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The longer the pandemic goes on the more the transmission risks become clearer and the greater hindsight reveals what we have failed to do, or just failed to do well enough.
For the first phase of this pandemic, the control measure spotlight fell on personal protective equipment (PPE). The perceived and/or real lack of it, the quality of it and the absence of assurance that what healthcare workers (HCWs) were asked to wear was itself sufficient to prevent transmission.
This encysting left other key control measures de-emphasised. This happened at all levels. The term ‘PPE’ is used over 110 times in the national guidance, while ‘social distance’ is only mentioned 12 times.
Four supplementary tables detail how to use PPE in different clinical settings. There are none for distancing. The current pandemic slow down provides time to rebalance the priority of other behavioural control measures.
I use the term ‘behavioural control measures’ as they necessitate a ubiquitous change in our behaviour. We must apply all of them, every time.
These behavioural control measures are: hand hygiene, social distancing, environmental decontamination and PPE. Leave any one out and it’s not enough – transmission becomes possible.
The most de-emphasised control measure was perhaps a failure to maintain social distancing. The supermarkets were quicker than hospitals at installing tape to show the required separation space needed and at installing perspex screens to prevent droplet transmission. In hospital staff tea rooms, where no patients with Covid-19 entered, the virus was, in some places, granted free access.
Incomprehensibly, many clinical teams wanted to demonstrate how well they could sing and dance while inadequately social distancing on social media. Shouting “Crikey, what are you doing?” at every post had no impact on the carers standing too close together at a clap or memorial.
There were obviously biases in thinking that made some HCWs assume social distancing excluded them. These were, and are, emotional times. Times when we are required to refrain from our normal habit of seeking comfort in the physical contact of a friend or colleague.
“One outbreak report illustrates just how simple transmission can arise”
But this was and remains unsafe. There will have been HCWs who acquired Covid-19 not from the dreaded lack of (or perceived inadequacy of) PPE but from the lack of a physical distance in an enclosed space. One outbreak report illustrates just how simple transmission can arise.
Pre-social distancing guidance, at one small conference of just 13 people, which included one evening meal, a pre-symptomatic individual managed to infect 11 people who travelled back to six countries. These authors concluded hand-shaking and face-to-face contact were the possible modes of transmission.
Later in the day than it should have been, the erroneous assumption of safety that social distancing excluded HCWs, was harshly learned.
It is difficult. Consider the handover – how, without being too close, do you communicate to every member of the team what is going on in the clinical area (while still maintaining confidentiality). The answer is you do it differently. While many people where sharing how to knit something that prevents sores behind the ears, no one was posting how to work effectively and keep apart at the same time.
The evidence that presymptomatic and asymptomatic transmission was important came perhaps after new ways of working had been established. For all we have achieved, let us prepare to prevent further transmission by using the ubiquitous and balanced application of all behavioural control measures – including social distancing.
We don’t know everyone who is infected and infectious; we don’t know whether the virus is contaminating any given surface. So, keep your distance and encourage everyone else to keep theirs. Social distancing – yes, they mean us.
Evonne Curran is independent infection prevention nurse consultant