January 15, 2021

I just took a coronavirus test at work. On my way into the building to get it done, I was asked to sanitise my hands. Then, just before I took the test, the guidelines informed me I should sanitise my hands again. After swabbing my tonsils and inside my nose (thankfully in that order, since it was the same swab), I checked the guidelines for what to do next. Guess what? “Sanitise your hands”.

The result came within 30 minutes — negative (phew!). It was accompanied by a text informing me that I should keep following the advice on stopping the spread of the virus. Top of the list: “regular handwashing”.

Okay, okay, I get it — I should be cleaning my hands. Clearly someone thinks handwashing is among our most potent weapons in stopping the spread of the virus. But is it?

Before I answer that, let’s see what the general public knows about the spread of the virus. A Savanta poll of 2,331 representative adults in England, carried out last week, included three questions on this topic. The first asked what the participants thought was “the single most common way that COVID spreads”. The results were as follows:

  • 16% said the coronavirus was mainly spread by “touching objects that have the virus on them”;
  • 46% said it was mainly “being breathed or coughed on by someone who has the virus”;
  • 28% said it was mainly “breathing in the virus that is floating in the air around you”.

Of the remainder, 1% said it was “something else”, and 9% said “none of the above” — it’s possible this is the fabled Lizardman Constant, where you can always rely on some small percentage of people to report bizarre views in a poll. (Either that, or they think Covid mainly spreads via the faecal-oral route.)

There’s good news and bad news from this poll. The good news is that a lot of people are aware that the virus can be spread by droplets — expelled in breath or in a cough — and that it can also be suspended in the air. But the absolute numbers are worrying — if 16% of the population think the main way the virus spreads is by “fomite” transmission (the technical term for touching objects or surfaces with the virus on them) that’s an awful lot of people who have it dangerously wrong.

Dangerously wrong because, amid much uncertainty —and despite the relentless messaging on handwashing — one thing that’s become very clear about the coronavirus is that it doesn’t spread much by fomites. Researchers have been hard-pressed to find many examples of outbreaks that can be traced to a contaminated surface (there are only a couple of possible exceptions). The Centres for Disease Control in the US have relegated this type of transmission to near the bottom of the list on their “How Covid Spreads” page – just above “catching it from your pet”.

At the beginning of the pandemic, the UK government took up handwashing in a big way (you’ll recall all the exhortations to sing Happy Birthday twice while scrubbing away). Back then, it was understandable: we were completely in the dark on how the virus spreads, and were modelling our response on diseases we knew better, like the flu. But nearly a year later, handwashing and hand sanitiser are still at the forefront of the advice – and “hands” is still the first item on government broadcasts on posters and elsewhere. Science has downgraded the importance of fomites — so why does our messaging still feature them so prominently?

Don’t take my word for it. Another question in the poll asked what coronavirus-related advice people had heard most from the Government in recent months. Here are the numbers:

  • 25% had heard most about handwashing;
  • 2% about sanitising surfaces;
  • 38% about wearing a mask;
  • 28% about keeping 2 metres apart;
  • and 5% about avoiding unventilated indoor places.

Although the mask-wearing numbers are encouraging, the rest doesn’t look great. Fully 27% of the population of England thought the Government’s main focus was on handwashing and surface-cleansing, and a mere 5% thought they’d been aiming the messaging at airborne transmission.

A third question described the scenario of a plumber visiting the respondent’s home, and asked them what they’d do to stay safe from the virus. The least popular response was “open as many windows as possible” — handwashing and surface-sanitising were both about 8 percentage points more commonly-chosen.

There’s still debate over the proportion of Covid cases that are due to larger droplets versus smaller, floating airborne particles (also known as “aerosols”). But the scientific consensus — and it’s really been quite clear since early 2020 — is that the majority of Covid cases are spread in these two ways – not by touching things. If the virus is airborne, it could defeat the strategy of staying 2 metres apart, since it can waft through the air to infect people much further away. Keeping rooms well-ventilated seems, in theory and in practice, to be a way to reduce risk; but the polling we’ve seen above — as well as lots of anecdotal evidence about office workers still sitting in closed rooms with their colleagues all day — suggests that much more work is needed to get this message across.

There are some tentative signs that the UK’s messaging is improving, but progress is incredibly slow. In November, TV adverts appeared that encouraged the opening of windows to allow fresh air into — and the airborne virus out of — rooms. But it took the NHS until early January 2021 to update their advice website to mention fresh air — and even then it’s at the bottom of a list of eight bullet points, six of which are related to handwashing (one is “wash your hands as soon as you get home”, a vestige from the first halcyon months of 2020 when most of us weren’t at home all the time).

The Government is similarly sluggish: even after so many months of learning about airborne transmission, guidance for the current national lockdown on January 4 was published that hardly mentioned it (only updating it with a paragraph on ventilation nine days later). Compare all this with Japan, whose government posted advice in March 2020 on avoiding the “Three C’s” – closed spaces, close-contact, and crowds.

As well as it lagging behind our scientific understanding, there’s another problem with sticking to the same old Hands/Face/Space slogan. It’s that guidelines can ossify over time: eventually, people only follow the letter, and forget all about the spirit, of the law. In this case, the spirit is that we need to keep away from people to the greatest extent possible, especially in indoor, poorly-ventilated places, because the virus is in the air. But the letter says “you need to remain a very specific two metres away from others”.

What else but unthinking letter-following could explain the now-infamous coda to the Queen’s 2020 Christmas Broadcast, where the Lewisham and Greenwich NHS Choir performed a version of “Joy to the World” while indoors, unmasked – but carefully standing two metres apart? The rules were being followed meticulously (I bet they’d all washed their hands, too) – and yet the example set was deplorable. Joy to the coronavirus, maybe, but not to the world.

Bleaker still, a volunteer vaccinator reported this week in UnHerd that elderly and vulnerable patients who had come in for their vaccine were being sat in unventilated, busy rooms before and after receiving their jabs — potentially putting them at risk of airborne transmission. When asked about this at a press conference, the medical director for London responded that, well, masks and hand sanitiser were available, so there’s no problem.

None of this is acceptable. Belatedly adding paragraphs and bullet-points to lengthy advice websites is an unimaginably timid response to an urgent situation. Endlessly repeating an outdated slogan is unforgivable now that the science has moved on. Airborne transmission isn’t an afterthought — it might even be the main way the virus spreads. It’s time to break the inertia, and change the message altogether.

Apparently we’re about to see a new round of “shock” Covid adverts from the Government (among the candidates is one that says “don’t let a coffee cost a life”). There’s definitely a place for so-called “fear appeals” in advertising, but I hope that some focus will also be on explaining the mechanisms of how the virus spreads. Because of droplets, being close to others or in crowds and being unmasked are bad ideas. Because of airborne particles, being indoors at all with poor ventilation is a risk too. Focusing on why we think these are dangerous — for instance, because we’ve traced lots of cases to these kinds of scenarios — would hopefully help people see beyond the slogans and act accordingly.

We needn’t wash our hands entirely of handwashing. But since everyone has a limited attention span, it can’t be right that so much of our messaging revolves around soap and sanitiser. As we all await our vaccine, a renewed advertising focus on droplets and aerosols could help people truly understand — and more effectively avoid — the virus.