Every winter during respiratory illness season, emergency departments (EDs) fill with sick patients. And this past December was no exception, with occupancy surges during a “tripledemic” of COVID-19, respiratory syncytial virus (RSV) and the flu indicating that the problem is only getting worse. But why?
There’s not nearly enough discussion of the culprit. It’s poor hygiene habits.
We saw dramatically fewer hospitalizations and deaths during the 2020-21 flu season — just 748 deaths were coded as influenza from Oct. 3, 2020, to July 24, 2021, according to data provided to JAMA by the Centers for Disease Control and Prevention (CDC).a That’s compared with nearly 22,000 flu deaths the year before, when 38 million people got sick.b CDC has underscored the importance of adherence to hygienic interventions in preventing the spread of influenza, having stated that the decline in deaths attributed to influenza during the pandemic is likely due to improved hygienic interventions prompted by COVID-19. These include mitigation measures such as wearing face masks, staying home, hand washing, school closures, reduced travel, increased ventilation of indoor spaces and physical distancing.c
What the science tells us
We as a nation know how to suppress disease spread. We have the science. So why are health systems – already short on staff – forced to budget ahead knowing they’ll pay through the nose for travel nurses during flu season? Why do schools dread finding enough substitute teachers as children “drop like flies” as norovirus or RSV spread through the population, keeping parents at home from jobs inside and outside of healthcare settings and reflecting in our very planning and vocabulary how accepting we are of preventable disease? Why are preventable hospital-acquired infections (HAIs) still one of the top causes of death in a high-income country with so many resources?
We have the tools to prevent disease from spreading. And as the CDC influenza data indicate, those tools also clearly worked during one of the most compelling “teachable moments” in the history of public health.
And then people forgot. We went back to “normal,” in the process eliminating the benefits we had gained when we were, as a society, practicing better hygiene.
Naming the problem is the first step in addressing it
Hospital leaders are all-too-familiar with the statistics that HAIs are among the most preventable causes of death. Researchers have been saying over and over that better hand hygiene in hospitals could prevent some of the 98,000 deaths associated with 1.7 million U.S. HAIs annually.d Hospitals are generally on board with this issue, and in fact updated hand hygiene guidelines for acute-care hospitals were published just this year.
What we don’t talk about enough, though, is the extent to which our community challenges outside a hospital’s walls are due to poor personal, domestic, environmental and food hygiene. We talk about it by proxy, discussing its symptoms rather than the root cause: teacher shortages, tuberculosis’s financial burden on public health departments, E. coli-related visits to the ED, corporate 10-Ksthat list “labor shortages” and “supply chain disruptions” as major economic risk factors, to name only a few examples.
Hygiene is not a word we use much in the United States when considering how to prevent disease transmission, such as food borne illness. The word is more often associated with personal cleanliness and sanitation.
But more broadly, hygiene is, at its core, humanity’s response to living together. And based on how accepting we are of disease transmission and our near-immediate regression to higher levels of transmissible disease and lower levels of science-backed practices such as proper handwashing, one could conclude we are still — even as a developed country with a high per capital income, (mostly) clean water and aisles of products that kill viruses and germs — fundamentally unhygienic.
An ounce of prevention is worth a pound of cure
This aphorism is borne out by the facts. The COVID-19 vaccine was a miracle of modern medicine on a par with the ones for polio and measles. But pharmaceutical interventions cost way more than an N-95 and soap.
Hygienic interventions such as hand sanitizer and handwashing need to be instilled not just within hospitals but also within American culture as normal behaviors instead of short-term measures when illnesses are at peak levels. Things people can and should do every day need to be solidified as routine, and provider organizations should take the lead in promoting hygienic practices.
Properly educating the public is crucial. Poor understanding of vaccines — which predates but was greatly exacerbated by communication around COVID-19 vaccinations — has made our population vulnerable to illnesses that had been on the verge of being eradicated.
The urgent need to counter misinformation
Misinformation proliferating on social media has made mixed signals even more confusing, not to mention the politicization of disease interventions. Now more than ever, we need hospitals and health systems, as pillars within community life, to use their influence to educate people about how diseases are transmitted and how hygienic measures work.
Nonpharmaceutical hygienic interventions are necessary for a healthy community. Otherwise, even when we can treat illnesses, antidotes will lose their effectiveness over time. Consider bacterial resistant infections on the rise from an increased reliance on antibiotics. Anti-microbial resistance is dangerous not only for patients, but also for health systems, as it leads to increased admissions, medication usage and, ultimately, costs.
By being outspoken advocates of simple hygienic behavior, providers can make a difference in reducing the need for lifesaving drugs, thereby helping to ensure they will remain effective for drastic cases. Providers understand this significant reality, but they also need to be as emphatic as possible in delivering the message.
Time to stop picking dandelions and cut the roots
Americans are falsely removed from the fear of hygiene-related sickness in the western world, and it is dangerous to assume diseases do not start domestically, or that we are immune to foreign-borne illnesses.
We are not, and the pandemic is a glaring reminder. Viruses mutate and fight back.
But so can we, through better communication around preventative hygiene. To do that effectively, we need two fundamental tools:
- Unassailable science to fortify hygiene guidance
- Well-conceived and more potent communication approaches to help individuals understand the rationales behind public health guidance
We need to raise public awareness so that pronouncements such as “wear a mask” or “wash your hands” are as universally accepted as “smoking is bad.”
This is an essential charge for public health departments, which must continue to be empowered to guide communities in protecting themselves. But hospitals — as places where people already come for care — should help.
It starts with better research
Our understanding of the subtleties of what constitutes good hygiene — particularly within healthcare — continues to evolve. And it is hygiene research that lays the groundwork for hygiene communication. Supporting, investing and engaging in hygiene research is investing in the evidence needed to create long-term habit formation that lowers the rate of HAIs, reduces AMR, decreases the burden on our health care system and empowers a healthier population. Improving hygiene at the micro level (communicating with patients and outreach with local communities) is critical, and so is the macro view. We need to nurture the hygiene field and fill current gaps in hygiene data. We need evidence that points to scalable, neutral, cost-effective interventions that can keep our communities safe and uplift individuals, businesses and economies globally.
A role for healthcare finance leaders
Health-system-led efforts focused on promoting hygiene range from bedside engagements to community outreach, and they can also come from the C-suite, including through strong support from finance executives. For example, finance leaders can play a role in empowering their organizations as leaders and influencers in a stronger hygiene culture by advocating for their organizations to engage in the following activities.
Add to science. Health systems should look for opportunities to partner with researchers to study the impacts of cleaning methods on bacteria levels and disease transmission within various hospital locations in ways that can be applied both inside and outside healthcare settings — e.g. looking at bacteria levels at a sink or in a public restroom.
Bring the outside inside. Health systems should elevate community hygiene habits, not just in-hospital protocols, as an addressable risk among their organizations’ leadership and board members.
Get local. Health systems should engage and educate local civic leaders who influence public health investment and policies, such as access to public restrooms, educational programming for children and other areas where hygiene education and access could influence utilization of the healthcare system. They should support and share research on community hygiene’s impact on the local healthcare system’s strength and ability to respond in times of high utilization and high disease transmission.
Now is the time to address hygiene challenges. Let COVID-19 be a lesson, not a premonition of what’s to come.
a. Rubin, R., “Influenza’s unprecedented low profile during COVID-19 pandemic leaves experts wondering what this flu season has in store,” JAMA Network, Aug. 25, 2021.
b. CDC, “Archived: estimated influenza illnesses, medical visits, hospitalizations, and deaths in the United States — 2019–2020 influenza season,” Page last reviewed, June 2, 2021.
c. CDC, “Prevention strategies for seasonal influenza in healthcare settings,” Page last reviewed, May 13, 2021; and CDC, “2020-2021 Flu Season Summary,” Page updated Oct. 25, 2021.
d.Haque, M., Sartelli. M., McKimm, J., and Abu Bakar, M., “Health care-associated infections – an overview,” Infection and Drug Resistance, Nov. 15, 2018.
12 CDC recommendations to healthcare providers for prevention of community-based infection from influenza
The CDC’s guidance to providers regarding steps required to help prevent the spread of influenza in their community includes the following recommendations:
- Promote and administer seasonal influenza vaccine
- Take steps to minimize potential exposures, before arrival, upon entry and during visit to a healthcare setting
- Monitor and manage ill healthcare personnel
- Adhere to standard precautions around hand hygiene, gloves and gowns
- Adhere to droplet precautions
- Use caution when performing aerosol-generating procedures
- Manage visitor access and movement within the facility
- Monitor influenza activity
- Implement environmental infection control
- Implement engineering controls
- Train and educate healthcare personnel
- Administer antiviral treatment and chemoprophylaxis of patients and healthcare personnel when appropriate
Source: CDC, “Prevention strategies for seasonal influenza in healthcare settings,” Page last reviewed, May 13, 2021.