Syra Madad, DHSc, MSc, MCP

The COVID-19 pandemic has highlighted the importance of understanding and consistently applying basic infection prevention and control (IPC) measures. These include wearing a well-fitted mask, seeking better-ventilated spaces, employing good hand hygiene and respiratory etiquette, and keeping one’s distance—all to prevent, mitigate, and curb the spread of SARS-CoV-2.

These basic measures are not new. For example, before the pandemic, hospitals routinely asked patients to wear a mask for source control if they were exhibiting respiratory symptoms and demonstrated how to wear it correctly.

 Additionally, study findings have shown that applying social distancing measures in non–health care workplaces can reduce influenza transmission.

Yet during the pandemic, these IPC measures became a novelty, one that much of the general public had difficulty understanding and consistently applying. An “infodemic” arose, causing an avalanche of what was often misinformation and disinformation as people sought recommendations and guidance on how to apply IPC measures to keep themselves and others safe.

The Centers for Disease Control and Prevention (CDC) developed numerous infographics on these measures, such as how to select a face mask (ie, 2 or more layers of fabric), how to appropriately wear a mask (ie, covering mouth and nose), and how to clean hands properly (ie, scrubbing for 20 seconds).

 But such public guidance regarding basic IPC measures fell short. It did not consider the 7% of Americans who don’t have access to a computer to seek this information or the 14% who struggle with basic literacy.

Other sources people consult to learn about current events, the latest public health guidance, and “how to” guides on applying IPC measures include their health care provider, social media, television, radio, and family, friends, and neighbors. But a key approach that has been lacking in the US COVID-19 response is the use of community engagement (CE) to share, teach, and promote IPC measures. CE is the act of promoting the role of communities in interventions that allow for education, participation, empowerment, and sensitization to public health topics. CE infuses cultural competency and addresses barriers such as language. It employs guiding principles including trauma-informed care through the use of trusted messengers in the community. It is an approach for the people, by the people, to the people.

It is vital to dissect CE’s importance and to operationalize outreach led by trusted local community members to offer a safe and inclusive method of promoting infection prevention education in hopes of embedding it in normal practice. This community-centric public health approach can play a significant role in overall infection prevention and control for both vaccine-preventable diseases and emerging infectious disease threats. It also can be leveraged to help tackle the lack of trust within specific communities due to health inequities. As perfectly stated in an analysis of CE in India, community-led advocacy and encouragement will lead to empowerment and equity. It will enable communities affected by health disparities and those who are affected by an “infodemic” to establish trust and decision-making.

CE is by far one of the most important tools that seems to be underutilized in the United States for various infectious diseases, including COVID-19, and needs prompt and ongoing attention. As we look to sustain the gains we have made, build back better, and further pandemic-proof our society, we must invest in solutions that work, are inclusive, and make an impact.

Globally, CE has been shown to be a valuable strategy in reducing the burden of disease through active peer-to-peer education and community participation. To help the public understand the risk of disease transmission during high-risk activities such as burials, the Democratic Republic of the Congo utilized CE during the sporadic outbreaks of Ebola virus disease, teaching about safe, dignified burials through community acceptance.

 During the 2018 cholera outbreak in Yemen, CE helped to encourage safe hygiene practices through “hygiene promoters” and community volunteers. These promoters and volunteers, as part of the United Nations Children’s Fund (UNICEF), used various approaches to reach out to community members and improve the understanding of basic hygiene and sanitation best practices.

The 2016 Zika virus outbreak in Cuba highlighted the critical role of CE and community participation to raise awareness and help control the outbreak through ongoing risk communication. Messages promoting preventive behaviors were employed at the individual, family, and community level to eliminate or treat Aedes mosquito breeding sites.

 In Laos, malaria elimination campaigns use elements of CE to promote uptake and adherence in target communities for mass antimalarial administration.

These examples of the effective use of CE in various infectious disease responses around the world highlight the critical role of CE interventions to mitigate, control, and prevent the spread of disease. These can include a range of approaches from education to outreach to improve health and economic or social well-being; promote equity; help with outbreak response; and ultimately, help save lives and prevent further illness.

The United States can learn a lesson or two from these examples of CE interventions in outbreak response. We can apply the various concepts, strategies, and lessons learned across the globe to threats we face here, such as vaccine-preventable diseases including measles and our annual foe, influenza.

During the US flu season, it is common to observe and receive reminders on when and where the flu vaccine will be available; however, an explanation as to 

 people should receive them seems to be lacking. Although health care professionals often explain the key facts on reducing disease severity, hospitalization, and death, they need to explain and promote much more. Hand washing, cough etiquette, and physical distancing have always played a major role in infection prevention but were only highlighted and enforced during a pandemic. Dispelling myths, providing evidence-based facts, and explaining the science behind these recommendations should not be forgotten during a flu season.

The Global Task Force on Cholera Control recently described best practices for community engagement, including facilitating routine feedback and engagement between the community and the response team; facilitating risk assessments and using locally generated data to develop an implementation plan for the community; forming small local task teams comprised of trusted leaders, respected community members, and religious representatives to engage with response teams; linking up with and using mass media to promote community engagement activities; and using local structures to discuss public health advice promoted in the media.

These best practices can lead to community empowerment and enable decision-making. Tapping into faith-based leaders, health care workers, and elected officials to educate and share information is a public health tool that should be used not only when dealing with a sudden outbreak but also during seasonal waves of infectious disease and on an ongoing basis. Whether it concerns seasonal influenza, tick-borne illness, sexually transmitted infections, or vaccine-preventable illnesses, the rationale for community-engaged health promotion, policy making, and research is largely rooted in the recognition that lifestyles, behaviors, and the incidence of illness are all shaped by social and physical environments.

Subject matter experts, health care organizations, and departments of health must be reminded of this rationale and continue to build a knowledgeable community base to ensure education is provided and instill trust and confidence within marginalized communities.

The infection prevention strategies we have all practiced thus far during the pandemic are fundamental practices that can be applied routinely to combat the spread of infection without the underlying pretense of pandemic safety. Coupling risk communication and effective engagement with the community can provide opportunities to change behavior and shape awareness of basic practices that can break the chain of transmission for many diseases. 

SYRA MADAD, DHSC, MSC, MCP, is senior director of the System-wide Special Pathogens Program and coprincipal investigator for the Institute for Diseases and Disaster Management at NYC Health + Hospitals.

PRIYA DHAGAT, MS, MLS(ASCP), CIC, is associate director of the System-wide Special Pathogens Program and adviser for infection prevention and control for the Institute for Diseases and Disaster Management at NYC Health + Hospitals.

Madad S. Preparing Frontline Hospitals for Dangerous Special Pathogens Beyond Ebola. Health Secur. 2021 Mar-Apr;19(2):209-213. doi: 10.1089/hs.2020.0134. Epub 2020 Dec 22. PMID: 33351700.

Ahmed F, Zviedrite N, Uzicanin A. Effectiveness of workplace social distancing measures in reducing influenza transmission: a systematic review. 

2018;18(1):518. doi:10.1186/s12889-018-5446-1

Your guide to masks. CDC. Updated August 13, 2021. Accessed August 25, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html

When and how to wash your hands. CDC. Updated June 10, 2021. Accessed August 25, 2021.

https://www.cdc.gov/handwashing/when-how-handwashing.html#:~:text=Follow%20Five%20Steps%20to%20Wash%20Your%20Hands%20the,Why%3F%20Read%20the%20science%20behind%20the%20recommendations.%20

Perrin A, Atske S. 7% of Americans don’t use the internet. Who are they? Pew Research Center. April 2, 2021. Accessed August 25, 2021. 

https://www.pewresearch.org/fact-tank/2021/04/02/7-of-americans-dont-use-the-internet-who-are-they/

Britt RR. 14 percent of U.S. adults can’t read. Live Science. January 10, 2009. Accessed August 25, 2021. 

https://www.livescience.com/3211-14-percent-adults-read.html

Dutta T, Agley J, Meyerson BE, Barnes PA, Sherwood-Laughlin C, Nicholson-Crotty J. Perceived enablers and barriers of community engagement for vaccination in India: using socioecological analysis. 

. 2021;16(6):e0253318. doi:10.1371/journal.pone.0253318

Scaling Up Ebola Response through Community Engagement (SUERCE). FHI 360. Accessed August 25, 2021. 

https://www.fhi360.org/projects/scaling-ebola-response-through-community-engagement-suerce

Shaem F, Kulynin G. Community engagement is key to contain ongoing cholera outbreak. UNICEF. November 14, 2018. Accessed August 25, 2021. 

https://www.unicef.org/yemen/stories/community-engagement-key-contain-ongoing-cholera-outbreak

Castro M, Pérez D, Guzman MG, Barrington C. Why did Zika not explode in Cuba? The role of active community participation to sustain control of vector-borne diseases. 

. 2017;97(2):311-312. doi:10.4269/ajtmh.16-0906

Adhikari B, Pell C, Phommasone K, et al. Elements of effective community engagement: lessons from a targeted malaria elimination study in Lao PDR (Laos). 

. 2017;10(1): 1366136. doi:10.1080/16549716.2017.1366136

Section 5: risk communication and community engagement. Global Task Force on Cholera Control. Accessed August 25, 2021. 

https://choleraoutbreak.org/book-page/section-5-risk-communication-and-community-engagement

Hanson P. Citizen involvement in community health promotion: a role application of CDC’s PATCH model. 

. 1988;9(3):177-186. doi:10.2190/FMWL-59TW-T3CL-VJ16

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Coupling risk communication and effective engagement with the community can provide opportunities to change behavior and shape awareness of basic practices that can break the chain of transmission for many diseases.

Syra Madad, DHSc, MSc, MCP

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