Several weeks ago, I visited a local NHS urgent care centre with my toddler on what might be called a semi-annual pilgrimage related to having a child in nursery. Owing to what is now a typical three- or four-hour wait, during which he made a recovery, I had the time to notice the hospital's waiting room cleaning practices. They amounted to someone pushing a mop around the floor and in the process moving, rather than removing, various fluids and items that had probably amassed over the preceding several hours.
Author
- Jonathan R. Goodman
Research Associate, Public Health, University of Cambridge
About 36 hours later, our toddler woke up with a stomach bug. The cleaning practices I saw - coupled with my inability to keep him from touching a lot of surfaces in the hospital, including the floor - suggested to me that this was not a coincidence.
Individual behaviour and practices play a role in the spread of disease. And many times it is our collective actions that lead to contagion, even if our goal is to prevent it.
Given the NHS has recently recorded its highest ever rate of norovirus cases - with the bug making up more than one in 100 hospitalisations in the country - we are due for a rethink about how we understand the social elements of illness.
As a social scientist working in public health, I've learned that diseases conform to our behaviour, which can keep us one step ahead - or leave us one behind.
How we develop policy around contagion is one example. Recently, NHS England published new national standards of cleanliness for NHS Trusts - the most recent update since 2021. These standards define cleanliness, what materials should be used and the frequencies necessary for adequate cleaning.
The guidelines are, unsurprisingly, very boring, but what stands out to me is the emphasis on which spaces and surfaces are the most likely to be contaminated, rather than taking a contextual approach to the relationship between people, germs and spaces.
The US Centers for Disease Control and Prevention (CDC), by contrast, uses a more complex function. Risk is evaluated by combining the probability of contamination of an item or surface, the vulnerability of patients and the potential for exposure within the space.
A waiting room where people have been vomiting, for example, would be taken more seriously as a risky area using these guidelines than the brute force approach taken by the NHS.
Another important element of risk, though one not evaluated explicitly in any policy guideline, is how germs evolve in response to our efforts against them.
Staphylococcus aureus bacteria, for example, are typically treated by antibiotics, though the rise of the methicillin-resistant Staphylococcus aureus ( MRSA ) subtype has complicated patient care around the world.
More recently, bacteria called carbapenemase-producing enterobacterales (CPEs) have started spreading in hospitals, and are both highly contagious and difficult to treat.
Both MRSA and CPEs are, however, direct results of our efforts to combat bacteria: our use of antibiotics selects, evolutionarily speaking, for resistance to our treatments.
Imperial College London's Fleming Initiative , named after the discoverer of the first antibiotic, penicillin, is an international effort that aims to stymie the spread of these germs, but they nonetheless present a real and serious risk to patients everywhere.
Clostridioides difficile, a bacterium linked with painful stomach bugs, has also shown increasing resistance to antibiotics, particularly strains found in hospitals. What's worse, evidence from 2023 suggests C difficile may even be resistant to bleach, which is typically successful at killing almost all germs and was found, in the past, to work against this bacterium, too.
Everyone plays a role
Blunt policies specifying cleaning schedules without reference to context are unlikely to be effective in a world of fast-evolving germs. What's needed, instead, is a population-level understanding about how everyone plays a role in contagion and in its containment. We're part of a broader ecosystem that bacteria and viruses live within, and which evolve to thrive when we become complacent in our behaviour.
The CDC's guidelines embrace context, but the work doesn't stop with hospital cleaning staff - who in the UK, by the way, earn an average of £21,000 a year for the critical work they do. Anyone who works in or visits a healthcare space has a responsibility to those nearby, whether that involves maintaining distance between people or shielding others from their own illness.
We can't expect stretched systems and overworked employees to prevent the spread of germs. And the UK's massive norovirus outbreak is a symptom itself of how bad we are at preventing viral contagion.
Yet people - including patients and their carers like me - can do a lot more than just idly watch dirty mops float by in waiting areas. We can educate ourselves about current risks, avoid where possible spaces with a high risk of contamination, and stay home to prevent infecting others, for example in the workplace.
Social approaches should be built into any framework that aims to combat disease. Knowledge, unlike antibiotics and bleach, is free - and the spread of information about how to help prevent contagion can only be good for healthcare systems and society more broadly.
Jonathan R. Goodman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
