Social distancing is not enough, we also need social networking awareness and much more attention to basic hygiene!
As a home care provider working and collaborating with persons with complex care needs, their families and the wider community we are especially aware of the greater vulnerability that many have to the Novel Coronavirus, both young and old.
There is a lot of information on the COVID 19 virus:
– Some sources say that it can be spread without symptoms, others say that it cannot;
– Others say that while it can be transmitted without symptoms it does not transmit “much”;
– Other sources however state that while you may not transmit as much in the early stages, because there may be a lot of people who are asymptomatic (have the virus without symptoms), the risks of transmitting it are high. Some sources state that that those in the 20 to 40 age range are more likely to transmit the virus without symptoms.
How do we limit the risks of contracting the virus? There are four main options:
1 – One is social distancing, or as the WHO now calls it, physical distancing;
2 – A second is social contact monitoring;
3 – A third is social isolation;
4 – A fourth is infection prevention and control, which means hand and surface washing and a number of other routines designed to minimise viral transmission.
In reality we will likely need to use a mix of all of the above.
Social/physical distancing is:
a) limiting the number of people you make contact with, at any one point in time, and
b) increasing the amount of space you have between the person or persons you are connecting with.
The study of intimate, social and personal space is known as Proxemics. The actual dimensions of space can differ amongst different cultures and amongst individuals.
Intimate space is any contact or communication within 18 inches of the person: many personal support workers and nurses engage at this level for quite some time, and this applies to physicians depending on their role. Health care workers may not be able to avoid intimate contact.
Personal space is anything between 18 inches and 4 feet usually. This would be reserved for anybody you are talking to.
Social space is between 4 and 12 feet, and social space is usually reserved for groups of people.
Social/physical distancing is essentially about a) reducing our contact with groups of people and b) pushing out the intimate and personal contact we used to have to this wider area.
But just how far should we be social distancing?
With respect to actual distance, the current recommendation is to have 2 metres of space (6 feet) between people.
This appears to be due to the fact that most airborne transmission of the virus is in droplet form, and droplets are meant to fall to the ground pretty quickly. A 2 metre radius is deemed sufficient to avoid the risk of passing the virus from person to person.
However, there are differences of opinion with respect to the ability of finer particles to remain in the air long enough to be of issue in an enclosed space. In this case being 2 metres in a confined area, without protection in certain instances, with someone exhibiting viral symptoms (coughing and sneezing especially) may not be sufficient distance without personal protection equipment and without infection prevention and control protocols. Most of the research we see on this suggests that the risks are very low and are usually associated with advanced medical procedures.
Clearly for people with compromised immune systems and for people in direct contact with people with compromised immune systems, being in the same room as someone with viral symptoms, without personal protection equipment, even with social distancing, is not something we would recommend. While we are required to follow appropriate protocols in this respect, we would refer persons and families to seek appropriate clinical direction from public health and/or primary physician.
In public space (12 feet or more away), the likelihood of contamination by direct contact, is likely to be infinitesimally small. However, while a person may not be close enough to pass the virus on via a cough or a sneeze, their touch and the transmission of the virus to surfaces might be.
Public spaces therefore pose a risk for transmission via touch and we need to sanitise our hands regularly after coming into contact with high contact areas; doors into grocery stores and store produce; malls; public washrooms; elevators; transportation etc.
Why is reducing our contact with groups of people important?
Over the course of a week the average person will have had a number of different types of contacts with people; intimate, personal, social and public. We are all potentially connected to a great many others at any one point in time.
Limiting contact to smaller numbers of people at a time and to those we know allows us to limit the uncertainty with respect to our overall number of contacts.
And remember you do not need to be close to someone to catch a virus from them. You just need to touch the same surfaces they have touched.
Social contact monitoring
The fewer people we have contact with allows us to better track the contacts of those we do see.
Do you know if a prospective contact has had one or more of the following?
a) Significant one on one and/or significant group contact in the last 14 days.
b) Direct contact with anyone who has COVID-19 or suspected to have had COVID-19 in the last 14 days.
c) Direct contact with someone with influenza or cold type symptoms in the last two weeks that have not been tested to rule out COVID-19?
Do you know if your prospective contact can confirm whether any of their recent contacts has or has not developed cold or influenza symptoms? Do you ask your contacts to keep you informed of any significant developments in their health or the health of their most recent contacts?
Limiting your contacts and knowing more about your contacts helps reduce the risk of infection.
If the person you are about to meet has been in close contact with someone with an undiagnosed influenza like illness, then knowing this in advance will help you prevent exposure to this person.
If you have had contact with a person, who subsequently finds out that one of their contacts has a viral infection, then keeping a track of that person’s symptoms is also important.
How social contact monitoring works to prevent virus transmission?
If a contact of a contact has just developed symptoms, by having this information you theoretically have an average warning of 5 days, a fire break as it were.
If each contact in a chain of contact informs their contacts of symptoms in the chain then we create important fire breaks in the chain of transmission. We believe that screening of visitors to homes, residential communities and long term care homes should incorporate this type of advanced screening protocol.
Advanced screening protocols should be used for all health care workers (persons) who have direct contact with vulnerable people.
Social contact monitoring principles
So keep a close eye on your social and support network for the contacts they have. Especially for those who depend on personal and other supports in the home and community and who may have weakened immune systems:
At the present moment in time limit the essential contacts you have to those who are practising social distancing (i.e. limited contacts) and good hygiene (hand washing etc).
Make sure your essential contacts know the importance of tracking their own symptoms and those symptoms of those they have had close contact with. You should do the same for the people you know.
Also, for the moment, it might make sense to avoid younger adults and children as the anecdotal and limited research evidence suggests that they have a higher risk of asymptomatic transmission (passing the virus to you with having symptoms themselves).
If you are about to have contact with people, always screen them with respect to their social contacts and frequency of contact and if they are up to date on the health status of their contacts. Merely saying that they have heard nothing is insufficient. To be safe, defer all contact until the person is able to confirm the health status of their recent contacts.
Keep track of all those you have met and ask them to provide information on their contacts, with respect to the number of contacts they have had, in particular group social contacts, and contacts with people with symptoms of viral infection.
Social isolation is a form of social distancing and it can be total, i.e. no visitors and no contact, or it can be selective, i.e. only health care workers and visitors practising good hygiene and social distancing protocols.
Isolating yourself from others and the outside world eliminates the risk of viral transmission by social contact and by public space surface contact.
However, total isolation for many people is not realistic. For those who rely on personal and nursing supports in the community they may need regular daily interaction and for those who do not we need to shop, work and perform essential functions.
Infection prevention and control
Infection prevention and control looks at the interaction of the person, the people they interact with and the places in which they live and interact (their home and community environment). It places additional protections against viral transmission. Many are basic and can be practised by all of us, and all of us who care for others.
Good hand washing techniques and procedures are an important foundation for infection protection and control important:
If visiting or providing care to a vulnerable person:
Wash hands immediately upon entering the home. Do not touch anything or any surface until you have washed your hands. Soap and water or a healthy dose of hand sanitiser are two options – hands need to be soaking for hand sanitiser to work effectively.
Wash hands before you touch a person, if providing assistance (bathing, toileting, moving, dressing, feeding), and after providing assistance.
Wash hands before preparing food and drink and before passing items to a person.
Wash hands regularly throughout the day if you are touching a person’s surroundings and/or yourself, especially if the area has high contact from others or if the number of person to environment contacts is unknown.
Make sure that the person you are looking after also washes hands after toileting, before eating, after close (touch) interactions with other people and regularly throughout the day. Please check with a health care practitioner with respect to skin care considerations and other health issues that may impact hand washing.
Extend washing protocols to all produce and goods that come into the house that are likely to be touched or used or consumed within say a 3 to 5 day period. Recent research on the virus suggests that it can remain active for up to 3 days on steel and plastic surfaces and up to 24 hours on surfaces like cardboard. You can easily quarantine non perishable items within a specific area.
Appropriately sanitize the environment: if you are briefly visiting someone make sure to touch as few surfaces as possible and/or to sanitise those surfaces you touch. Sanitise all affected surfaces after toileting and bathing and before and after food preparation. Otherwise regularly sanitise contact surfaces (door/cupboard handles, countertops, taps, water jugs, kettles etc).
Clean your cell phone regularly!
Exercise good judgement with respect to hygiene.
Hands can be washed with soap and water or with hand sanitiser, if there is no visible sign of dirt or other contamination.
Here is instruction from Public Health Ontario, Best Practices for Hand Hygiene in All Health Care Settings.
Here is a link to instruction from the World Health Organisation on hand rubbing (alcohol based hand sanitizers).
Here is a link to instruction from the World Health Orgnisation (WHO) on hand washing.
Masks and other protections
In the current COVID-19 environment where it may be difficult to know when and if a person can transmit the virus, we believe that those who look after those who may be more vulnerable to the virus should wear a mask, if at all possible, when interacting closely with the person.
This does not mean that failure to wear a mask represents a high risk in all cases, just that the risks are uncertain and the costs of transmission for certain portions of the population extremely high. As a provider of health care services our objective in this environment is to manage risks to a far higher standard.
With respect to the care of persons with undiagnosed influenza and other viral symptoms as well as diagnosed COVID-19 cases, while we have our own protocols for the management of these risks, we would direct persons and families to current Public Health Ontario guidelines, recommendations and supports.
Ontario.ca – General Guidance https://www.ontario.ca/page/2019-novel-coronavirus#section-3
Public Health COVID-19 Resources – https://www.publichealthontario.ca/en/diseases-and-conditions/infectious-diseases/respiratory-diseases/novel-coronavirus/public-resources
When and how to wear a mask – https://www.publichealthontario.ca/-/media/documents/ncov/factsheet/factsheet-covid-19-how-to-wear-mask.pdf?la=en
COVID-19 – Health Care Resources for Health Care Professionals- https://www.publichealthontario.ca/en/diseases-and-conditions/infectious-diseases/respiratory-diseases/novel-coronavirus/health-care-resources
CDC – Cleaning and Disinfection for Households https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cleaning-disinfection.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fprepare%2Fcleaning-disinfection.html