Coronavirus: dem hands

07/03/2020

Contrasting sharply with his reluctance to be seen anywhere near flooded areas, offering somewhat lame excuses for his absence – and after something of a hiatus before he was prepared to get involved with the Covid-19 crisis - it seems impossible to keep our idiot prime minister away from the front line.

One wonders, though, why he feels it necessary to dress up wherever he goes, in order to display himself in some sort of action pose. If it is genuinely necessary for him to wear protective clothing, either because he's likely to contaminate the environment or to protect him from infection, why is he there anyway?

Interestingly, in his rather unconvincing guise as a laboratory worker (pictured) when he visited Bedford Technology Park yesterday, neither he nor the technician he posed with were wearing PPE correctly. Both were thus setting a bad example.

And since Johnson's official workplaces are the House of Commons or No.10, he might be better advised to use the facilities dedicated to his use. All too often he is missing from both, practising his own rather peculiar form of self-isolation.

Then, there is a very real question of the nature of his involvement in this ongoing drama. It is certainly the case that, as prime minister, he should be at the helm, making sure that the machinery of state is functioning as well as it can under the circumstances. But there are good reasons for suggesting that his public interventions should be limited and carefully controlled.

For instance, if you visit the subject of communications strategy in the context of serious episodes of disease and other such events requiring public input, it has long been established that public health messages are best coming from scientists or independent medical experts.

In an outbreak situation, using politicians - and especially controversial figures such as Johnson – can severely impede delivery of a message – as painfully illustrated by this piece.

Thus to have had Johnson recently preach the benefits of hand washing - persisting even yesterday with his charade - was and is precisely the wrong thing to do. He should not allow himself to be in the position of delivering that message – with or without singing "happy birthday". Even if the fanboys adoringly slurp up every instruction, his many detractors will scorn his advice, for no other reason than the fact that he gave it.

As to the utility of handwashing, this is not as clear-cut as it might seem. I have spent the best part of my professional career studying, monitoring and assessing handwashing practices in high risk environments (food and medical), evaluating the results of different strategies, and training personnel in correct practices. And the results can be very mixed.

In the round, handwashing (often imperfectly performed) in a contaminated environment (i.e., any public place) is of very little value. Recontamination from hand contact surfaces is often so rapid that there is little perceptible difference in results between those who wash and those who don't.

In controlled environments such as limited access areas in medical facilities, there is some effect, provided adequate hand-washing facilities are available, properly positioned, cleaned and maintained. But this can easily be negated by poor aseptic technique, so inveigling untrained personnel to wash their hands, even in these environments, can be of limited value.

When hand-washing disciplines are good, and closely supervised – with the availability of strong disciplinary sanctions - results tend to improve, but sometimes only marginally. In field tests I carried out, our best results came when, in addition to hand-washing routines, we also carried out concurrent disinfection of hand contact surfaces.

One should also note that there is a downside to over-frequent hand washing in that it denatures the skin and provides more and better harbourage for transient pathogens, especially when the skin is kept wet or improperly dried. And if over-enthusiastic washing gives rise to skin damage and discomfort, personnel may be unwilling to continue a regime.

The best option, therefore, might be to wash sparingly, as necessary, making efforts to keep the skin dry and in good condition. In terms of overall results, drying the hands carefully is as important as the washing process. It is then important to adopt aseptic techniques, i.e., the learned behaviour of avoiding touching eyes, nose or mouth, or fingering potentially contaminated surfaces.

This is actually reflected in the current advice from Public Health England. It offers a six-point guide, starting with a warning to cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze. Secondly, when dealing with the tissue, they offer a slogan "Catch it, Bin it, Kill it". The tissues should be binned straight away.

The advice goes on to encompass the avoidance of close contact with people who are unwell and only then do we come to the Johnsonian requirement to "wash your hands with soap and water often", using hand sanitiser gel if soap and water are not available.

But the guidance goes on to suggest cleaning and disinfection of frequently touched objects and surfaces (the so-called hand contact surfaces). This must include items such as shared computer keyboards and static telephones, as well as the more obvious things such as door handles, handrails and counter tops.

Finally, the advice wraps up by cautioning people not to touch their eyes, nose or mouth if hands are not clean – the adoption of what are known as aseptic techniques.

Taken as a whole, this is good advice. You will note that it covers my points of adopting aseptic techniques and disinfecting hand contact surfaces. In the context, hand washing is only one precaution. It is not necessarily the most important and, as I point out, may only be effective in concert with other measures. The protection afforded is the sum of its parts.

To over-emphasise hand washing, as the main safeguard - as Johnson did - is actually quite misleading, possibly giving a false sense of security. In a hospital environment, for instance, hand washing is of almost no value unless simultaneously, you are carrying out an extensive programme of concurrent hand contact disinfection.

However, a well-devised programme, properly executed, will contribute significantly reducing the transmission of illnesses such as Covid-19, and there is some room for optimism, especially as the seat of infection in China seems to be under control.

One must always take the greatest of care in accepting any reports from China at face value but it does seem as if the recent news is real, and the health authorities have turned the tide.

There are also suggestions that an aggressive, rapid, pro-active testing programme, targeting those who exhibit signs of flu-like illness - followed by self-isolation or other means of exclusion from the community of those found positive for the virus – is an effective control, especially if accompanied by diligent contact tracing.

But that said, the great sage Simon Jenkins is "taking the coronavirus hype with a pinch of salt". "When hysteria is rife", he writes, "we might try some history":

In 1997 we were told that bird flu could kill millions worldwide. Thankfully, it did not. In 1999 European Union scientists warned that BSE "could kill 500,000 people". In total, 177 Britons died of vCJD. The first Sars outbreak of 2003 was reported by as having "a 25 percent chance of killing tens of millions" and being "worse than Aids". In 2006, another bout of bird flu was declared "the first pandemic of the 21st century", the scares in 2003, 2004 and 2005 having failed to meet their body counts.

Despite those and other examples, though, Jenkins omits to mention the 1918 Spanish Flu pandemic, which killed an estimated 100 million, when the world's population was only a fraction of what it is today.

Nevertheless, Jenkins notes that the government's action plan points out that the virus is highly contagious, but the "great majority" of those who develop symptoms will experience only a "mild-to-moderate but self-limiting illness". Every medical expert he has heard on the subject, he tells us, "is reasonable and calm".

The caution here might be merited, but possibly not. The most terrifying thing about the Sars-CoV-2 virus – identified as the epidemic organism – is mostly that it produces "mild-to-moderate but self-limiting illness". It is the "mild to moderate" organisms which spread best and while a one percent death rate might seem small, if 80 percent of people succumb, that is an awful lot of dead bodies.

On the other hand, despite the depicted terrors of fictional pandemics, on a par with the Marburg virus (aka Green Monkey Disease), these simply don't spread. The 90 percent mortality rates are so high and illness is so rapid and debilitating that it has little opportunity to spread. For a virus, high mortality in your host is not an optimal evolutionary trait.

To give him his due, Jenkins admits he could be wrong. He could get ill. Millions could die. But, he says, it is also possible that come the spring, this crisis will have passed. We can but hope, but if he is wrong and governments do nothing, the body count will be a multiple of what it might otherwise have been. Newspaper columnists have the luxury of being able to pontificate. Governments don't.

In the meantime, it makes sense to adopt reasonable precautions of known effect, and at the same time to avoid the obvious gaffes to which Johnson is prone.

And while that might also include the occasional washing of hands, measures might benefit more from a higher budget. For all his enthusiasm for promoting ablutions, he is only allocating £46 million to control the epidemic – just a fraction more than one percent of the £4.4 billion expended on Brexit preparations. Johnson's hands might be clean, but his priorities are skewed.