I count myself so fortunate to work with the most amazing infection prevention and control team at Great Ormond Street Hospital (GOSH). Not only are they experts, but they work incredibly hard to always keep the patient at the centre of all of their decision making. On top of this they are a creative bunch, with brilliant ideas about how to communicate complex ideas in a way that is easy for anyone to understand. They are a constant source of inspiration to me, and so I am overjoyed to share with you all a project they have been working on, a podcast aimed at offering an accessible starter for patients, families, and staff on how infection control works at GOSH, and why things may be a little different to what people have encountered in adult or other healthcare settings.
NB I may invade for a few episodes but the concept is all theirs, so please ignore mine and go for the others first, you hear enough of my voice 🙂
I started thinking about this topic some time ago when I wrote a blog about it (above), but our great Director of Infection Prevention and Control (Helen Dunn) and Lead Practice Educator (Kate Harkus) have done a lot more than think, they’ve created an entire academic module. So, if you are a healthcare member of staff and enjoy this introductory podcast series, you might want also think about joining this course where you can meet like minded people and dive deeper into a fascinating topic:
Cruise ships and cruise ship outbreaks have been in the news a lot this month. So much so, that I’ve already posted about the Hantavirus outbreak that was associated with a cruise ship in South America:
There have also been headlines, however, linked to 48 passengers displaying symptoms consistent with gastrointestinal illness, as well as one crew member, that has led to another cruise ship asking passengers to isolate.
This second kind of cruise ship outbreak isn’t all that unusual, and I wonder if it would even have reached the headlines if it hadn’t happened during the same month as everyone was talking about Hantavirus. Cruise ships are mobile cities, with large numbers of people confined within a limit space, usually drawn from all over the world. Places where everyone is outside of their ‘normal’, eating different food together, spending time in close quarters with strangers, and sometimes reticent to lose holiday time if they start to feel unwell. That’s without throwing in sea sickness as an alternate reason for nausea and vomiting, which may mean people don’t realise they are ill with something infectious as early as they may do at home.
I’ve always sworn, for all of these reasons that I would never go on a cruise. I’ve spent way too many hours in lectures listening to outbreak stories related to ships, and yet, due to a birthday surprise, I went on my first ever cruise in 2025 and it surprised me, so I thought I would spend this week talking about a few of the reasons why, but first some outbreak context.
Multi-Year Outbreak Comparison (2019–2026)
According to historical Centres for Disease Control (CDC) data tracking of official gastrointestinal outbreaks across major cruise lines, the frequency of notable incidents varies dramatically by cruise line brand:
Princess Cruises: Highest frequency with 14 outbreaks
Holland America Line: 13 outbreaks
Royal Caribbean International: 10 outbreaks
Celebrity Cruises: 6 outbreaks
Carnival Cruise Line: 2 outbreaks
Disney Cruise Line: 1 outbreak
It’s worth noting, however, that different cruise lines not only have very different numbers and types of ships, with wildly different passengers numbers, but they also have very different passenger profiles. Some, like Virgin, host adult only cruises. Others, like Viking, serve older passenger demographics and undertake river cruising rather than ocean based cruising. Then you have lines like Disney, that focus on family centered cruising, and so will have a high proportion of families and young children as part of their passengers. Some cruises are also much longer than others, with cruises over six months becoming more common, and some cruise ships now consisting of passengers who have permanently brought cabins as their primary homes. All of which is to say, that numbers alone may not tell the whole story, and it is probably important to compare like with like.
NB Interestingly, as the recent Hantavirus outbreak did not impact 3% of passengers, I don’t know believe it would be reported via this system, and I suspect that they only manage US related outbreak numbers.
Outbreak Organisms (CDC list 2023 – 2026)
When you are training in microbiology, virology and infection prevention and control, you study A LOT of outbreak scenarios. Some of theses are almost always linked to outbreaks on cruise ships and/or navel carriers. Studies of re-supply and bringing in vegetables used for salads that took down 2/3 of the ship cohort with multiple organisms. I thought it might, thereofore, be interesting to look at the CDC data related to some recent outbreaks and see what the causative organisms actually are.
From 2023 – 2026 (to date) there were 54 reported outbreaks on the CDC website reaching the 3% of total passengers threshold. The causative organisms, where known, included:
Norovirus
Salmonella
E. coli
Combined Salmonella and E. coli
Now, I’ve previously posted about Norovirus, and how difficult it can be to control, especially the challenges of getting it out of environmental reservoirs (carpets, curtains, bedding) and so I’m not surprised that it is on the list.
I was interested to see how dominant norovirus was compared to other causes. When you look at the numbers it shows that norovirus really does seem to be as dominant as I was taught, with nearly 90% of outbreaks due to noro:
Norovirus: 48 outbreaks
E. coli: 4 outbreaks
Salmonella: 1 outbreak
Combined Salmonella and E. coli: 1 outbreak
Whilst noting that this feels like a lot of cases, it is also worth considering that the CDC states that cruise ship outbreaks account for just 1% of all reported norovirus cases globally. The other interesting thing is that the numbers seem to be pretty stable year on year, whereas out in the community I would expect there to be a significant rise in norovirus cases every 2 – 3 years, as strains change due to mutation, this doesn’t seem to be the case within the cruise data available.
Disney cruise line specific outbreaks
Having noted that Disney had only 1 outbreak listed recently on the CDC site, I thought I would investigate a little further. Disney Cruise Line has had two major officially documented gastrointestinal illness outbreaks that reached the CDC mandatory reporting threshold of 3% or more of passengers or crew, one in 2016 and one in 2002, each on a different ship:
Disney Wonder:
April–May 2016 (Official CDC Outbreak): During a 4-night Bahamian itinerary heading into a Panama Canal cruise, 131 of 2,680 passengers (4.89%) and 14 of 991 crew members (1.41%) fell ill with laboratory-confirmed norovirus.
Disney Magic:
November 2002 (Official CDC Outbreak): A total of 175 passengers and crew members out of 2713 passengers and ~950 crew, contracted norovirus during a Bahamian voyage. Disney temporarily pulled the ship from service for a week to break the infection cycle through a deep chemical sanitation.
Not all ships are equal
Something that struck me, is the outbreaks listed for Disney are to do with the two older ships in the Disney Cruise Line fleet, as they are both part of the Classic Class. This is interesting for 2 reasons:
Is there an accumulation of outbreak risk due to age? Especially for organisms like norovirus which can be linked to environmental reservoirs
The oldest 2 Disney Cruise Line ships were early custom Disney build and so lack some of the specific design features that may support risk reduction on the newer ships
To aid with understanding this, it is noteworthy Disney has built a number of custom ships since the production of the Classic Class, and therefore have had the opportunity to include many more custom features in the later classes of ships.
The Classic Class – purchased by Disney but built in a different ship yard and to a different design than the other ship classes
Disney Magic (1998) ~2700 passengers
Disney Wonder (1999) ~ 2700 passengers
The Dream Class – commissioned by Disney for Disney
Disney Dream (2011) ~4000 passengers
Disney Fantasy (2012) ~4000 passengers
The Wish Class – commissioned by Disney for Disney
Disney Wish (2022) ~4000 passengers
Disney Treasure (2024) ~4000 passengers
Disney Destiny (2025) ~4000 passengers
The Global Class – purchased by Disney but part built before acquisition
Disney Adventure (2026) ~6700 passengers
One thing I didn’t realise, until I started to investigate this area more, is that cruise ships need to go into dry dock at least twice in every 5 year period by maritime law. Obviously mostly this is to do with safety, linked to the hull etc, but most cruise lines will use this opportunity to re-fit and manage any fittings and soft furnishings, which can aid with managing ongoing outbreak risk.
Why does Disney Cruise Line have to do things differently?
Full disclaimer here, I haven’t been on cruise lines with anyone else, but I have done a lot of talking to people and watching videos to enable some comparison, but my only first hand knowledge is from what I have experienced. I have only been on the Fantasy, and there are other classes of ships, obviously if Disney Cruise Line would like me to travel on them all to do an infection control audit, I’d be happy to, they wouldn’t even have to pay me.
I think, from my experience, one of the reasons that Disney Cruise Line is different, and has to be different, is because of the passenger demographic they serve. Their passenger number contain a huge amount of children under the age of ten. Children who may be shedding high viral loads, and carrying asymptomatic infection. Children who may also be too small to be able to communicate how they are feeling when symptoms come into play, and who may also not be compliant with hand and other hygiene practices, and are likely to be in close contact with others when playing etc. The ships are therefore at higher risk, potentially, than other cruise lines of having significant spread once a virus is onboard. It is also much harder to be able to isolate small children, and they are much more likely to need clinical support if they become unwell, which is a risk to the child and logistically complicated to manage. It is therefore much better to invest in steps to prevent infection spread.
What does Disney Cruise Line say they do to prevent the transmission of infectious disease?
Disney consistently ranks in the top five cleanest cruise lines globally. Their fleet frequently achieves perfect 100 scores during unannounced CDC sanitation inspections. They also have an advantage as they are an independent fleet, they don’t rent their ships out to others for events or specialist cruises, where they would have periods of time where they couldn’t control their risk. This allows them to maintain control of their fleet, what activities are undertaken, and ongoing control methods. The ships are also on the smaller size in terms of passenger numbers compared to some of the very large cruise ships managed by other companies (~2,700 to ~6,700 guests compared to ~5500 to ~7600 on some other lines).
Below is what Disney Cruise Line states about how they control their infection risks:
Key Quarantine and Isolation Protocols
Mandatory Isolation: If you test positive for COVID-19 or another contagious illness during your cruise, you and your stateroom occupants will likely be required to isolate in your stateroom or a specially designated, safer area of the ship.
Medical Evaluation: Shipboard medical centers are staffed with experienced doctors and nurses to provide care, and you may be required to quarantine at the sole discretion of the shipboard physician.
Disembarkation/Evacuation: If necessary, you may be required to disembark early for medical reasons, which could occur in a foreign port.
Pre-Boarding Screening: While pre-boarding testing is not always required, all guests must complete a mandatory health questionnaire before boarding, which includes screening for symptoms like fever, cough, vomiting, or diarrhea.
Compliance: You are required to abide by all health safety protocols, which can change without notice, and failure to comply may result in denied boarding or forced disembarkation.
Stateroom Support: If you are required to isolate, Disney provides necessary support, including food delivery and medical check-ins.
Illness Prevention: The crew conducts extensive cleaning and sanitization of common areas and staterooms
Now, luckily for me, I didn’t experience any sickness onboard and so I can’t testify to the accuracy from all of these portrayals. I can, however, attest to many of other aspects, such as pre-screening, cleaning, and hand hygiene support.
Operational approaches
There were some brilliant operational choices that made me both happy and also surprised me. There were also some really simple design decisions, which now I’ve seen I don’t understand why they aren’t present everywhere. The best example of this was the way that plates on the buffet were stored upside down. This means that no one is in contact when taking a plate with the surface that someone else will then eat off. This is such a simple change but makes so much sense in terms of infection control I can’t believe I have neither thought about it myself or seen it elsewhere.
Other simple things included the fact that all cutlery was left fully wrapped, and so no one was touching the implements that anyone else was going to eat with. This fully enclosing, rather than just wrapping, is another easy way of prevention cross transmission routes, as asymptomatic, or even symptomatic excreters, are not in a position to pass on their organism to others. It also prevents deposition on cutlery from other routes, such as when people sneeze, effectively providing a protective barrier.
Self serve vs cast member led
Another key thing, on some ships, is that the buffet is served by cast members rather than self serve. This means that the food is kept behind screens and significantly lowers contamination risk. All main meals are served plated by cast members, which also reduces reduces the risk. Even self serve items, have guidance linked to risk reduction. For instance the fizzy drink dispensers advice people not to use reusable cups, so that the dispenser outlet does not risk re-contamination after someone has drunk from the cup.
Keeping hand hygiene easy
Something else, that is very prominent, is the emphasis placed on hand hygiene wherever you go onboard. Hand hygiene stations are conspicuously present with both adult and child height basins. Special sinks are also present in all the child specific areas that can help children with hand hygiene, as all they have to do is submerge their hands and the sink itself undertakes the agitation. This helps hygiene efficacy for children who younger or less engaged.
Multiple hand hygiene stations are available at the entrances to the buffet, and there are enough of them that no one should skip unintentionally because they haven’t seen them, or because people are off-put because of queues. Making hand hygiene easy and visible has been found to be key from healthcare studies, and I imagine cruise ships are no different.
Gatekeeping
At main dining room meals, in the evening, hand hygiene is actively enforced. As there are too many people entering the dining rooms at each sitting (as everyone eats at either early or late dining) Disney enforce hand hygiene by having crew members physically hand out hand sanitising wipes directly to each passenger as they enter the dining room. The same happens at the buffet at busy times. This is very different (from what I can tell) to other cruise lines and definitely contributes to risk reduction. Having these multiple points, every day, where hand hygiene is enforced really helps to impact the collective risk level onboard.
Bathrooms
Even the bathrooms pleased me, and not just because of the Mickey shaped mirrors. Having a feature that attracts people towards the sink does help with hand hygiene compliance, however. They also have signage on how to wash your hands by every sink, to encourage that it is done appropriately. Additionally, many have access to hand hygiene in areas after you have exited the bathroom door, to manage any exit contamination risk, as an additional option.
Domestic cleaning
Cleaning is obvious everywhere you go. I may have been the only person on that cruise who spent time photographing the cleaners trolley rather than the ‘big five’. All rooms got cleaned at least once a day, but in my experience many rooms got cleaned twice a day, as they get a morning clean and an evening turn down. Eating areas are also rotated and open at different times which allowed cleaning to be supported. Spending so much time auditing, I am often super aware of environmental grime, and no once was I brought out of the magic of being onboard by seeing anything that triggers my IPC brain.
Cleaning trolleys have freshly made up cleaning solution, alongside cleaning wipes. Fresh cloths and easy access to gloves. The level of cleaning we experienced was immaculate, and this does seem to align with the CDC audit scores.
Pre boarding
There are steps taken to reduce risk, however, before you even get on board. Disney Cruise Line requires all guests to complete a mandatory, online health questionnaire on the morning of embarkation, typically arriving via email between 5:00 a.m. and 6:00 a.m. The is pretty brief and asks a series of “Yes/No” questions regarding recent fever/respiratory symptoms, gastrointestinal issues, and pregnancy status (specifically for those 24 weeks or more). Although not infection related the pregnancy question is an interesting one and often catches people out. Disney, like many cruise lines, won’t let women sail if they are over 24 weeks pregnant. This appears to be standard across the industry because , if a medical emergency or preterm labour occurs, ships do not carry the specialized equipment or staff required to safely manage delivery or provide neonatal care for a premature infant.
If you reply in the positive to any question, other than the pregnancy question which is an immediate no board, then you will usually be reviewed prior to boarding and a risk assessment performed.
During cruising
If you develop symptoms of any kind, once you are onboard, there is support available from the medical team. It may be hard to distinguish between gastrointestinal symptoms and sea sickness, and everyone is encouraged to flag anything in order to ensure the right risk review is undertaken. If it is felt to be an infectious cause, passengers will be asked to isolate, and enhanced cleaning is undertaken.
Not only is hand hygiene reinforced during signage, by telling you not only how but when to wash your hands, it also clearly flags that you should contact medical support staff if you experience symptoms, and helpfully even flags what they are. All of this means that they are multiple contact points every day where passengers can access information that may be helpful in reducing infection risk (also, how clean are those tiles).
During excursions
Hand hygiene is also enforced after excursions before you get back onboard the ship. Alcohol gel dispensers are brought out by the crew, and cool towels, as well as water, are available to aid passengers stay cool and hydrated. I’m sure if you were in colder climes these would be aimed at warming you up.
Signage is also placed outside of disembarkation points that can help guide whether special measures may be needed or advised before you start on excursions. I think most people are more concerned with COVID still than norovirus, whereas I am very much concerned about diarrhoea and vomiting as part of my ship board experience.
Visible prioritisation
In general the communication of the need for hand hygiene is ubiquitous onboard. The signage below was part of the display in the lifts on the Fantasy. Embedding this guidance, and having it reinforced by cast members, means that for the most part everyone just complies without the need for prompting. I suppose it should be no shock that Disney do communication well, so much so I think there are some things we could learn in hospitals about how it is approached.
Design led solutions
The other area that healthcare could learn from is some of the design based solutions. We obviously have a lot of hands free options in healthcare but it was great to see these design points across the ship to minimise areas where hand contact is concentrated by needing to touch single points. A lot of thought has been given to pinch points in the system, and actions like manually supporting hand hygiene using wipes really also helps to address these.
Things I still can’t get over
Having talked about everything I loved, there is one thing that I don’t think I’ll ever get over, the people soup that are shared spa pools. The idea of sharing warm bubbling water with strangers and imagining our shared bacteria growing is something I can’t get passed. Also, I need to see the Pseudomonas testing certificates. This isn’t a Disney specific aversion, I just don’t think I can get my head around them anywhere. Nothing is perfect.
Where can I learn more?
I was taking on my cruise as a surprise, but Mummy and Mr Girlymicro has done a LOT of research before we want, so much so they even had to delete their YouTube histories so I wouldn’t notice. All lines have different risks, so I would advise doing some research to see which ones have risks that you are prepared to engage with. For me, I’m a Disney girl and I’m yet to see information from any other cruise line to temp me into doing something different. What can I say, I’m a convert to cruising, but only under a very specific set of parameters, and if Disney ever need infection control support, all they have to do is call me.
If you want to learn more, or check out your own cruise line of choice, the CDC website that contains a lot of info:
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:
Good personal hygiene (artist and client)
Effective cleaning
Separating clean and dirty materials
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
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.
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!
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.
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:
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.
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.
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.
It’s Halloween weekend, and in previous years I’ve talked about all things Zombie and infection transmission. This year, though, I thought we talked about something a little different, infection control precautions through the lens of the Alien movie series. Most importantly, I’m going to talk about those initial interactions with the unknown that we frequently see in both these movies and in infection prevention and control (IPC), and whether we too would open the door when someone presents at the air lock?
Spoiler warning! This post is going to mention things that happen in various Alien movies. If you haven’t seen them it may, therefore, contain spoilers – the best way to deal with this oversight in your viewing (if you are concerned) is to just get out there and watch them as Alien is the same age as me 😁
This post was inspired by watching Alien Romulus again this weekend, which, if you haven’t seen it is the best Alien movie in forever.
In preparation for the cinema release I also did a re-watch of a number of the movies in the franchise. Just in case you are less familiar, and inspired to do the same, the list includes a variety of films in different sub-genres as listed below:
Whilst watching these I was struck by a number of moments that made me think about behaviours during the pandemic, but also tales of heard of some activities that occurred during the response to the Ebola pandemic and other high risk clinical settings. Not all of these moments would have been massively out of place, in terms of parallels with these films, and demonstrate that both risk assessment and clarity of thinking can be impacted and lead to responses outside of what would be normally expected.
The thing to remember is that there are usually protocols for just about everything, so most of the decision-making should occur and have been thought out long before the situation ever arises. The problems are almost always linked to human factors in the way we respond to stress and unexpected situations, and when the protocols appear to go out the window. So, just like every character and every space ship in the Alien franchise has a protocol for how to behave when they encounter new life, strange situations or sick crew members, every healthcare facility also has protocols to help deal with illnesses we see less often or that get issued when new diseases are encountered. Healthcare facilities may not have air locks, but they do have labs and isolation facilities, so the parallels may be more present than you’d imagine.
Infection is not always obvious
One of the first themes that recurs throughout all the movies is that infection is not always obvious, either to those on the other side of the air lock, or to the individuals outside waiting to come in. Infection with the parasite sometimes occurs when the stars of our show are unconscious, be that due to trauma or medical interventions, and so they are unaware of the Facehugger on character action that has occurred.
In terms of IPC the same if frequently true, both for viruses and bacteria. Some viruses have what is known as a pre-symptomatic phase, where you are infectious to others before you even know you are sick. This was a big problem in the early stages of the SARS CoV2 pandemic. Even for bacteria, when we talk about antibiotic resistant bacteria, most people are colonised and have the potential to act as silent sources without even knowing it, with only small numbers going on to develop infections.
The truth is not always apparent
Even when an individual knows that something has happened, and are aware of their close encounter with Alien kind, the truth of their scenario may still not be apparent to either them or to others. If you look at the Facehugger situation, surely once the terrifying creature has dropped off without apparent poor consequences, then everyone breaths a sign of relief and is grateful for the near miss, not knowing that this is only the beginning. When you combine this with the fact that some people will determine this to be a low risk event and therefore not want to disclose, as they are aware of the inconvenience that will result, you end up in situations where not all the information is available.
This can also be true in real life clinical situations. Patients may not know they have been exposed. Patients may also present with symptoms that they haven’t recognised as significant, or that they have risk assessed themselves and decided they aren’t concerned about and so don’t disclose. This can happen more easily they you think, especially at the start of something, where patients don’t feel particularly unwell, or they just have a couple of vesicles/small rash. In the latter stages, when patients are presenting because they feel unwell, they may be confused or not always able to accurately disclose what’s happened. Occasionally, this may be a deliberate attempt to withhold personal details, but most often it’s because they are rightly focussed on how they are feeling in the moment. Plus, if you asked me to accurately recall everyone I met and everything I ate a week ago, I’m not sure I could, even when well.
By the time you realise the condition is a threat it may already be a risk/out of control
One of the consistent themes across all of the movies is that situations get out of control before anyone truly understands the situation and the risks. It’s only when the person that you breached protocol for suddenly starts to writhe and the horror stands before you in all its glory do you truly understand the implications of the decisions you’ve made. At that point you are trapped in your glass med bay with a growing Alien and your self recriminations are not going to save your life.
This one is a rather more dramatic version of some of the conversations that happen amongst healthcare workers when you phone to give results and have conversations about whether patients had been in the right precautions and the staff member was wearing the right personal protective equipment (PPE). There have definitely been times when staff have made a risk assessment and not followed the protocols about what PPE to wear and have then responded to these phone calls with ‘what can you do?’ in relation to the exposure. Sadly, in some cases there is nothing that can be done once the guidance has been bypassed but to wait and see, which is the reason for the guidance in the first place. Fortunately, for most scenario’s in the real world, the consequence isn’t bloody horror, death and an alien threat to mankind.
Risk assessment is linked to risk management
One of the reasons that protocols are in place in the Alien movies is that someone, somewhere, has obviously recognised the risk of infection in a small contained community where everyone interacts and lives on top of each other. Even in Aliens, when you’re talking about somewhere the size of a colony, this principle stands. This is because you are unlikely to be able to access a clinical trial on a mining ship, or develop a novel antiviral on terraforming mission, even if what you’re importing is a more traditional style of infection, versus an Alien parasite. The extent of the risk mitigations needed will always align to the risk itself. If you are concerned about an introducing something that is untreatable, then your measures are going to be much more extreme than if your infection is likely to just mean someone goes to bed and takes paracetamol for a weekend. If you can’t treat, then prevention is your only option. After 9 movies there doesn’t appear to be a Xenomorph (Alien) cure and so measures taken to prevent allowing one into your space need to match the risk they present.
This approach is definitely seen in response to infection in IPC. If you have a condition that spreads easily, rapidly and can be incapacitating for a period (i.e. norovirus) then you will use a different set of precautions to those that you use to manage something which may not be as transmittable but is untreatable or has life threatening consequences such as a haemorrhagic fever. Having conversations and being open with people about the risks of getting things wrong and ensuring that individuals understand why responses are different in different circumstances are a key requirement for people working in IPC, and something I think we should all endeavour to do better at. I think the days of asking people to blindly follow protocols should probably be behind us, as I think the Alien movies demonstrate that if people don’t get the why, they often ignore some of the core components based on external drivers
So, what lessons can we learn?
Beware of acting on incomplete information
Decisions are consistently made in these movies based on incomplete information, which leads them to underestimate both risk and consequences. A great example of this is the way people use information related to the black goo, especially in Alien Romulus, maybe don’t inject yourself with a substance that doesn’t have a proper name let alone a full data set for you to understand what it does. The other thing is that information is often treated as static, and so there is very little rapid inclusion of new info, rather than being mindful of an iterative response to new data, so help constantly inform and improve your risk assessment. It’s always worth being conscious of when is enough is enough when it comes to information and decision making.
Emotions get in the way of logic
During the movie Covenant, the entire crew is made up of couples. I get this in terms of colonisation, but in terms of good decision making, and in relation to risk this is just a one way route to bad outcomes. There’s a reason that in a certain Zombie series husbands have kept their zombie wives locked in basements rather than removing the risk to them and others. There’s a reason medical professionals should not manage their loved ones. Emotions interfere with logic, and there is no way under this setting you are managing to make decisions without your emotions getting in the way. It’s a reminder that if we become aware that we are in an emotive place, it may be the time to step away and take a deep breath, before making that judgement call or even tap out entirely and allow someone more removed to take our place.
The contrast between human emotional decision making and evidence based decision making, usually undertaken by the android cast, is beautifully explored during Romulus via Andys story arch and is one of the highlights for me in terms of enjoyment.
Science doesn’t change based on how much you wish the outcome to be different
One of the reasons that emotional involvement in decision making can be so challenging is that it can interfere with perspective and accurate interpretation of risk, thus impacting risk perception. Sadly the truth that wishing does not impact outcomes is hard to argue with, but it is human to try to persuade ourselves we have more control and ability to influence the outcome than we do. Under stress, our natural tendencies towards pessimism or optimism are definitely amplified. All of this means that when there is someone at the door banging and begging to be admitted, it is easy to persuade ourselves there is a) enough time to manage to open the door safely and b) the consequences of opening said door will not be as bad as we fear. Emotions don’t change outcomes but we are almost programmed to hope that they can.
An individual will always want to be the 1 in a million
The reason someone opens the door is the same reason that when one character looks at another and utters the fateful and true words ‘it’s too late’, and it almost definitely is, neither one acts before everything gets out of control. Humans are not good at dealing with numbers and risk when they are actively involved in the situation. One of the reasons we aren’t in that we throw sentences around saying it is a 1/million chance. We, as humans, have a tendency to focus the fact that, although it is a long shot, there is a chance that things can go your way. Sadly, as someone who has experienced the opposite, where my sister died in a 1/10,000 pregnancy, someone always need to be the one. The stats work both ways, whereas most of us survive in the world by only focussing on one side of the equation. This therefore impacts our capacity to evaluate any risk in situations we are involved with. Somebody always bears the cost and few of us can bear the vulnerability of acknowledging that that somebody could be us.
The people with the most experience are not always the ones making the decisions
One of the other main themes in these movies is that decisions, when not being made by friend and loved ones, are often being made by people in positions of power, not necessarily based on knowledge or even accepting of prior experience. This works well or not so well based on how well they listen to those who do have the information to help improve their decision making. Chains of command, especially in high stakes scenarios, are not necessarily bad, as we’ve already talked about the risks linked to emotional decision making, but so much depends on how well they work and how they place value on evidence based choices rather than hierarchy.
The other theme here is the trusting of unknown sources, especially ones with no evidence of expertise, over those who have either lived experience or expertise. I think this one resonates a lot right now, when there are so many sources of misinformation out there, and so many conspiracy theories that rely on speculation and rumour. Fact checking is key, be that on a space ship or deciding on your vaccination options.
Not everyone has the same thought processes
One of the other reasons decision making goes astray in these movies is because those involved in that decision making often have undisclosed values, beliefs or drivers that are impacting their choices, and this process is not always obvious to those others involved. This is true from androids that may or may not be obviously androids and who will have programmed ‘primary directive’, as well those working for the corporation. This is interesting as they often have more complete information than the others involved, as well as seeing the situation through a different lens because of how they view the world. This means that they can see others as disposable or views risks different, as they have a set of criteria that they wish to achieve which is more than just survival. Although in clinical life the juxtaposition is rarely so extreme, the challenge of reaching alignment when people come with different world views can definitely impact shared decision making.
Smart people can do stupid things
Having said all of that, smart people can in general do stupid things, even without all of these complications. Even when the experts are the ones making the decisions they can still make the wrong ones, especially when tired, stressed, or lacking all the information. This is the reason why protocols are key, drawn up and decided upon when all of the confounders to good decision making are not present.
You need to follow the standard operation procedures
In the end this entire post has been a very very long way of saying ‘JUST FOLLOW THE SOP!’
Many of these movies but have been much shorter with a much reduced body count, if those involved had just followed the pre-established procedures laid down for their safety. Obviously, we don’t have so many Xenomorphs as a daily risk factor in healthcare, but the same is true for us. SOPs are rarely there for the sake of it, they are there to support decision making so that in times of stress or information overload, you are not having to seek extra information to support good decision making, you have it freely pre-digested and available to you. So the next time you think twice about donning that PPE or the closing that isolation room door, ask yourself ‘would you open the airlock door?’, think twice and do the right thing.
And now for something completely different
Finally, because this is something that has amused me whilst watching these films and is probably not something that I can talk about in general down the pub. The computer in the Alien movies is usually referred to as Muthur, pronounced Mother. I just want to share my joy that the analysis software that is used to help analyse 16S rDNA runs, to give you microbiome analysis i.e. tell you what bacteria are present in your sample, is called Mothur, and also pronounced Mother. I’m sure the two things have nothing to do with each other, but allow me my scientific joy that something which was so ‘other world’ when it came out to me as a scientist has the same name as something imagined from ‘another world’.
Also, if anyone needs a science advisor on their next project, give me a shout as this post has brought me much joy and I think I may have missed my calling 🙂
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!
