A feature article in the Nov issue of Perspectives in Public Health written by Professor Sally Bloomfield (IFH) discusses how confused we have become about our microbial world, and why this needs to be urgently addressed. On one hand we are told we need exposure to microbes to build a healthy microbiome in our gut, on our skin etc., because failure to do so is an underlying cause of rising levels of diseases ranging from allergies to diabetes to depression - although not, as many people believe, because of obsession with cleanliness. On the other hand we are told we must not relax standards of hygiene which is a key part of the strategy to tackle the global problem of AMR by reducing the need for antibiotic prescribing. The paper outlines the results of an online poll of 2000 people carried out by the Royal Society for Public Health which suggests that we are no longer clear about what “being hygienic” means and how hygiene is different from cleanliness. The paper suggests that the problem is not complacency. The poll showed that 98% of those polled acknowledged the importance of hygiene with 50% agreeing that poor hygiene contributes to antibiotic resistance and 74% believing that hygiene is important to reduce pressure on the NHS by preventing ill health. The 2019 UK Action Plan on AMR says “Health & social care providers can only do so much; when it comes to preventing infections, the public have a huge part to play” But it seems we need clearer advice about what hygiene means in our daily lives if we are to play our part. The paper suggests that the best way to manage everyday life risks is through targeted hygiene, which means cleaning at the times that matter – when harmful microbes are most likely to be spreading. If we can do this immediately, the risk is contained. The paper identifies 9 risk moments in our everyday life where practising hygiene is particularly important:
- During food handling.
- Whilst eating with fingers.
- Using the toilet and changing a nappy
- Coughing, sneezing and nose blowing.
- Touching surfaces frequently touched by other people
- Handling and laundering ‘dirty’ clothing and household linens
- Caring for domestic animals.
- Handling and disposing of refuse.
- Caring for an infected family member.
The RSPH poll looked at people’s beliefs about infection risks to see how this affects their actions. On one hand, there was relatively good awareness of risks associated with not washing hands after handling raw meat (76%) and after using the toilet (57%) which correlated with over 70% of people saying they always did so at these important times. But it seems that the presence of “dirt” is still a predominant risk indicator with 72% of people saying it is important to remove harmful microbes from the toilet and 79% of people said it was very or fairly important to remove harmful microbes from floors, both of which are traditionally regarded as dirty places. To achieve change, an urgent need is to change public understanding of hygiene. We need to blow the myth about being “too clean”. This fake news has persisted since the hygiene hypothesis was proposed in 1989. We now know that the exposures children to protect against need are not infectious diseases, but microbes we share with friends and family and our natural environment. Loss of exposure to these essential microbes is most likely due to lifestyle changes such as smaller family sizes, less outdoor activity, C section rather than natural childbirth and bottle rather than breast feeding. If home cleanliness is involved, its impact is likely to be small relative to these other factors. The other key issue we must address is getting people to understand that the most effective way to protecting against infection is by practicing good hygiene at key moments to break the chain of infection. The bottom line is that if we don’t also take steps to change public understanding of microbes in their modern world and dispel prevailing myths, the impact of investment in hygiene promotion will not be realised.