From our recent survey it’s become clear that we are now more favourably disposed to working online or by phone than we were at the start of the pandemic. Most of us who were working face to face, however, seem desperate to return to business as usual. But is it safe? If not now, then when?
After this blog, we’re done with COVID-19. To our great relief, and perhaps to the relief of regular readers too, this is the last time we’re going to mention the topic.
DISCLAIMER: Within this blog we are outlining a recognised framework for conducting risk assessments and applying this to question of when and under what circumstances it may be safe for us to resume seeing clients face to face. It is not comprehensive, and is intended as a guide only, rather than definitive advice. It is your responsibility to make the final judgement, in the context of the risks that are currently known, and those that can be reasonably foreseen.
The Health and Safety Executive (HSE) provides a simple five-point framework for assessing and managing risk in the workplace. I used to work for a union, and have previously managed a service, so I’m familiar with its principles and also its application.
The five steps within the HSE’s framework are:
Identify the hazards
Decide who might be harmed and how
Evaluate the risks and decide on precautions
Record your significant findings
Review your assessment and update if necessary
Whether we work as sole practitioners from our homes or elsewhere, or are employed in service settings, we each need to adopt a rigorous approach to assessing the risks of resuming face to face work. Personally, I’m struggling to get beyond stage 3 of the above framework: evaluating the risks and deciding on precautions. My basic problem is this: the more I learn, the more I feel there’s too much I don’t yet know enough about in order to feel safe.
Within this blog we consider some of the things we think we know, and some of those we don’t. We hope these deliberations may be helpful in your own assessment. It would be impossible to highlight every known and foreseeable risk, but we’ve made a start on which we hope you can build. Bear in mind that the picture is developing on an almost daily basis, so what may be true at the time of writing may not be true when you read this.
We’ve considered two main areas of risk:
General risk factors that apply to us all
Specific risk factors connected to our occupation and the environments that we work in
The factors that we’ve considered are not a definitive list, and you’ll certainly have your own to add to them. Let’s get started.
1. What is the general risk of infection that we all face?
In this section we look at the development of the pandemic in the UK and policy and public health responses to date, as well as what is currently known about our general risk of contracting the virus. We need to ask ourselves if the measures taken to date, as well as those proposed, should now give us confidence that the virus is being contained and will continue to be so.
In South Korea, Patient One was detected by a thermal imaging camera on her arrival at the airport, fresh off a flight from Wuhan. She was immediately whisked away to isolation. Despite a calamitous outbreak linked to the secretive Shincheonji Church, South Korea has limited its death toll to 269.
As of now, at 37,837, the UK has the second highest COVID related death rate in the world, second only to the US. We have the fifth highest rate of deaths per million of the population behind San Marino, Belgium, Andorra and Spain.
The UK went into full lockdown on 23 March, on the same day as Germany, and one day later than Greece. To date Germany has recorded 8,570 COVID related deaths, and Greece 175. In virus time, Germany went into lockdown after 86 reported deaths, the UK after 359. Analysis broadcast on the BBC’s More or Less programme has estimated that had the UK gone into lockdown just one week earlier, our current death toll would now stand at only 25% of the current level.
The first person to test positive for the virus in the UK was a businessman from Hove who likely contracted the virus at a conference in Singapore. He returned to the UK after a ski break in the French Alps. In all he is linked to at least nine further confirmed coronavirus cases.
At that stage significant efforts went into tracing and isolating this individual’s contacts. This may have contributed to Brighton and Hove now having one of the lowest rates of confirmed cases by local authority area in the UK, at 149.5 cases per 100k of the population. Among local authorities in mainland UK, highest is Rhondda Cynon Taf at 655.1 per 100k and lowest is Ceredigion at 57.5 – a ratio of more than 11:1. You can find details of your local authority area here.
In the UK anyone over five years old with symptoms is now eligible for a coronavirus test. But while knowing the number of confirmed cases in a given area is helpful, it is not the same as knowing the real degree to which the virus is circulating in that community. Confirmed cases are likely to reflect the extent of circulation, but there will always be a lag.
We’re beginning to understand just how infectious the virus is, and how a small local outbreak, left unchecked, can rapidly escalate. Spikes in infection rates have been noted, for example, that seem to be associated with major outdoor sporting events, examples being the Cheltenham Festival and Liverpool’s Champions League match against Atletico Madrid at Anfield on 11 March.
New clusters of infection are constantly testing efforts to keep the virus contained. In South Korea, the capital’s metropolitan area, home to half of South Korea’s 51 million people, has been placed under fresh lockdown which will remain in place until June 14. In Spain, an outbreak occurred in Catalonia after 20 people ignored lockdown rules and gathered for a birthday party. Four had the virus and ended up infecting the other 16.
Track and trace was effectively abandoned in March and is only now being revived. The new system, albeit without the app that was supposed to a central part of it, was launched yesterday. Serco, one of the private sector firms appointed to run the system, didn’t get off to a good start when it recently shared the email addresses of 300 contact tracers in breach of data protection rules.
An editorial published in the British Medical Journal on 15th May 2020 described the UK’s response to the pandemic as “too little, too late, too flawed.” At the recent bank holiday weekend, we saw worrying pictures of people crowded onto beaches around the UK spectacularly failing to maintain social distance. We’ve also had the spectacle of the Prime Minister’s chief adviser failing to show any contrition for flouting the regulations designed to promote our safety.
It is clear the virus isn’t going away any time soon. Neither is there a guarantee we will ever find an effective vaccine against it. Covid-19 may join the list of viruses which includes the common cold, Sars, Mers and HIV for which a vaccine remains to be discovered.
In yesterday’s Downing Street news conference, the Chief Scientific Adviser to the Government Sir Patrick Vallance reminded us that we still have a significant burden of infection. Looking at the numbers, in England there are over 7,700 new infections each day. That compares with Germany, which has 400 – 600, and France, with 200 – 400.
Soon, for the first time since lockdown, we will be able to gather in parks and gardens in groups of up to six in England, and eight in Scotland. Some schools will begin to reopen from June 1st. An Ipsos MORI poll reported on this morning puts the proportion of people that think we are moving too quickly into lifting lockdown restrictions at 54%.
This is the context in which we are operating in the UK. Given the catalogue of missed opportunities to date, the current state of testing, tracking and tracing services, and the prospect of restrictions being further lifted, how confident do you feel about the prospect of resuming face to face work?
What are my risks of contracting and transmitting the virus?
The risk of contracting any virus would appear to depend on two factors: the level of virus to which we are exposed, and the length of time we are exposed to it. Successful infection = exposure to virus x time.
The minimal infective dose is defined as the lowest number of viral particles that cause an infection in 50% of individuals. Based on what is known about this and other coronaviruses, it’s been estimated that the number of virus particles required for infection may be in the high hundreds or low thousands. Let’s say 1000 – 1500 for convenience sake.
While there have been significant outbreaks of infection connected with outdoor events, the majority of outbreaks seem associated with indoor environments, confirming “that sharing indoor space is a major SARS-CoV-2 infection risk”.
People may be infected by respiratory droplets / exposure or what is known as fomite transmission, that is, via objects or materials which are likely to carry infection, such as clothes, utensils, furniture, doorbells and handles, keypads, shared office equipment and so on. The latter route is perhaps more obvious and easier to control for. For therapists working face to face, however, the risk from respiratory droplets / exposure is perhaps less well known, but something that we need to be equally concerned about.
Picture this. You’ve recently resumed seeing your face to face clients once again. You’ve instigated a rigorous cleaning routine that takes in all surfaces with which the client might come into contact. You’ve made clear your mutual responsibilities to hygiene and what happens in the event that either of you displays Covid-19 like or other respiratory symptoms. It’s a sunny day at the height of the pollen season. You’re in your counselling space and your client is unable to suppress a sneeze.
I don’t wish to be alarmist, but it’s going to happen.
One of our most basic problems is the incubation period of the virus. The average incubation period seems to be around 5 days, but may be up to 14. We and our clients may not have any clue that we are infected until two weeks have passed.
According to one estimate, each cough or sneeze may contain as many as 200,000,000 (two hundred million) virus particles which can be dispersed into the environment around us. The sneeze may release around 30,000 droplets, with droplets travelling at 200 miles an hour. A cough, 3,000 droplets that may travel at 50 miles an hour. The smallest of those droplets may hang in the air, in aerosol form, for several minutes.
Viral transmission needn’t require a cough or a sneeze. An infected person talking, even breathing, is shedding virus. Breathing may shed 20 viral particles per minute into the environment, talking, 200 particles per minute. According to this rather graphic 3-D simulation an infected person talking for five minutes in a poorly ventilated space can produce as many viral droplets as one infectious cough.
They won’t all come your way, but some will. If every virus particle were inhaled, it could take around five minutes to receive an infectious dose. We’re usually in rooms that are enclosed, sometimes with limited ventilation, for around 50 – 60 minutes on average. Face masks or so called ‘face coverings’ may help, but they will not eliminate the risk of transmission, as the simulation on the image linked below shows.
As time goes on and we learn more about the virus and its effects, a range of ever more alarming symptoms emerge. These include blood clotting, apparent in 20 – 30% of critically ill patients, and which may disproportionately affect black people, according to emerging evidence from the US.
Let’s put things in perspective. Generally speaking, unless we’re careless, complacent or just plain unlucky, we’re unlikely to come into contact with someone who has the virus. As I’ll argue later, however, the nature of our occupation carries with it risks of both contracting and transmitting the virus which we would be unwise to ignore.
Assuming we’re not self-isolating or being shielded, we’re likely to be spending at least some time out of our homes, be it food shopping, exercising, or lying on the beach. Right now, we have no way of knowing who, of those we come into contact with, may have the virus. And the likely truth is, neither will they.
Estimates of the proportion of people with the virus who remain asymptomatic vary between 25 – 70%. Another study has estimated that people with no symptoms were the source of 44% of diagnosed Covid-19 cases. It’s also thought that people might be at their most contagious during the period before they have symptoms.
As the restrictions to movement and mixing are lifted, it’s inevitable that there will be further waves of infection, as we’ve already mentioned. We have to hope that the as yet untested new system for tracking and tracing new outbreaks is agile enough to stay on top of outbreaks.
2. What are the specific risk factors connected to my occupation?
The short answer is it depends. Our work involves being in close proximity to clients in a relatively enclosed space for close to an hour per client. As we’ve seen already that level of exposure to someone who is infected (whether or not we or they know it) seems to carry a significant risk of infection.
Based on a US study, data from the Office for National Statistics (ONS) puts into context the risk of exposure to disease for a range of occupations. The US data is drawn from the Department of Labor, Annual Population Survey and Annual Survey of Hours and Earnings. It asked respondents two questions:
How physically close to other people are you when you perform your current job?
How often does your current job require that you be exposed to diseases or infection?
A post on the BBC website enables a search of the data by occupation. In terms of frequency of exposure to disease, counsellors were ranked at 39 of 359 occupations, one being the highest level of exposure. In terms of proximity, counsellors rank lower at 157. We rank exactly the same as social workers on both indices, and significantly lower than, for example, police officers and nurses.
One thread in particular caught my eye: “But the people who might be most at risk to a new infectious disease like Covid-19, are those who have lots of close contact with people but aren’t used to being exposed to disease. Bar staff, hairdressers and actors fall into this category, as well as taxi drivers and bricklayers.” To that list we might also add ‘counsellor’.
These data don’t factor in Covid-19, however. If we were to ask another question such as “What proportion of your client contacts are of a length sufficient to acquire a minimal infective dose of Covid-19?” I suspect we might find ourselves somewhat higher up the rankings than 39.
What of our clients?
A good proportion of my clients are referred by EAP’s. Thinking about the profile of these and other clients by occupational group, I can see that they include police officers, social workers, healthcare staff, social care and retail staff whose work may involve potentially high levels of exposure to disease, close proximity to other people, as well as contacts of a significant length.
I feel instinctively that working with a high proportion of clients whose work may place them at relatively higher risk of infection places me at relatively higher risk of infection too, but I confess that I really have no idea of how to weight this risk. The only thing I can do is to mitigate against the risk or eliminate it by not seeing clients face to face. This isn’t a comfortable choice.
What risk do I represent to my clients?
Three days ago, Radio 4’s Today programme featured the experience of the TV producer and screenwriter Dominic Minghella, who contracted and was hospitalised with Covid-19. Below is an extract:
You probably know how my story ends, or you might think you do. I caught it, right, at the post office, or the chemist, or Tesco’s? No, I was never going to catch virus, because I already had it. I probably picked it up on a packed train from Northallerton the weekend before. So, I wasn’t catching it that day, I was spreading it. That same evening, I went down with the shivers……. (listen here at 2hrs52mins)
If I haven’t contracted the virus, I represent no risk to my clients. Should I be unfortunate enough to do so, then I represent a considerable risk to anyone with whom I come into close contact. At present, for the purposes of the new contact tracing system, close contact means a distance of two metres or less, for a period of 15 minutes or more. That’s going to include any client I have seen face to face since I became infected.
The problem is I may not yet know that I’ve been infected. I may already have been infected – I was quite ill for three to four weeks over the Xmas period. Without an antibody test I will never know. Either way, infected but asymptomatic I will represent a risk to clients and others with whom I come into close contact. I may, in effect, become a ‘super spreader’.
So, under what circumstances should I resume seeing face to face clients?
Like all the most difficult decisions, this is a decision that only you can make. It’s a choice that you should freely make, free of pressure from anyone else, including clients, practice partners or your employer. You can only work effectively when you can work free from compulsion.
If pressure is coming from your employer, you need to be clear that it is your employer’s duty to provide a safe working environment for you. Seek support if you need it from either your union or your professional body in the first instance.
Given the nature of this virus and the way it can be spread without symptoms being apparent, we can never fully eliminate the risks involved in working face to face. We can be scrupulous about hygiene and cleaning. We and our clients can wear masks. We can ensure that we maintain appropriate distance. We can contract with our clients about the circumstances under which we will meet, and those we won’t. We can manage as many of the risks as we can reasonably foresee.
We can never eliminate the risk, however, that we may be infected by an asymptomatic client and that we in turn, may infect other clients.
Whatever decision you come to dear colleagues, may you and your clients stay safe and well.
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