infection control

Guest Blog by Julie Russell: And now for something completely different ……or is it? A microbiologists guide to tattoos

girlymicro General, Guest blog, Microbiology (Clinical) , , , , ,

I am so excited by todays’ guest blog post. I’ve been so eagerly awaiting sharing it with you all. I don’t have any tattoos myself but it is something that is common amongst my friendship group, and I get asked about tattoo related infections A LOT. Partly as I was involved in some of the investigations when there was an issue some time back. So, a post that could help address some of the risk assessment and best practices linked to this art form felt very necessary, even though I didn’t feel I was best placed to write one. Then I saw this great article from Julie Russell on LinkedIn and I just had to reach out and see if she fancies writing a guest blog for me, and thankfully she said yes!

I first met Julie as Head of Culture Collection at Public Health England, that has since changed it’s name to the UK Health Security Agency. She was an inspiring microbiologist, who just had so much knowledge, and she became a great phone a friend. Since then she has moved on to work in a really different area where she still gets to put her microbiology and infection prevention and control knowledge to good use, as the director of a tattoo/art studio in Muswell Hill. No one is better placed therefore to answer the questions that I always get asked and have not felt best placed to answer.

Blog post from Julie Russell

After years in NHS microbiology laboratories, I joined the Public Health Laboratory Service, where I provided external quality assessment schemes and reference materials to laboratories worldwide. After that, I decided to do something completely different. I now co-own and manage Old Marine Arts Group, a tattoo studio in Muswell Hill, London.

It hadn’t occurred to me that tattooing, one of the oldest art forms in the world, essentially creates controlled wounds on people to decorate their bodies. I’ve had tattoos since my 20s – my first done in a legalised squat by a friend who’d never tattooed anyone in his life before. There was no personal protective equipment (PPE) involved; it healed beautifully, and I didn’t think about it anymore.

Many thousands of people across the UK have similar stories with no ill effects. Yet infections linked to tattooing have been recognised since the 19th century, and the government quite reasonably seeks to minimise such risks.

Tattooing, Skin, and Infection Risk

Bear in mind that the skin has a rich, diverse microbiome consisting of millions of microorganisms, some of which can cause infections if the skin is broken. Tattooing involves puncturing the skin with needles thousands of times, to a depth of approximately 1.5-2 mm, to place pigment into the dermis, creating a permanent design. Invariably, the tattoo process causes some bleeding, and after it’s finished, short-term redness, swelling and scabbing are normal. Resisting the urge to scratch is essential to minimise the risk of infection.

A July 2024 YouGov1 poll suggests 28% of UK adults – around 15 million people – now have tattoos. The UK Health Security Agency (UKHSA) notes that the true prevalence of tattoo-associated infections is unknown. There are no statutory notification procedures in place for infections specifically caused by tattooing, and no indication that such infections significantly burden the NHS. Various estimates suggest that approximately 1-3% of tattoos become infected in the UK. Most infections are mild local skin infections that can be treated with a single course of antibiotics; severe infections remain rare.

Interpreting the Evidence

Publications on tattoo-related infections must be read with caution. A December 2024 paper in The Lancet Microbe2, “Microbiology of tattoo-associated infections since 1820”, highlights rare severe cases such as necrotising fasciitis, leprosy and atypical mycobacteria outbreaks. The authors state that, “Despite advancements in public health policies and increased awareness of tattoo-related risks, a notable rise in both the number and diversity of microbial infections has been observed with an increase in the population opting for tattoos, particularly since 2000”.  However, they provide no population-level denominators and conflate expected irritation, redness and swelling with true microbial infections. The authors fail to note that severe cases are overrepresented in the literature precisely because they are unusual. The paper may be a useful clinical catalogue, but it is not an incidence study.

A Brief History of Safety

Tattooists and clinicians have long recognised infection risks in tattooing. In the late 1800s, some artists infamously spat into powdered ink and sucked the needles during the tattooing process. Meanwhile, London-based artists in the early 1900s, such as Alfred South, promoted “the most perfect antiseptic treatment, painless and absolutely harmless”, whilst Tom Riley warned: “Caution to Ladies and Gentlemen thinking of being tattooed – First see the work of two or three tattooists then make choice {sic}. See that a complete set of new needles are {sic} used at each sitting as well as antiseptics”. Some early tattooists even wore white coats to convey a clinical level of cleanliness.

Legal regulation, however, arrived much later. It was still legal to tattoo children in the UK until the Tattooing of Minors Act 1969. Some aristocratic families reportedly tattooed babies for identification – in case, for example, their children were hospitalised or kidnapped.

Modern Regulation

Mandatory licensing changed the landscape. Under the Local Government (Miscellaneous Provisions) Act 1982, tattoo studios need to be registered. More recently, there is the British Standard BS EN 17169:2020, which covers safe and hygienic practice, although not many councils use it as a benchmark. This standard covers workplace preparation, equipment sterilisation, PPE, client consultation and aftercare. It requires studio owners to implement a comprehensive hygiene protocol to protect clients and staff, and tattoo artists to provide evidence of continued professional development.

Wales now requires tattooists to complete and pass a regulated Level 2 Infection Prevention and Control Award. Requirements in England and Scotland are less specific. Barnet Council licenses my studio; their Code of Practice 13 details the specific requirements for tattooing activities, in addition to those laid down in the Regulations applicable to all special treatment licensed premises. It notes that tattoo artists who are unable to demonstrate hygiene competence may be asked to complete a Level 2 hygiene certificate.

Reducing the Risk

Infection risk can be reduced through:

  1. Good personal hygiene (artist and client)
  2. Effective cleaning
  3. Separating clean and dirty materials
  4. Correct sterilisation or disposable equipment

Artists must assess clients for skin issues (including rashes, moles and scarring), alcohol or drug use, and relevant health risks (e.g. allergies, immunosuppression, pregnancy). Artists must be vaccinated against Hepatitis B.

Tattoo stations should be treated as clinical areas. Equipment must be protected from contamination; inks must be decanted into disposable cups; distilled water used for dilution of ink and ‘green soap’ (a vegetable-oil-based surgical soap used in the tattoo industry) or for washing the needles between colours.

Dressings applied afterwards are usually transparent, self-adhesive, polyurethane film (known as second skin in the industry), similar to those used for burns and post-operative incisions, or cling film attached to the skin with surgical tape. Clear aftercare guidance should be provided verbally and in writing about how to care for the tattoo whilst it heals (no swimming, spa pools, sunbathing, perfumed soaps or scratching).

Unlicensed Tattooing

Although it is illegal to tattoo in unlicensed premises, this is rarely enforced. Anyone can buy machines and inks online and tattoo friends at home, often with limited knowledge of hygiene.

Inspections across the UK vary, with some councils inspecting only once when the studio opens, while others do so more regularly. Licensing rules differ widely outside the UK. Excellent tattoo studios can be found abroad, but so too can be deplorable hygiene. Getting a tattoo may be a more permanent souvenir of a fun holiday than a fridge magnet, but it can be risky, and alcohol and sunshine don’t help healing.

Final Thoughts

Tattooing in the UK, when performed by licensed professionals, carries a low risk of infection. I believe the demand for tattoos will grow, and I support nationally enforceable, pragmatic safety standards.

Takeaway messages:

  • Tattooing by licensed professionals in the UK is low risk
  • Nationally recognised training and regulation are likely to emerge
  • A tattoo is a controlled wound—so please, as I once observed, don’t let your dog lick it

References

  1. YouGov 16 July 2024: When it comes to tattoos, which best applies to you? | Daily Question
  2. Kondakala, Sandeep et al. Microbiology of tattoo-associated infections since 1820 The Lancet Microbe, Volume 6, Issue 4, 101005

Training For Aspiring Tattoo Artists:

After two years in the tattoo industry, I now work with licensed tattoo artist, TomCatTatt, to provide introductory training for aspiring tattoo artists, covering the basics in safety and hygiene, legislation and licensing, and an introduction to tattooing techniques. Contact me for more information: julieru13@hotmail.com.

All opinions in this blog are my own

Halloween 2025: Let’s talk all things vampirism and infection

girlymicro General, Healthcare Science, Science Communication , , , , , , , , , , ,

I am not a big Halloween girly, to be honest I can take it or leave it because I’m mostly excited about the build up to Christmas. That said, what I do love are movies and TV, and despite never being someone who can tolerate a lot of slasher or gore based horror movies, I love a good vampire movie.

A lot of this may be because I enjoy the world building and lore that seems to be more integral to vampire movies and series. This is because, although they share some of the same rules, depending on how the world is built they always need to explain which of the nuance comes into play in that particular setting. It felt fun this Halloween therefore, to write a blog post that talks about some of those tropes when vampirism is linked to infection, and how those rules compare to the real world.

Common vampire tropes to be aware of and to bear in mind as you read on:

  • Experiencing pain or physical damage in relation to sunlight
  • Needing to consume blood as a protein source
  • Inability to eat or digest food other than blood
  • Avoidance of animals
  • Ability to influence humans to undertake acts that may be against their will
  • Violent reactions to garlic
  • Inability to see themselves in mirrors or via cameras
  • Death only by beheading
  • Death by wooden stakes
  • Damage linked to holy water
  • Aversion to signs of faith
  • Aversion to alcohol or drug use

Not all of these are present in every piece of world building, hence why I find the variety of vampire mythos so interesting. The choice of which ones go together combined with different origin stories and creation processes enable a pretty large tapestry to be created from some similar thematic components.

Mystical, infections or something else?

The place to start I guess is by discussing whether all vampire world building includes infectious transmission? And the answer is a definitive no. Sometimes the way that the creation of new vampires works isn’t discussed. Sometimes the rules about the underlying process is unclear. That said, the fear of becoming something new is a frequently used trope for dramatic purposes and so the process by which a human is turned into or by which vampires exist is discussed pretty frequently as part of world building, and from what I can see there are three main routes:

  • Mystical – some form of occult/magic/cause not routed in science
  • Genetic – vampires are born and exist as a stand alone species
  • Infection – transmission via blood or other infectious transfer, even if the agent is unclear or unspecified

Now, I’m not going to cover the mystical/magically as that’s not anything based in science and the science is what I’m here for. The other two, however, are often based (sometimes loosely) in science as they are often inspired by things that actually exist and so I’m going to talk about both of those in a bit more details.

Genetic

I’m going to kick off by talking all things genetics. There are an increasingly large number of vampire movies and TV series where the vampires that featured were born vampires. This includes movies like Abigail, Perfect Creatures, the finale of the Twilight series, but also TV series such as A Discovery of Witches, First Kill and Vampire Academy. Sometimes within these there are vampires that are made through other means (discussed below) in the same world. Often these genetic vampires exist as a separate species to their Homo sapien neighbours either openly or in hiding.

There is often much discussion about where the vampire myth comes from, and in many way these stories of genetic vampires who are birthed through a similar route to standard human deliveries, links in most with what is considered to be a real world inspiration for many vampire myths. The origin is thought to be linked to a rare inherited condition known as Porphyria, the presentation for which may account for for some of the common components of vampire portrayals.

Porphyria is a rare, inherited blood disorder that occurs when the body can’t convert porphyrins into haeme, a vital component of haemoglobin. The resulting symptoms vary depending on the type of porphyria. Acute porphyria presentations include symptoms such as gastro intestinal pain and symptoms like nausea and vomiting – symptoms that are often portrayed linked to vampires attempting to eat normal food. Whilst cutaneous porphyria symptoms include pain, burning and swelling in response to sunlight, skin fragility and a tendency towards skin blistering – all of which are frequently included as vampire responses to exposure to sunlight.

Porphyria
D. Montgomery Bissell, M.D., Karl E. Anderson, M.D., and Herbert L. Bonkovsky,
N Engl J Med 2017;377:862-872
VOL. 377 NO. 9

Interestingly, in some of the genetic origin vampire stories, the impact of some of the limitations of the lifestyle limitation of traditional vampires are not so extreme. In some of these cases they can be seen in daylight, although not for long and don’t enjoy it, and they may be able to tolerate some, if not all, of human food. They are possibly therefore most aligned to their real world inspirations. I could write pages and pages on this, but infection is where my heart lies so I’m going to crack on.

Virus, parasitic, others?

Now we’ve covered off those born vampires, let’s move onto the most common version of vampirism outside of the traditional Dracula more mystical inspiration, that is vampires who are created linked to transfer of infection by blood or other means.

There are three main ways that this commonly comes into play:

  • Viral causes
  • Parasitic routes
  • Bacteria intoxication

I’m still trying to find a vampire movie where the main infectious agent is fungal, but it seems that most of the movies based on fungi are linked to zombie outbreaks. That makes a lot of sense, due to the fact that fungi are eukaryotes (like us) rather than prokaryotes (like bacteria), and so fungi tend to be linked to changing behaviour linked to interfering with the human nervous system. If you’ve seen a vampire version though please do let me know as I’m collating a list of where different organisms might come into play.

By far the most common route depicted is where the causative agent is a virus. Viruses are featured in movies such as Blade and Daybreakers and TV series such as Ultraviolet. This is because viral transmission in general is associated with transfer of bodily fluids, be that faecal-oral, respiratory via saliva, bodily fluids such as breast milk, or in the case of vampire movies via blood.

The most uncommon causative agent I’ve discovered is the parasitic cause of vampirism as shown in The Strain TV series. During the series transmission of the virus to create a full vampire is via something known as ‘The White’ that contains parasitic worms. These then lead to anatomical changes, including the growth of a proboscis that enables the biting and transmission of the parasite to others.

Bacterial coverage is mostly linked to potential methods of intoxication that supports the control over humans by vampires. Rather than being a direct cause of the vampirism, this seems to be about how transfer of the bacteria releases, or causes anatomical change, which then changes behaviour via things like hormonal or neurological changes. I’ve talked before about why bacteria may feature less in horror movies than other causes, but this can mostly be summed up by the fact that audiences tend to know more about bacteria and therefore it is less tempting for writers, but also horror tends to sit better in ‘the possible but not too close to us’.

Transmission

Obviously it’s not just the infectious agent that is important, but the mode of transmission for that agent. This being all about vampires the biggest mode of transmission is by bite, but it’s not always so straight forward. In mystical vampire movies, there’s usually a whole lot of removing of the original human blood and then transfer of the vampire blood, leading to a mystical baptism and rebirth. Infectious causes are much more one way, any bite could lead to someone turning into a vampire and the most important thing is load related. If someone is in contact for longer, if more blood is drunk and therefore more saliva and fluids exchanged, then the chances of conversion are much higher.

It’s not just blood as a bodily fluid that features in conversion during vampire movies. There are also films, such as Requiem for a Vampire and Trouble Every Day, where vampirism is treated more like a sexually transmitted disease, rather than transfer occurring during feeding on the blood of their victims. It seems that these films have increased since the 1980s, maybe as a result of fear processing linked to the HIV/AIDS pandemic during that time period or maybe because our knowledge about and ability to detect infections has increased and therefore there are a larger part of the collective public awareness. It will be interesting to see how the SAR CoV2 pandemic will impact this further.

The most unusual transmission, and one that aligns most highly with blood borne transmission is the presence of congenital transmission as featured in Blade. Where the main character Blade becomes a vampire hybrid by acquiring the vampire virus at birth, due to his mother being bitten and placental crossing of the virus into his blood stream. As a result, he exhibits some of the characteristics of a vampire due to the virus, but the effects are attenuated linked to his exposure route. It can often be that congenital infection presents differently to primary infection via other causes, and it appears vampirism is no different.

The other variable is linked to the time to turning once the infection has been introduced. I would speculate that this too is load related, as well as the infectious agent behind the symptoms. Viruses, for instance, are likely to reproduce and induce change at a much higher rate than anything linked to bacteria or parasites. This is partly due to their reproductive rate, but also linked to the level of dose that tends to be available. The exception to viruses resulting in the fastest change is likely to be bacterial intoxication and influencing. As the toxin acts immediately, when this is present in media and TV the change is almost instantaneous, but also time limited and therefore requires top up or re-application. Not all impacts are until beheading, some require a more time boundaried set of interventions.

Interventions

Once your characters are aware that vampires exist within their mist, then they will want to look for actions in order to protect themselves. One of the classic ones as featured in many movies, including the classic Lost Boys, is garlic.

In some ways the impact of garlic makes even more sense if you think of vampirism through an infectious transmission route, as garlic has been considered to have anti-infective properties for a long time, although warning you may have to ingest a LOT of it!

Bedir, A.S.; Almasri, R.S.; Azar, Y.O.; Elnady, R.E.; Al Raish, S.M. Exploring the Therapeutic Potential of Allium cepa and Allium sativum Extracts: Current Strategies, Emerging Applications, and Sustainability Utilization. Biology 2025, 14, 1088

Another common feature in vampire movies is the roles that animals play as protectors. For instance, in 30 Days of Night, the vampires kill all of the dogs before they launch their main attack. This kind of thing also often happens in films and TV where vampires are hiding in plain sight. It could be that they are taking out animals as they don’t want to be found, and animals are easier than humans, but I have another proposition. There are a number of infections where animals can be used to sniff out and identify infected individuals. Therefore, if animals could detect vampires they are much more likely to be a risk and warrant removal. Animals could therefore act as a front line of diagnostic defence to enable you to tell friend from foe.

Volume 26, Issue 4, April 2020, Pages 431-435

Having determine that a common weakness of vampires is their damage response to ultraviolet light (UV), films such as Underworld weaponise light against the vampire protagonists. Light, and especially UV-C (200 – 280nm), has been known to impact viruses and bacteria for well over 100 years. When light is in this frequency is can damage both RNA and DNA, resulting in cell death, and it is possible that if the infectious agent is the only thing that is keeping your body moving the damage would be more pronounced. We’ve also discussed how the lack of some biochemical pathways can lead to UV-C causing much larger amounts of pain an damage.

Normally, penetration of the light to cause damage might be an issue, but if you are using bullets or other means this may not impact. The most important thing I have to say here is, that despite what is shown in Blade 2, light does not bend around corners. This is also important for when you are considering using UV-C in hospitals to support cleaning, it doesn’t have good penetration and doesn’t go around corners of work in shadows. Using UV-C may work against your vampires but you are going to need to think carefully about where you use it so it does what you think it can.

Vampire movies have amazing world building and are often my favourite genera in terms of their string internal logic. I love the fact that so many types of infection and route of transmission that reflect real world cases are present as part of these pieces of entertainment. They can actually teach us a lot, even when we don’t realise it, and so much of it has origins in real world knowledge, even if only loosely. So, this Halloween evening find one you haven’t seen before and let me know which intervention you would use to stop your town being turned into creatures of the night!

Before I go, I thought I would share a few of the previous years Halloween blog posts in case you are looking for some more spooky season and infection reading:

Saturday Morning Zombies: how infection is portrayed in the genre

Infection Representation in Popular Culture: Why infection and infection risks, as discussed in movies and TV, may matter more than you think

Would You Let Them In? Celebrating Halloween by discussing what not to do in infection control as modelled in the Alien movies

Let me know your favourite vampire movies and if there are any other infection related Halloween topics I should cover.

All opinions in this blog are my own

Let’s Talk Antimicrobial Resistance for World Antimicrobial Awareness Week (WAAW) 2024

girlymicro General, Microbiology (Clinical), Science Communication , , , , , , , ,

I’ve posted in previous years about what antimicrobials are, what antimicrobial resistance may mean for individuals, as well as some thoughts about how we might communicate around some of the challenges linked to antimicrobial resistance in a difference way, or plan our outreach differently. This year I wanted to sign post to some resources that I have either been involved with or found useful in order to help support both our own learning and planning responses to some of the common misconceptions about AMR  I hear when I’m out and about talking to people.

What is antimicrobial resistance?

The World Health Organisation (WHO) talks about it like this:

Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites no longer respond to antimicrobial medicines. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become difficult or impossible to treat, increasing the risk of disease spread, severe illness, disability and death.

I think it’s easy to forget that although AMR is a big part of the professional life of most Infection Control and microbiology professionals, even for other healthcare professionals it features less often, let alone for members of the public. It can be surprising therefore when you do go out and about, or even just talk to friends and family, to hear some of the ways that non infection professionals think about how AMR works and who it impacts.

Common misconceptions I hear when talking to people about AMR:

  • It’s the body that becomes resistant to antibiotics
  • I have never taken antibiotics so I cannot get a resistant infection
  • Antibiotics treat all types of infection
  • Antibiotics can be stopped when the symptoms stop
  • Only infected patients can transmit antimicrobial resistance

If you reflect on some of these myths, it’s actually pretty easy to understand how they come about. Most people are focused on themselves and act from a human centric point of view. Many people give little, if any, thought to the multitudes of living bacteria that co-exist in their bodies. Once you accept this as the starting point, most of these myths are actually based on pretty small mental leaps. If, however, you don’t switch your point of view before you start having conversations about AMR, you can unwittingly end up reinforcing the very misconceptions you were aiming to address.

One of the reasons that I think this post is timely right now, is that I am already seeing more posts linked to how we should not be putting artificial medications into our bodies, alongside the back lash against vaccines, and so it seems to me a good time to remember what a difference these, now common, medical interventions have made to the lives of individuals and public health in general.

Let’s start with a little bit of context

Hardly any of us will have living memory of life without access to antibiotics and what life was like in a world without vaccination. One way to really get a feel for the impact these common interventions have made is to look at the impact in the last 30 years on reducing child mortality (death). Even in this recent time period, massive progress has been made due to advances such as the rota virus vaccine, but also in getting more global access to antimicrobial therapy where it is most needed.

Public health is multi factorial, with impacts being cumulative and made by more than just one thing, so not all of these impacts are made by antibiotic and vaccine availability. Other steps to reduce death linked to infectious disease include everything from clean water and sewer systems to pasteurisation and other means of food safety controls. The impact of these combined approaches is massive, but as the UN sustainable development goals show us, those of us who are access to clean water are not actually in the majority and more is yet to be done to ensure equality of access.

To aim to undo some if not all of this century plus of progress is something I find pretty hard to process. If you’ll forgive the momentary indulgence, I have to state that I think the current anti-vaccine and general anti medical stance that is being seen within some groups and communities is ultimately an act of extreme privilege It’s a privilege to be able to choose not to access something that is readily available to you and not available to others.  It is a privilege not to have to live first hand the consequences of what the alternative might hold. It’s also a privilege to be able to change your mind and choose to access something later. Thinking of things in this light doesn’t necessarily help with having conversations in a supportive and open way when some of the underlying thinking may be so different, but it may mean we can flip the dialogue from one of imposition to one about the power of choice, and supporting evidenced based decision making for all.

Where does AMR come into this?

There’s a big stat that everyone quotes about more people dying from AMR than cancer by 2050, with an estimated 10 million deaths. As a scientist, I get the need to quantify and use numbers, as a human being however, I find that numbers that are so big can just be off-putting. They are so large it can make us, as individuals, feel powerless to impact them.

For me, the reason this conversation is so important to have in the right way, and pitched to the right communities, is because if we are going through a period of global push back against the common interventions, such as vaccination, that have successfully reduced mortality and provided first line protection, then our final line of defence in terms of treatment is now even more vital. 2050 isn’t that far away, and we are already seeing consequences linked to more resistant organisms being identified in severe infections. Therefore, the time to be having conversations and really raising awareness to impact decision-making is now. Sadly, this is coinciding with a period of time when trust in healthcare professionals and science in general feels very low. Instead of being defeated by this, however, we need to use it a driver to really focus on how we can do it better.

One of the other reasons that AMR is both important and challenging to communicate is that it is always in constant flux. You can’t just learn about it and move on. The mechanisms change, the diagnostics change, and the interplay of all of these factors within the bacterial host interactions can make it even more complex and hard to engage with. To exemplify this, the figure below was something I saw posted on Bluesky and fell in love with, as I adore the fact that it lists all kinds of routes to AMR in a single image, thus capturing the complexity of what we’re dealing with.

That said, you don’t have to understand all or any of this image to understand the core of why AMR is going to be a problem moving forward. The main thing to take away from it is that AMR is complicated, and as a result you will hear many different messages linked to it, and those messages will continue to change as we learn more and the impacts are felt differently. As a result, it can then sound like we don’t know what we’re doing, or just end up really off putting, as there isn’t one clear message we are getting out there for people to cling onto. We, therefore, need to build this flexibility into messages and link around core themes rather than trying to talk in absolutes. Otherwise, we risk losing more of the public confidence than has already occurred.

What is being done nationally?

This year, a new version of the UKs National Action Plan for confronting AMR has been released and within it there is a strong focus on the acknowledged need to educate both members of the public and healthcare professionals on AMR.

https://www.gov.uk/government/publications/uk-5-year-action-plan-for-antimicrobial-resistance-2024-to-2029/confronting-antimicrobial-resistance-2024-to-2029

There is also plenty in there about increasing equitable access to antimicrobials, the need to improve diagnostics to help support both diagnostic and antimicrobial stewardship, and something that pleased me greatly, a special mention of the role of the built environment in managing AMR.

The thing is, top-down approaches will only ever get us so far. At some point, those of us involved in all things infection also need to be consciously including some of these drivers in our own every day practice.

No one can do everything, but whether you are collaborating with industry, undertaking research, or working in clinical practice, we have to embed AMR based action into our encounters. Do you include an AMR slide into all of your teaching? No matter the audience? Do you take the moment when it comes up with friends and family to just talk about the fact that this issue exists? Can you free up some capacity and undertake some public engagement?

Recognising there is a need is not the same thing as addressing that need, and we also have to be there to hold strategic partners and organisations to account in order to make sure action happens. So, let’s consciously match that top-down approach with a bottom-up drive for change.

What resources are there to help talk about AMR to other professionals

Having talked a lot about the need to talk to other healthcare professionals and seeing so much about #WAAW this year, it does really feel progress is being made to support us all to do this better.

Those of you who are UK based have probably heard of and support the Antibiotic Guardian programme (https://antibioticguardian.com/). This programme has lots of resources and supports personal action by asking you make a specific pledge about what you will undertake linked to addressing AMR.

Every year, new infographics come out that talk about different aspects of AMR. Some of these, like the one above, link AMR into commonly known components of healthcare practice, such as hand hygiene, in order to support individuals to feel empowered to act. Others focus more on messaging about antibiotic courses, or as we heard a lot about at the FIS/HIS conference last week, things like IV to oral switches, and sending the right samples to enable a switch from broad to narrow spectrum antibiotics. There’s plenty of ones out there now that can be really useful to embed in talks or laminate and put up on walls. The UKHSA especially have recently released a lot for WAAW, and because there are so many, you can keep them on rotation so that they don’t just become invisible as people see them too frequently.

I’ve also been involved in creating various content this year, as have many others, including webinars and podcasts to explore some of the issues linked to AMR and provide different routes via which healthcare professionals can engage with information and CPD on this topic. I’ve included a link to just one of these below in case it’s of interest, but a quick internet search will provide you with all kinds of others.

https://www.selectscience.net/webinar/resistance-on-the-rise

The main thing to remember is that we all like to receive our learning in different ways, and so ensuring that we remember that when we’re designing our education strategies is one of the best ways to be impactful.

What resources are there to help talk about AMR to members of the public

The resources you might want to use linked to AMR will vary greatly based on your target audience. It’s important to remember that even if someone is a healthcare worker they are also a member of the public, and depending on their personal background or setting they work in, utilising content created for the general public may serve both purposes.

There is some really great video, podcast, infographic, blog, and other content aimed at public outreach on AMR. There’s even a musical called The Mold that Changed the World, about Fleming and Penicillin, as the first antibiotic.

There are lots of different entry points when you are thinking about content that might be appropriate, and you’re likely to go to different depths depending on whether you are doing a one off encounter or a more prolonged piece of relationship building.

The post that is linked to at the start of this article on AMR as a Super Wicked Problem may help with choosing your content. You may also want to consciously address some of the myths mentioned at the start or even start your conversation with the fact that many antibiotics actually started as products identified in nature, and so are not as far from natural compounds as may be frequently thought.

Some of you who have been reading this blog for a while will know how proud and passionate I am about The Nosocomial Project, which aims to use a science, technology, engineering, arts and mathematics (STEAM) approach to talk about infection and infection risks.

As part of this work, we organised a two part festival linked to AMR entitled Rise of the Resistance Festival. All of the content is split across YouTube and the website. I’ve included linked here in case any of it is useful in your own settings when you are looking for inspiration or planning content. The content covered in the festival included everything from a play aimed at pre-school aged children entitled Sock the Puppet, who is a hand puppet who is scared of germs, expert panels, comedy sets, and Klebsiella as a drag queen. I still have so much fun rediscovering this content, and I hope you’ll feel the same way.

I would make a plea that we all work together on this one to do some myth busting and get messages about AMR out there, but also find a way to get messages across that are entertaining/joyous and filled with hope for what we can achieve, rather than focusing on the horrors of what happens if we don’t get our act sorted. I think all of us, including healthcare professionals, have had our fill of trauma in the last few years. So, let’s focus on empowerment and positivity to make this change happen, rather than following in the footsteps of those who want a world of decisions driven by fear.

All opinions in this blog are my own

Environment Network 2024: Environmental risk assessment what do we need to know?

girlymicro Microbiology (Clinical) , , , , , , ,

As Girlymicro has a) got tonsillitis and b) attempting to run the day, todays blog is a guest blog brought to you by frequent Girlymicrobiologist contributors and Environment Network stakeholder members: Sam Watkin and Dr Claire Walker.

It’s the most wonderful time of the year! Today is the Environment Network meeting where we gather together to talk all things environmental risk assessment.  This is a network for people in clinical, scientific and engineering roles within the NHS and other associated organisations who are interested in the role of environmental infection prevention and control in preventing infection. Despite being an immunologist (Claire Walker) for most of my career, this is one of my favourite meetings of the year. Everyone is deeply passionate about what they do and how we can work together to exchange ideas and improve practice.

Too kick us off, we have the wonderful Professor Elaine Cloutman-Green and Lena Ciric welcoming us to a day of interactive sessions on key issues in the field. Prof C-G sets the scene for our day introducing the concept of our different perceptions of risk assessment and the challenge of unexpected consequences. Of course we understand the triumvirate of identify, understand and mitigate problems but how an engineer approaches risk is quite different to how a clinician might. As Prof C-G says clinical risk assessment is not a zero harm game, it is about controlling real rather than theoretical harm. A balance needs to be stuck between what is most appropriate for the patient – we could keep patients in bubbles and not even have healthcare professionals approach them, but I doubt that patient would fare very well! There is a need to balance the approach of the clinical and the engineer to find an optimal position to minimise harm. To make these decisions we need to consider the interaction between organism, patient and the built environment in order to work out what the control measure should look like. Problems aren’t simple, we need to accept and embrace that risk assessment is a complex process. And perhaps most importantly we need to take the time to see the perspectives of others, or we might never see the elephant in the room.

Risk assessment has the potential to make use all uncomfortable, as scientists we do not enjoy the unknown. In good risk assessment A plus B does not always equal C, it might do 50% of the time so we have to rely on our best judgement. Moreover, risk is not static. All patient and clinical environments are quite different as we need to pick the point that works for that situation – National guidance can never cover all of these unique situations. A multi-disciplinary team approach is essential to ensure we are asking the right questions.

Next up we have Dr Susanne Surman-Lee giving a talk on combining clinical and engineering risk and why working in silos hinders risk assessments. Silo working at all levels, even within a team, can cause a raft of problems, with poor communication, different priorities, resource conflicts and inefficiencies. This can mean those in each silo work to their desired outcomes, not taking into account what other requirements may be. The danger of this is that it ultimately increases the risk to patients.

A poll found that the event was well attended by people from a range of disciplines, covering many relevant professions to environmental infection control. We often all want different things from a building, be that aesthetic, cost or usability. What is critical, and reflected in new guidance, is that the purpose of a building must be to put the patient first.

To escape working in silos, the audience recognised that communication is absolutely key. Working as a single team, sharing respect, data sharing and fostering a collaborative culture is all needed to break down individual working silos. This enables the project team to work as a single unit, supporting faster, safer decisions across strategic levels.

A set of examples on real-world decision-making processes highlighted not only the importance of accurate record keeping when it comes to decision-making, but also what can happen when an IPC challenge is only viewed through teams working in silos.

When considering waterborne infection risks, a multitude of challenges, both from an engineering and non-engineering standpoint must be considered. This can range from inadequate usage leading to stagnation, poor hygiene during installation and poor labelling, outlet misuse, poor cleaning techniques and inappropriate assessment if transmission risks as examples.

Ultimately, we must consider the problem as a whole. Different hazards and sources of pathogens overlap, meaning we must work across disciplines to mitigate risk. We also must gather information from multiple sources to identify risks to make sure a risk isn’t overlooked.

Updated guidance has recently been produced following an outbreak of non-tuberculous Mycobacteria for the safe design and management of new buildings calls for collaborative working throughout the project, with continual risk assessments and project ownership by the trust. Having a multidisciplinary approach can help effectively design and manage risk, improving IPC risk assessment and decision-making procedures.

In this final session before some essential caffeine, we have Andrew Poplett taking us on a whistle stop tour of derogation management. Derogations, like puppies, are for life – if you agree to one you must be sure as they are extremely difficult to reverse. We know that unless specifically stated much of the guidance in not mandatory. However departure or derogation from HTM should provide a degrees of safety NOT LESS THAN that achieved by following the guidance laid out in the HTM.

A derogation is an exemption from or relation of a standard or rule but it must be carefully managed, documented and justified. It must be risk assessed and cannot be to reduce costs. Of course, the bugs haven’t read the HTMs and they really don’t care about the budget! Minimum standards and patient safety guidelines cannot be derogated, but for those for those ‘nice to haves’ there is some wriggle room. So why do we want to derogate? Situations like conflicting guidance and refurbishment of existing buildings. Once again we are lead to the conclusion that these decisions must be the result of a multi-disciplinary team approach and risk assessments – these decisions can’t be made solely by a financial manager, an engineer, a microbiologist or infection prevention and control, but requires a meeting of minds to reach the right conclusion. The cornerstone of derogations is communication, ideally reaching a sensible and agreed consensus that balances risk, compliance and other important factors (like cost!). Ego needs to be left at the door or we might need to start hiring some referees!

If you break the rules, you really need to document why, what, who and when. It’s not to say that we shouldn’t, as we know every circumstance is difference. But transparency is essential to the process, and they do need to be reviewed regularly. As a final thought, Andrew invites us to consider that it is important to remember that it is always cheaper to invest the time upfront because short cuts tend to end in expensive disaster.

After a quick coffee break, we have Louise Clarke from GPT Consult discussing capturing water and ventilation risks as part of governance strategies. First off, we must understand what risks we actually need to assess and manage. We often have aging infrastructures, changes in usage, hidden infrastructure, access challenges and maintenance works. Not only that, how people use and view spaces factors into the risks we must assess.

When assessing risk, it must be suitable and sufficient. But what does that actually mean? It depends on what you are trying to deliver, what you are looking for and what is being managed. Five-by-five risk matrices do not necessarily capture the complexities of these risks. Not only this, a huge amount od information is required for effective assessment. Factors like patient factors, unique building features, data from building management systems must all be considered. Not only that, but there are a large amount of unknown factors which need to be considered. The current state of a building and the equipment in place is important to consider, with the impact these may have in the future on risk taken into account. Overall risk profiles are needed but challenging to achieve as many people view the risk of a setting from different perspectives.

All risk assessments must be performed within the appropriate legislation. This covers government legislation, approved codes of practice and best practice guidance (such as the HTMs). To ensure that all standards and met and the process of derogation is appropriately followed, governance structures have to be followed. But these structures themselves can be difficult to navigate. The reporting of information gathered from the building (such as information from the building management system) can be challenging through these structures. How do we ensure the data is appropriately recorded, interpreted and presented? Do governance structures effectively allow for this process and make sure that the data collected useful and enables risk assessment? So, how should the data we collect from the building be presented? As with many things, it depends. What the intended use of the information is, how is needs to be interpreted and disseminated all matter.

Typical governance structures include water and ventilation safety groups. These groups serve to bring together estates, infection control, representatives from the relevant clinical units, contractors in order to assess risk and make informed decisions. Are such meetings suitable to address risk? The volume of data that must be presented, understood and used to inform decisions is massive, and these meetings are time-constrained. A lot of the processes will be informed by the risk appetite of the organisation. Information may not be available and work may not be possible. As such, appropriate record keeping and reporting is crucial. Taking this all in, governance strategies which to be implemented must be practical, realistic, effective, suitable and sufficient.

Sadly Dr Derren Ready from UKHSA is enjoying a marvellous holiday so we have a recording from him today. We are venturing into the field of community risk assessments and the considerations that are notably different from in the hospital. There are significant challenges, as highlighted by the consideration of the prison system where an outbreak might further restrain the liberty of the prisoners impacting significantly on their mental and physical wellness, thus careful balances need to be struck. In essence, the challenges of the community require a different set of questions to be answered in risk assessment.

In community risk assessment the first stages fall to information gathering and fact checking. Information gathering might focus on the clinical, epidemiological, microbiological or environmental factors. Context of the information should be considered. In public health we often act on suspicion as time is of the essence. In the initial stages there is often simply anecdotal information and there is a need to all the facts to be checked through this dynamic process.

UKHSA bases its risk assessment of five key areas. The first of which is severity which is the seriousness of the incident in terms of the potential to cause harm to individuals or to the population. This is graded from 0-4 where 0 has a very low severity like head lice in a school whilst class 4 are extremely severe illnesses which are almost invariably fatal, like rabies or Ebola virus outbreaks. The second area is uncertainty, how sure are we that the diagnosis is correct based on epidemiological, clinical, statistical and laboratory evidence. The third area is the likelihood of the organism spreading covered by an assessment of the infective dose, virulence of the organism, mode and routes of transmission, observed spread and susceptibility of the population. Again the areas are graded from 0 to 4 allow qualification of the potential risk. The fourth area is intervention, what could be done to alter the course of the outbreak? This ranges from minimal, non invasive procedures like handwashing to an urgent mass immunisation campaign or withdrawal of all contaminated food products. Clearly some outbreaks don’t lend themselves well to specific interventions an example would include responding to a cluster of vCJD disease where remedial intervention is particularly challenging. The last key area is context. The easiest way to consider this is to think about the broader environment in which the event is occurring. Factors like public concern, attitudes, expectations, strength of professional knowledge and politics have the potential to influence decisions about the appropriate response to an outbreak.

The best way to approach this complex process is through the use of a dynamic risk assessment where the risk assessment is continually reviewed throughout the outbreak. This allows UKHSA to make the best possible decisions based on the best information available. These dynamic risk assessments can be classified an routine, standard or enhanced based on the response required to an event. The take home message is very much that risk is not static and we need robust frameworks to ensure we make the right decision at the right time.

In our final talk of this morning, we have our own soon to be Dr Sam Watkins from UCL/UKHSA. Sam’s research interest in detection of surface based pathogens in the hospital. Surfaces can be come contaminated and play an important role in the spread of infection around the hospital. Once considered tenuous, the role of surfaces in the persistence of healthcare associated infection is now well established for several pathogenic organisms. The current standard is for surfaces to be visibly clean but there is no guidance on assessment of microbiological hygiene of surfaces. It’s extremely important to remember that just because something looks clean, doesn’t mean it isn’t crawling with bugs! Again, we must consider that a one size fits all approach cannot be enforced across the NHS as we have so many different situations and patient requirements.

Sam’s research focuses on development of new tools for assessing surface-based transmission risk. Surface sampling can be many different things from contact agar plates, to specific swabbing or sponges, to PCR identification of specific viruses in a outbreak scenario all of which have different purposes. All of this information can help support clinical risk assessment and the actions of infection prevention and control. Currently surface sampling is most commonly used as a retrospective measure after a clinical incident during outbreaks. Sadly there is little guidance or framework in place to guide process in this area. Furthermore, the identification of a pathogen on the surface doesn’t provide sufficient information on if this is the cause of the outbreak. Sam’s work has been to gather prospective evidence gathering through surrogate markers which mimic a microorganism in the environment without posing any infectious risk. In Sam’s work, he has been using cauliflower mosaic virus across an outpatient and inpatient haematology oncology unit. Three markers derived from the genome of the cauliflower mosaic virus were used and inoculated on various risk level surfaces. After 8 hours the swab samples were collected from pre defined sites. The movement of the surrogate markers across the unit were investigated over the course of five days. Within 8 hours there was widespread movement of the markers across the outpatient unit. A slightly less dramatic spread was noted in the inpatient site. From this we see that there is huge variability in the dissemination of markers, markers deposited on high risk sites where identified in a greater number of places. Paediatrics certainly adds an additional dimension to this work, with children spreading viruses through an exciting game of hide and seek in the department! An important take home message here is that a one size fits all approach is unlikely to be successful, given the highly varied nature of clinical settings. A unique approach to surface-based transmission risk assessment and mitigation may therefore be needed.

With the morning session drawing to a close. We look forward to a delicious lunch, more coffee and interactive case based discussions this afternoon!

If you want to find out more about environmental infection prevention and control and future events you can check out the Environment Network here. Girlymicro has also previously posted about risk assessment and the role of the environment in healthcare settings, links to more posts can be found here. The main theme of the day was that we all need to get out of our silo’s and talk more, so let’s start that change by being bold, starting conversations and getting out of our boxes!

All opinions in this blog are my own