuals develop sepsis every year in the WHO European Region, and 700 000 of these patients do not survive. An additional one third of survivors die within the following year, and many face lifelong consequences, such as physical, psychological and cognitive challenges.

The financial burden due to sepsis has been calculated to be more than US$ 24 billion, representing 6.2% of total hospital costs in 2013. Studies in Europe and Canada estimated the daily costs of hospital care of a septic patient to be between €710 and €1033 in 2000 (equivalent to about US$ 645 and US$ 939, respectively).

On Hand Hygiene Day, observed annually on 5 May, WHO calls on health facilities to prevent health care-associated sepsis through hand hygiene and infection prevention and control (IPC) action. By working together to each play our part, we can prevent sepsis and save millions of lives every year.

To stop sepsis, prevent infection

The first step to stopping sepsis is implementing measures that prevent infections from occurring. The second is preventing infections from evolving into sepsis. In both communities and health-care facilities, this requires early detection of sepsis signs and symptoms and appropriate antibiotic treatment.

In health-care settings, sepsis may result from health care-associated infections. This makes it all the more important for health workers to practise good IPC measures, including effective hand hygiene. Washing hands properly prevents infections and, in turn, reduces the risk of sepsis in health-care facilities.

This year’s Hand Hygiene Day campaign follows a resolution, adopted in May 2017 by the Seventieth World Health Assembly, recognizing sepsis as a global health priority and calling for improved prevention, diagnosis and clinical management of sepsis. It emphasizes 5 calls to action for 5 target audiences:

• health workers: “Take 5 moments to clean your hands to prevent sepsis in health care”;
• IPC leaders: “Be a champion in promoting hand hygiene to prevent sepsis in health care”;
• health facility leaders: “Prevent sepsis in health care, make hand hygiene a quality indicator in your hospital”;
• ministries of health: “Implement the 2017 WHA sepsis resolution. Make hand hygiene a national marker of health care quality”; and
• patient advocacy groups: “Ask for 5 moments of clean hands to prevent sepsis in health care”.

It is also vital to ensure that health workers can recognize, diagnose and rapidly treat sepsis. Despite its tragic impact, sepsis is frequently underdiagnosed at an early stage when it is still potentially reversible.

The evolution of an infection to sepsis can be prevented through early detection of the signs and symptoms, followed by prompt medical care and especially treatment with appropriate antimicrobials. This is crucial to increasing the chances of surviving sepsis. In the case of antimicrobial-resistant infections, which are becoming increasingly common, a patient’s condition can deteriorate rapidly, further underscoring the need for early diagnosis.

Working towards a sepsis-free world

It is possible to envision a world free from sepsis, but this vision will only become a reality through concerted action taken by a range of actors. On Hand Hygiene Day, it is time to collectively commit to raising awareness about the proven approaches to preventing infection, and to encourage everyone – particularly health workers – to recognize that stopping sepsis is in their hands.

WHO/Europe