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Dr Gabriel Birgand is an Infection Control consultant at the Nantes University Hospital in France and Head of the Regional Center for Infection Control. The Regional Center for Infection Control is the French national reference centre for antimicrobial and healthcare associated infections surveillance and prevention in the community and long-term care settings. Dr Birgand is a collaborative researcher at the National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London. His research interests include the diagnosis and prevention of surgical site infections and evaluating measures to control the spread of multidrug resistant organisms.
First and foremost, are there any key leadership messages you want to get out to our readership?
The first message would be optimism. In these phases of anxiety, everybody needs optimism. The second is to be strong on measures you think to be appropriate, and do not answer automatically to people’s anxiety, notably for personal protective equipment. But, be flexible when necessary and adjust your message to the growing evidence. The final message is to be cautious with all statements and forecasts. We suffered from people being very sure of themselves and having their say, notably in media and being totally wrong afterwards. In these situations, we also have to be humble, and sometimes acknowledge what we do not know.
Tell us a little bit about your leadership role and how it is changing as a result of the pandemic?
The regional centre for infection prevention and control (IPC, Pays de la Loire region) is providing support and advice to primary care, nursing homes and healthcare settings to prevent Healthcare associated infection (HAI) and the transmission of communicable diseases. COVID-19 very soon became a political problem in France due to the public health impact. Immediately, organisation and responsibility for COVID-19 prevention shifted to the ministry of health and the regional agency for health which resulted in a packed agenda of policies and orders being provided to hospital administrators for implementation. This arrangement sometimes left aside key actors, including those specialised in Infection Prevention and Control (IPC). In the second stage of the outbreak, the situation required more expertise, that is, supplies shortages required advice from specialists, and actions for extended infection prevention required more resources. At this stage, an awareness was raised of the requirement to involve IPC specialists.
What events in your past experience are most informing your leadership in this pandemic?
The Ebola outbreak in 2014 was probably the most similar situation I have faced. At this time, I was an IPC registrar at the Bichat Claude Bernard hospital, which is one of the reference hospitals for emerging infections in Paris. However, the situation was just preventive because no cases were reported in our hospital during the outbreak. But the media were putting pressure, with consequences on the hospital organisation, and there was a rush to get everything in place to accurately manage a potential case. During this period, I experienced crisis management at the hospital and regional level.
What are you finding the biggest challenges?
The first biggest challenge is the dynamics of the pandemic. The outbreak was going so fast that everything needed to follow after in terms of advice and recommendations: political decisions, guideline recommendations. Facing this tsunami, a lot of guidelines, policies or press releases have been published with anticipation, sometimes leading to confusion. Sometimes, the usual rules for publication of national guidelines were not followed due to the rush; national guidelines were being written 1 day, by a single person, reviewed by a couple of available people the same day, then published the day after. To take the example of face masks, 12 different guidelines from 11 different societies/organisations were published within a 3-month period. The anxiety from healthcare professionals, emphasised by the mass communication in the press and social media, generated irrational, but understandable, behaviours, leading to the use of a full panoply of protection equipment. In a period of confusion and, sometimes, panic, stability and precision in recommendations are a strength, for a better understanding by frontline staff, and to best use information from infection control specialists.
The second is the fact that everybody became a specialist of the topic, and infection prevention and control in particular. Infection control became everyone’s business, including clinicians, politicians and some clinicians not specialised in the topic.
The external pressure from politics and media is probably the main determinant of these challenges. In general, these factors are considered as essential for improvement. However, for COVID-19 in France, this led to disorganisation, inconsistency and, finally, confusion. The time of the outbreak is not the time for media and politics to influence scientific and guideline publications.
The supplies shortage was another big challenge. Guidelines were severely impacted by these shortages and required a downgrading of all our standards. The use of single use gowns is a good example. We usually recommend gowns for blood and fluid exposure. However, early in the outbreak, this was used to protect professionals against the virus, without any scientific evidence. Then, everybody wanted gowns for every type of care. This led to a shortage and the use of cloth gowns for several patients or having to wash single use gowns. Going from one patient to another with the same gown may lead to major cross-transmission of not only SARS-CoV-2 but also other micro-organisms.
Any particular surprises?
In this situation of emerging infectious diseases, we may expect the full involvement of the infection control team and a strategy relying on this expertise to prevent the spread of COVID-19. However, things were very different. Some actors (not specialised in IPC, including administrative) felt able to provide expertise and provide guidelines on infection control measures, at the national, regional and even local scale. This was the case from doctors, intensivists, etc, like they considered IPC not as a specialty but something that anyone can deal with. This situation was very paradoxical to usual behaviours. Usually, most clinicians seem to consider IPC as a secondary, like something in the background. One event may summarise this issue: The French president and government created a scientific advisory board for the outbreak; this board included infectious diseases doctors, epidemiologists, intensivists, anthropologists, sociologists, however, no IPC specialist was invited to be part of this committee.
Are you seeing any behaviours from colleagues that encourage or inspire you?
In these circumstances, we have seen large motivation from all healthcare workers on the front line. Despite an obvious danger for their life, few people were reluctant to take care of patients. This is a very good sign and encouraging. To be honest, I was not expecting such a positive reaction.
How are you maintaining kindness and compassion?
The uncertainty associated with this phenomenon naturally led to cohesion and solidarity.
Are there any readings that you find helpful for inspiration and support that you would recommend to others?
Yes, Twitter can be a very nice source of information. This provides very early information on the outbreak, with the sharing of vision and experience from colleagues working in early affected countries. Finally, in the massive release of publications, the major articles are easier to get from Twitter.
What are you looking for from your leaders?
Being respectful of the knowledge acquired by specialists. Being consistent and not too cumbersome in the publication of advice and recommendations.
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Author note Interview conducted by RA on 9th June 2020 behalf of BMJ Leader. RA and Ms Sara Yadav edited the transcript.
Funding RA is Knowledge Mobilisation Lead, and supported by, the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London in partnership with Public Health England (PHE) and affiliated with the NIHR HPRU Modelling and Health Economics, and the NIHR HPRU Respiratory Infections. RA and GB gratefully acknowledge the support of ESRC as part of the Antimicrobial Cross Council initiative supported by the seven UK research councils, and also the support of the Global Challenges Research Fund.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.