Covid-19: breaking the chain of household transmission
BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3181 (Published 14 August 2020) Cite this as: BMJ 2020;370:m3181Read our latest coverage of the coronavirus outbreak
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Dear Editor
This paper raises compelling points regarding intra-house transmission of pathogens during pandemics. A point of particular interest is the additional risk faced by essential workers. A further consideration relevant to this position is the impact of healthcare student education on household transmission. For example, a key priority of the Medical Schools Council and Nursing Midwifery Council is to continue final year education with as few disruptions as is safe in order to qualify healthcare practitioners to deal with the increased demand on the NHS (1) (2).
Furthermore, additional to continued clinical placements, healthcare students are often considered a utilisable reserve workforce during pandemics (3). Subsequently, it is often the case that students will come into contact with COVID-positive patients during these times. Many healthcare students live with other healthcare students, and it is common for students within one household to be allocated separate clinical placements (i.e. separate hospitals or trusts). This increases the potential exposure for each individual student in the household.
To mitigate this, a potential positive action could be to bubble healthcare students and allocate clinical placements by household, reducing the exposure of each individual and thus the risk of widespread transmission through homes. This may also limit inter-household transmission by reducing the frequency with which students from one household drive to clinical placements with members of other households.
Mohini Panikkar and Jack Sharman
1) Medical Schools Council [Internet]. Advice from Medical Schools Council to UK Medical Schools on actions surrounding Covid-19. c2020. [Cited 2020 Aug 23]. Available from: https://www.medschools.ac.uk/media/2620/msc-covid-19-advice-for-uk-medic...
2) Nursing and Midwifery Council [Internet]. Statements: Coronavirus (COVID-19) Information and Advice. c2020. [Cited 2020 Aug 23]. Available from: https://www.nmc.org.uk/news/coronavirus/statements/
3) O'Byrne L, Gavin B and McNicholas F. Medical students and COVID-19: the need for pandemic preparedness. J Med Ethics. 2020 Jun 03; DOI: 10.1136/medethics-2020-106353
Competing interests: No competing interests
Dear Editor
Thank you for drawing into sharp focus the importance of managing infectious spread within the household: as you state, this should be a key point of intervention. I think, however, that we should also consider the importance of clear, easy-to-follow guidance, and the fatigue many are feeling about this pandemic.
Whilst I agree that it is important to effectively isolate infected household members from the other household members, it is important that people know when isolation is necessary. Although the guidance on self-isolation is that the most important symptoms are “a new continuous cough, a high temperature and a loss off, or change in, your normal sense of taste or smell (anosmia)” more recent evidence suggests that the infection can manifest in many ways, or can even result in no symptoms.(1) Therefore it is understandable if an infected household member without these “textbook” symptoms might not follow isolation guidance.
As stated previously, some of the guidance on self-isolating from your household is also difficult for many. For one example, many may not have access to separate bathroom and eating facilities as advised, and it can be difficult to clean these facilities to an adequate standard without risk of cross-contamination.(1,2) I agree that it’s important to consider new measures that might make full isolation possible, such as the alternative accommodation you mention.
Finally, it seems appropriate to mention the fatigue that many in the population may be experiencing at this moment with respect to the SARS-CoV-2 pandemic. In New Zealand, there has been evidence of “COVID fatigue” with many people no longer strictly adhering to guidance to use the tracing app and social distance.(3) Such fatigue might make it more difficult to control outbreaks, when the population is no longer willing to follow advice.
In summary, I feel it is important to empower the population to make sensible, safe decisions based on clear, viable guidance. It is partly due to vague, unrealistic guidance that we end up in a scenario where people become fatigued and less compliant. We also need to be honest and realistic about the scope of this virus. As I heard in the hospital a lot during the first peak, “this is a marathon, not a sprint”.(4)
1) Public Health England. Stay at home: guidance for households with possible or confirmed coronavirus (COVID-19 infection). GOV.UK website 2020; Updated 13 August.
2) Centers for Disease Control and Prevention. Detailed Disinfection Guidance: Interim Recommendations for U.S. Households with Suspected or Confirmed Coronavisus Disease 2019 (COVID-19). CDC.GIV website 2020; Updated 10 July.
3) Graham-McLay, C. ‘A matter of when not it’: New Zealand begins battle against Covid fatigue. The Guardian 2020; 5 August.
4) Le Page, M.; Wilson, C. et al. Covid-19 news: Risk of coronavirus resurgence in Europe, says WHO. New Scientist 2020; 20 August
Competing interests: No competing interests
Dear Editor
I have long seen the public health 'community' as a Family, whose diverse and argumentative members nonetheless support each other, to 'collaborate for Health'. Haroon wisely identifies that if large multigenerational households are to sustain action for Covid-19, a joined-up system to test, trace, isolate, support families is needed.[1] Many of my public health relatives work for Public Health England, and I was sad to read in a Sunday newspaper that PHE is soon to be axed for what the Government sees as their failures..[2] First, Test: no evaluation of PHE's performance has yet been published. An All Party Parliamentary Group is carrying out a limited look-back on the UK response to Covid-19, but they have neither the objective nor the expertise to evaluate the failures or successes of PHE, to inform future developments. Second, Trace: public health works within Systems including health care, local government, social care and academic research. Government ministers keep talking about 'the Science' but scientific evidence has to be applied within systems that connect many stakeholders . I am unaware of any published mapping that traces these connections in 2020. Third, Isolate: how do we locate the critical elements of the system that have 'failed'? If they are to be replaced or re-designed we need to know precisely where they are and fix them, without disrupting the whole public health workforce. Fourth, Support: in 2012 the Lansley Act 'reforms' of health undermined the workforce, professional training, planning and collaboration across organisations. Any new public health body that emerges now will need consideration of morale, workloads and team building. It will need clear objectives, understood by partners in other bodies, and clear accountability. The wider Public needs to understand how its resources (£ Bilions) relate to both its objectives and accountability.
[1] Haroon S, Chandan JS, Middleton J, Cheng KK. Covid-19: breaking the chain of household transmission. BMJ 2020;370:m3181
[2] Hope C. Hancock axes 'failing' public health body. Sunday Telegraph 2020; 16 August: 1.
Competing interests: No competing interests
Dear Editor,
In addition to this we also need clearer guidance for frontline health care workers potentiaaly exposed to covid patifmtd who have vulnerable family members to reduce and eliminate chain of transmission to their own family members.
Competing interests: No competing interests
Lets promulgate simple measures
Dear Editor
70% of COVID-19 transmission is within households. While affluent doctors have second toilets and spare bedrooms, our patients often do not and so are effectively excluded from internal isolation advice on practical grounds.
I (and others) have previously drawn attention to the need to shut toilet lids for flushing (1), the need to cover toothbrushes (or even advise toothbrushing in the kitchen) seems distinctly lacking from the advice on which millions has already been spent in professional deliberation and television advertising. Where the single toilet is situated in the bathroom where teeth are cleaned infection via aerosol is likely. Shared toilets (for example in Nursing Homes) are a hazard to be managed where they cannot be avoided. Other simple domestic strategies to be considered might be increasing washing machine temperatures, personalising drinking cups and opening windows. Interestingly no-one seems to have studied the impact of the removal of shoes before entering the home in certain cultures. The WHO recommended hypochlorite solution turns out to be a 1 in 10 Domestos solution: a much more easily understood and available recommendation for wiping surfaces.
While strategies over which we have little professional influence such as special isolation facilities and Nightingale hospitals might help, surely simple measures and messages to reduce probable transmission mechanisms should be considered and promulgated as winter drives us together.
1. BMJ 2020;369:m1728
Competing interests: No competing interests