The Ventilation and Warming of School Buildings By Gilbert B. Morrison Published by D. Appleton and Company, New York ( 1887 ) Accessed 10 Apr 2024 Preface (p.xxii) ❦ ‘I am fully convinced that people are prematurely dying by thousands simply from a lack of correct and positive convictions concerning impure air; for, when the true nature of a danger is fully appreciated, the requisite means to avert it will generally be found.’ ❂ Chapter II: The Effects Of Breathing Impure Air (pp.20-23) ❦ ‘Impure air is also believed by the best authorities to be one of the principal causes of epidemics. Dr. Carpenter, than whom there is no abler authority, says: “It is impossible for anyone who carefully examines the evidence to hesitate for a moment in the conclusion that the fatality of epidemics is almost invariably in precise proportion to the degree in which an impure atmosphere has been habitually respired.” The Board of Health of New York conclude that forty per cent of all deaths are caused by breathing impure air. In view of such alarming facts, this same board declares: “Viewing the causes of preventable diseases, and their fatal results, we unhesitatingly state that the first sanitary want in New York and Brooklyn is ventilation .” Direct experiment proves that the air in our school-rooms is impure in almost all cases, and in a majority of them to a degree far beyond the danger line. In view of these facts, and the results as proved by the authorities above cited, why is it regarded by the public with such indifference? When a school-house is blown down by a hurricane, killing and maiming a score of children, it is justly regarded as a great calamity; a vacation is given to quiet the excited fears of parents and children; investigating committees are appointed to locate the responsibility, and the faces of the whole populace are blanched with apprehension. Why is this? Why does the intelligent parent send his child to a school-room poorly ventilated and crowded with children, some of whom are breathing into a stagnant air the germs of disease and death, while others, from unwashed bodies, are delivering into it their deadly emanations, and all without a protest on the part of those even who provide proper hygienic conditions at home? It is because the effects of the one are immediate, occupy little time, the number killed can be actually counted, and the exact magnitude of the calamity estimated all at once. In the other case the process is slower, but of far greater extent; the actual results are by the general public less definitely known, and custom and attention to other matters divert the attention, and the deadly destruction of the innocents by impure air goes on silently, constantly, and powerfully. While noisy demonstrations like that of the cyclone attract attention, and inspire fear and terror, it is in the silent forces that the danger lies. Nature’s most destructive forces, as well as her strongest constructive ones, are silent in their operations; but when Science detects a silent, insidious enemy to human welfare, it is not only our duty to assume an attitude of self-defense and self-protection, but it should be regarded as folly not to do so.’ ❦ On high CO₂ levels connected to poor performance in schools: ‘The effects of breathing impure air thus far considered are pathological, but it has its pedagogical and economical aspects. Every observing teacher knows the immediate relation between the vitiated air in the school-room and the work he wishes the pupils to perform. Much of the disappointment of poor lessons and the tendency to disorder are due directly to this cause. The brain unsupplied with a proper amount of pure blood [oxygen] refuses to act, and the will is powerless to arouse the flagging energies; the general feeling of discomfort, dissatisfaction, and unrest which always accompanies a bad state of the blood. From an economical standpoint it would, of course, be impossible to estimate the financial waste of breathing impure air, but it can not but be enormous. In any discussion of the feasibility of incurring the additional expense of the most perfect ventilation, this loss occasioned by the want of such ventilation must not be ignored.’ ❂ Chapter III: The Air (pp.25-26) ❦ On ventilation, air filtration, and the super-spreading of diverse diseases in classrooms: ‘Wherever an unusual amount of unwholesome matter is being evolved, there especially should the purifying conditions be present; air in such places, to remain pure, must be changed in rapid succession, in order that dilution, diffusion, and oxidation may fulfill their legitimate functions. In a school-room the contaminating process can not but be rapid, and wherever ample provision is not made for rapidly changing the air of the room a dangerous condition of affairs is sure to exist. Bacteria of many forms, and spores of fungi, are also found in the air, and all these organisms are known to thrive in the organic impurities found in the air.’ ❂ Chapter IV: Examination Of The Air (p.33) ❦ On measuring CO₂ levels as a proxy to establishing content of (infectious) re-breathed air: ‘A complete analysis of impure air comprehends the quantitative and qualitative tests for carbonic [sic] dioxide, free ammonia, and other nitrogenous matter, oxidizable matters, nitrous and nitric acids, and hydrogen sulphide; but for ordinary practical purposes the determination of the CO₂ is by far the most important, and is ordinarily the only one which need be made. While the poisonous qualities of the air are not wholly due to the presence of the CO₂ per se, the amount of this gas found to be present is, in air made impure by respiration, generally a good measure for other impurities to which the poisonous quality is principally due. Owing to this fact, a careful test for the amount of CO₂ contained in a given atmosphere is generally the only one which need be made where air is tested merely to determine its respiratory purity.’ ❂ 📖 (Accessed 10 Apr 2024 ~ D. Appleton & Company / Google Books) The Ventilation and Warming of School Buildings ➤ ❂ My thanks to Maarten De Cock for alerting me to this gem of a book. ➲

❦ A comprehensive collection of review articles regarding airborne transmission of pathogens , by Jonathan Mesiano-Crookston. ❂ Accessed : 4 March 2024 . 📖 (November 2022 ~ Geoscience Frontiers) Aerosol Transmission of Human Pathogens: From Miasmata to Modern Viral Pandemics and Their Preservation Potential in the Anthropocene Record ➤ 📖 (21 Aug 2022 ~ Indoor Air) What were the historical reasons for the resistance to recognizing airborne transmission during the COVID-19 pandemic? ➤ 📖 (31 Jan 2022 ~ Indoor Air: Editorial) Hypothesis: All respiratory viruses (including SARS-CoV-2) are aerosol-transmitted ➤ 📖 (November 2021 ~ Interface Focus) How Did We Get Here: What Are Droplets and Aerosols and How Far Do They Go? A Historical Perspective on the Transmission of Respiratory Infectious Diseases➤ 📖 (27 Aug 2021 ~ Science ) Airborne Transmission of Respiratory Viruses ➤ 📖 (August 2021 ~ Nature Reviews: Microbiology) Transmissibility and Transmission of Respiratory Viruses ➤ 📖 (July 2021 ~ Annual Review of Biomedical Engineering) Fluid Dynamics of Respiratory Infectious Diseases ➤ 📖 (14 May 2021 ~ Science) A Paradigm Shift to Combat Indoor Respiratory Infection ➤ 📖 (1 May 2021 ~ The Lancet) Ten Scientific Reasons in Support of Airborne Transmission of SARS-CoV-2 ➤ 📖 (18 Jan 2021 ~ Clinical Infectious Diseases) Airborne Transmission of SARS-CoV-2: What We Know ➤ 📖 (12 Jan 2021 ~ The Journal of Hospital Infection) Dismantling Myths on the Airborne Transmission of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) ➤ 📖 (1 Jan 2021 ~ Canadian Medical Association Journal) Mitigating Airborne Transmission of SARS-CoV-2 ➤ 📖 (November 2020 ~ Environment International) Aerosol Transmission of SARS-CoV-2? Evidence, Prevention and Control➤ 📖 (16 Oct 2020 ~ Science) Airborne Transmission of SARS-CoV-2 ➤ 📖 (1 Sep 2020 ~ Environment International) How Can Airborne Transmission of COVID-19 Indoors Be Minimised? ➤ 📖 (August 2020 ~ Anaesthesia) Airborne Transmission of Severe Acute Respiratory Syndrome Coronavirus-2 to Healthcare Workers: A Narrative Review ➤ 📖 (6 July 2020 ~ Clinical Infectious Diseases) It Is Time to Address Airborne Transmission of Coronavirus Disease 2019 (COVID-19) ➤ 📖 (June 2020 ~ Environment International) Airborne Transmission of SARS-CoV-2: The World Should Face the Reality➤ 📖 (May 2020 ~ Risk Analysis) Consideration of the Aerosol Transmission for COVID‐19 and Public Health➤ 📖 (16 April 2020 ~ The Journal of Infectious Diseases) Airborne or Droplet Precautions for Health Workers Treating Coronavirus Disease 2019? ➤ 📖 (26 March 2020 ~ JAMA) Turbulent Gas Clouds and Respiratory Pathogen Emissions: Potential Implications for Reducing Transmission of COVID-19 ➤ 📖 (28 Aug 2019 ~ Encyclopedia of Microbiology) Airborne Infectious Microorganisms ➤ 📖 (31 Jan 2019 ~ BMC Infectious Diseases) Recognition of Aerosol Transmission of Infectious Agents: A Commentary➤ 📖 (September 2016 ~ American Journal of Infection Control) Generic Aspects of the Airborne Spread of Human Pathogens Indoors and Emerging Air Decontamination Technologies ➤ 📖 (15 Nov 2011 ~ Advances in Preventive Medicine) Preventing Airborne Disease Transmission: Review of Methods for Ventilation Design in Health Care Facilities ➤ 📖 (October 2006 ~ The Journal of Hospital Infection) Factors Involved in the Aerosol Transmission of Infection and Control of Ventilation in Healthcare Premises ➤ 📖 (January 1987 ~ Critical Reviews in Environmental Control) Spread of Viral Infections by Aerosols➤ ❂ © 2024 ➲ Jonathan Mesiano-Crookston . ➲

❦ SARS-CoV-2 – the virus that causes Covid-19 – is airborne. In May 2021, the WHO officially recognised that SARS-CoV-2 is airborne via microscopic aerosols – meaning that the virus is transmissible through the air at both long and short range .

❦ ‘ Long Covid can manifest in people across the life span (from children to older adults ) and across race and ethnicity, sex, and baseline health status. It is a complex non-monolithic multisystemic disease with sequelae across almost all organ systems . The prototypical (classic) form of Long Covid (with brain fog [brain damage] , fatigue , dysautonomia *, and postexertional malaise ) is more common in younger adults and in females . Other forms of Long Covid, including those with cardiovascular and metabolic sequelae , are manifest more often in older adults and those with comorbidities . A common risk across all types of Long Covid is severity of acute infection; the risk – on the relative scale – increases according to the severity of the acute infection. However, despite the lower relative risk, more than 90% of [Long Covid] cases occur in people who had mild SARS-CoV-2 infection , owing to the much higher prevalence of mild cases. Because non-pharmaceutical interventions [ NPIs , such as respirator-wearing and air filtration ] to reduce the risk of SARS-CoV-2 transmission have largely been abandoned , vaccines are now the primary line of defense against both severe disease in the acute phase of the infection and Long Covid. Studies have consistently shown that vaccines reduce the risk of Long Covid by 15 to 75% , with a mean of ~40% reduction in risk . Yet vaccine policies in much of the world restrict boosters to older adults or those with risk factors for severe COVID-19, and with pandemic fatigue, the public’s appetite for boosters seems to be waning . Reinfection , which is now the dominant type of SARS-CoV-2 infection , is not inconsequential; it can trigger de novo Long Covid or exacerbate its severity . Each reinfection contributes additional risk of Long Covid : cumulatively, two infections yield a higher risk of Long Covid than one infection, and three infections yield a higher risk than two infections. Despite this cumulative knowledge on mechanisms, epidemiology, and prevention, there are several major challenges. Patients are often met with skepticism and dismissal of their symptoms as psychosomatic. The attribution of symptoms to psychological causes has no scientific support ; it perpetuates stigma and disenfranchises patients from accessing the care they need. The lack of consensus on terms , definitions , and clinical trial end points for Long Covid is slowing progress and hampering industry engagement in clinical trials. Evidence from multiple studies with 2 to 3 years of follow-up indicates prolonged risk for many sequelae and that spontaneous recovery or return to baseline status is uncommon . Extended follow-up of the 1918 influenza pandemic , poliomyelitis outbreaks, and Epstein-Barr virus infections has demonstrated that new, disabling sequelae of these infections can occur multiple decades later ; it is uncertain whether this will also occur with COVID-19. Tied with the antiscience , antivaccine movement , a tide of Long Covid denialism is rising . This movement sows doubt about the scale and urgency of Long Covid, conflates Long Covid with vaccine-adverse events, and seeks to hamper progress on addressing the care needs of people suffering from this condition. The pandemic has laid bare a blind spot in epidemiology and surveillance data systems for infectious diseases. Nearly all surveillance data systems are built on the archaic , and now obsolete , notion that accounting for cases, hospitalization, and death in the acute phase is sufficient to capture the health burden of the infection. This approach does not account for the burden of long-term health loss due to infectious illnesses, which obscures their true toll. Adding to this challenge are the absent , underdeveloped , or siloed healthcare data systems in much of the world. Long Covid will have wide-reaching effects that are yet to be fully appreciated. In addition to the prototypical form of Long Covid, SARS-CoV-2 infection increases the risk of a wide array of chronic diseases and will contribute to a rise in the burden of cardiovascular disease , diabetes , neurologic impairment , and autoimmune conditions . Long Covid affects the development and educational attainment of children and reduces labor participation and economic productivity in working-age adults . Both the direct effect of increased risk of death in people with Long Covid and the indirect effect on mortality through increased burden of chronic diseases caused by SARS-CoV-2 may contribute to further decline in life expectancy, potentially erasing decades of progress. Finding treatments for Long Covid must be prioritized. Preventing infections and reinfections is the best way to prevent Long Covid and should remain the foundation of public health policy. A greater commitment to non-pharmaceutical interventions , which include masking , especially in high-risk settings , and improved air quality through filtration and ventilation , are requisite . Updating building codes to require mitigation against airborne pathogens and ensure safer indoor air should be treated with the same seriousness afforded to mitigation of risks from earthquakes and other natural hazards. Reducing the risk of serious outcomes after COVID-19 and some prevention of Long Covid can be attained with vaccination of a wider spectrum of the population . Development of more durable , variant-proof vaccines that are not vulnerable to evasion by the ever-mutating virus needs to be accelerated. Nasally or orally administered vaccines that induce strong mucosal immunity to block infection and transmission should be pursued. It is also necessary to broaden the pipeline of SARS-CoV-2 antivirals , especially because of rising resistance.’ ❂ 📖 (22 Feb 2024 ~ Science) Solving the puzzle of Long Covid: Long Covid provides an opportunity to understand how acute infections cause chronic disease ➤ © 2024 Science .

❦ This study confirms everything that I have seen in the microscope over the last few years. The authors of the study use a technique called dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), an imaging technique that can measure the density, integrity, and leakiness of tissue vasculature. Comparing all individuals with previous COVID infection to unaffected controls revealed decreased general brain volume in patients with brain fog along with significantly reduced cerebral white matter volume in both hemispheres in the recovered and brain fog cohorts . Covid-19 induces brain volume loss and leaky blood-brain barrier in some patients. How can this be more clear? © 2024 Danielle Beckman. ➲ ❂ 📖 (22 Feb 2024 ~ Nature: Neuroscience) Blood–brain barrier disruption and sustained systemic inflammation in individuals with long COVID-associated cognitive impairment ➤ 📖 (22 Feb 2024 ~ Nature: Neuroscience) Leaky blood–brain barrier in long-COVID-associated brain fog ➤ ➲ Layperson overview: 📖 (February 2024 ~ Genetic Engineering and Biotechnology News) Leaky Blood Vessels in the Brain Linked to Brain Fog in Long COVID Patients ➤ Related: 📖 (7 Feb 2022 ~ Nature: Cardiovascular Research) Blood–brain barrier link to human cognitive impairment and Alzheimer’s disease ➤ ❂ © 2024 Nature .

❦ Mitigation = ‘Lessening the force or intensity of something unpleasant; the act of making a condition or consequence less severe.’ 1. Clean indoor air . The priority should be air filters in schools and hospitals . New ventilation and air filtration standards for all public spaces . Grants made available to businesses to upgrade ventilation and air filtration . 2. FFP2/3 [N95/N99] respirators (masks) in all healthcare settings . 3. Free Covid vaccines available to everyone. 4. Wider access to Covid anti-viral treatments . 5. Free LFT/PCR testing . 6. Improved Covid surveillance , including wastewater monitoring and Long Covid prevalence . 7. Paid sick-leave , so that people don’t go to work when ill. 8. Respirators (masks) on public transport , including flights . 9. Better support and treatments for Long Covid patients . ... and last, but by no means least: 10. A public education campaign on the long-term risks of Covid – and why people should do more to protect themselves. ❦ Addendum : Allocate adequate research funding for a sterilising vaccine as well as treatments/cure for Long Covid . ❂ © 2024 Cat in the Hat . ➲

❦ ‘The occurrences of respiratory disorders among patients who survived for 30 days after the COVID-19 diagnosis continued to rise consistently, including asthma, bronchiectasis, COPD, ILD, PVD, and lung cancer. With the severity of the acute phase of COVID-19, the risk of all respiratory diseases increases progressively. Besides, during the 24-months follow-up, we observed an increasing trend in the risks of asthma and bronchiectasis over time, which indicates that long-term monitoring and meticulous follow-up of these patients is essential. These findings contribute to a more complete understanding of the impact of COVID-19 on the respiratory system and highlight the importance of prevention and early intervention of these respiratory sequelae of COVID-19. In this study, several key findings have been further identified. Firstly, our research demonstrates a significant association between COVID-19 and an increased long-term risk of developing various respiratory diseases. Secondly, we found that the risk of respiratory disease increases with severity in patients with COVID-19, indicating that it is necessary to pay attention to respiratory COVID-19 sequelae in patients, especially those hospitalized during the acute stage of infection. This is consistent with the findings of Lam et al., who found that the risk of some respiratory diseases (including chronic pulmonary disease, acute respiratory distress syndrome and ILD) increased with the severity of COVID-19. Notably, however, our study found that asthma and COPD remained evident even in the non-hospitalized population. This emphasizes that even in cases of mild COVID-19, the healthcare system should remain vigilant. Thirdly, we investigated differences in risk across time periods, as well as the long-term effects of COVID-19 on respiratory disease. During the 2-years follow-up period, the risks of COPD, ILD, PVD and lung cancer decreased, while risks of asthma and bronchiectasis increased. Fourthly, our study showed a significant increase of the long-term risk of developing asthma, COPD, ILD, and lung cancer diseases among individuals who suffered SARS-CoV-2 reinfection. This finding emphasizes the importance of preventing reinfection of COVID-19 in order to protect public health and reduce the potential burden of SARS-CoV-2 reinfection. Interestingly, vaccination appears to have a potentially worsening effect on asthma morbidity compared with other outcomes. This observation aligns with some previous studies that have suggested a possible induction of asthma onset or exacerbation by COVID-19 vaccination. It suggests that more care may be necessary for patients with asthma on taking the COVID vaccines. The underlying mechanisms associated with COVID and respiratory outcomes are not fully understood, but several hypotheses have been proposed. First, SARS-CoV-2 can persist in tissues (including the respiratory tract), as well as the circulating system for an extended period of time after the initial infection. This prolonged presence of the virus could directly contribute to long-term damage of the respiratory tissues, consequently leading to the development of various respiratory diseases. Second, it has been observed that SARS-CoV-2 infection can lead to prolonged immunological dysfunctions, including highly activated innate immune cells, a deficiency in naive T and B cells, and increased expression of interferons and other pro-inflammatory cytokines. These immune system abnormalities are closely associated with common chronic respiratory diseases – asthma, bronchiectasis, COPD, as well as the development of lung cancer. Next, SARS-CoV-2 itself has been shown to drive cross-reactive antibody responses, and a range of autoantibodies were found in patients with COVID-19. In conclusion, our research adds to the existing knowledge regarding the effects of COVID-19 on the respiratory system. Specifically, it shows that the risk of respiratory illness increases with the severity of infection and reinfection. Our findings emphasize the importance of providing extended care and attention to patients previously infected with SARS-CoV-2.’ ❂ 📖 (17 Feb 2024 ~ The Lancet: eClinical Medicine) Long-term risks of respiratory diseases in patients infected with SARS-CoV-2: a longitudinal, population-based cohort study ➤ © 2024 The Lancet: eClinical Medicine .

❦ Chronic disease is like the perfect medical crime. The cause is usually long gone by the time the disease manifests, and nobody links the two until it’s much too late for most. ❂ © 2024 Henry Madison . ➲

❦ Every single case in which a person with Covid-19 infection infects another person in a healthcare setting – patient, relative, or hospital staff member – is a significant failure of hospital procedures.  Every single instance. ❂ © 2024 Professor Steve Robson MPH MD PhD ~ President, Australian Medical Association (AMA) . ➲

❦ Mike Honey’s Variant Visualiser (COVID-19 Genomic Sequence Analysis). The region of ‘Oceania/Australia’ is set by default, as the visualiser was created by Mike Honey , a Data Visualisation and Data Integration specialist in Melbourne, Australia. ➲ Choose your country by clicking on the ‘ Continent, Country, Location ’ dropdown menu in the top-right-hand corner . The variant visualiser is free to use, and is automatically updated every time you open the link. Click on the image below to open the visualiser in a new window. ❂ © 2024 Mike Honey. ➲

❦ ‘Although some studies have shown neuroimaging and neuropsychological alterations in post-COVID-19 patients, fewer combined neuroimaging and neuropsychology evaluations of individuals who presented a mild acute infection. Here we investigated cognitive dysfunction and brain changes in a group of mildly infected individuals. We conducted a cross-sectional study of 97 consecutive subjects ( median age of 41 years ) without current or history of psychiatric symptoms (including anxiety and depression) after a mild infection , with a median of 79 days (and mean of 97 days ) after diagnosis of COVID-19. We performed semi-structured interviews, neurological examinations, 3T-MRI scans, and neuropsychological assessments. The patients reported memory loss ( 36% ), fatigue ( 31% ) and headache ( 29% ). The quantitative analyses confirmed symptoms of fatigue ( 83% of participants), excessive somnolence ( 35% ), impaired phonemic verbal fluency ( 21% ), impaired verbal categorical fluency ( 13% ) and impaired logical memory immediate recall ( 16% ). Our group… presented higher rates of impairments in processing speed ( 11.7% in FDT- Reading and 10% in FDT- Counting ). The white matter (WM) analyses with DTI * revealed higher axial diffusivity values in post-infected patients compared to controls. * Diffusion tensor imaging tractography , or DTI tractography, is an MRI (magnetic resonance imaging) technique most commonly used to provide imaging of the brain. Our results suggest persistent cognitive impairment and subtle white matter abnormalities in individuals mildly infected , without anxiety or depression symptoms. One intriguing fact is that we observed a high proportion of low average performance in our sample of patients (which has a high average level of education ), including immediate and late verbal episodic memory, phonological and semantic verbal fluency, immediate visuospatial episodic memory, processing speed, and inhibitory control . Although most subjects did not present significant impaired scores compared with the normative data, we speculate that the low average performance affecting different domains may result in a negative impact in everyday life , especially in individuals with high levels of education and cognitive demands .’ ❂ ❦ Note how these findings might negatively affect daily activities that demand sustained cognitive attention and fast reaction times – such as driving a car or motorbike, or piloting a plane. Consider air-traffic control. Consider the impact on healthcare workers whose occupations combine long periods of intense concentration with a need for critical precision. ❂ 📖 (19 Jan 2024 ~ Nature: Scientific Reports) Microstructural brain abnormalities, fatigue, and cognitive dysfunction after mild COVID-19 ➤ © 2024 Nature .

❦ We cannot individually assess the risk of infection from poor indoor air quality. Just as we cannot individually assess food safety in restaurants, or fire safety in cinemas, or aviation safety on flights. These are in the control of others, and are regulated for our health and safety. ❂ © 2024 Orla Hegarty . ➲

❦ ‘Acute infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cause a respiratory illness that can be associated with systemic immune cell activation and inflammation , widespread multi-organ dysfunction , and thrombosis . Not everyone fully recovers from COVID-19, leading to Long Covid, the treatment of which is a major unmet clinical need. Long Covid can affect people of all ages , follows severe as well as mild disease , and involves multiple organs . Patients with Long Covid display signs of immune dysfunction and exhaustion , persistent immune cell activation , and autoimmune antibody production , which are also pathological features of acute COVID-19. The complement system is crucial for innate immune defense by effecting lytic destruction of invading micro-organisms, but when uncontrolled, it causes cell and vascular damage . The complement cascade is activated by antigen–antibody complexes in the classical pathways or in the lectin pathway by multimeric proteins (lectins) that recognize specific carbohydrate structures, which are also found on the SARS-CoV-2 spike protein that facilitates host cell entry. Both pathways may contribute to the pronounced complement activation in acute COVID-19. Long Covid symptoms include a postexertional exhaustion reminiscent of other post-viral illnesses , such as myalgic encephalomyelitis ( ME ) – chronic fatigue syndrome ( MECFS ) with suspected latent viral reactivation . Antibody titer changes in Long Covid patients indicate an association of fatigue with reactivation of latent Epstein-Barr virus ( EBV ) infections , and Cervia-Hasler et al found that the severity of Long Covid symptoms is associated with cytomegalovirus ( CMV ) reactivation . A better understanding of the connections between viral reactivation, persistent interferon signaling, and autoimmune pathologies promises to yield new insights into the thromboinflammation associated with Long Covid. Although therapeutic interventions with coagulation and complement inhibitors in acute COVID-19 produced mixed results, the pathological features specific for Long Covid suggest potential interventions for clinical testing. Microclots are also observed in ME-CFS patients , indicating crucial interactions between complement, vWF, and coagulation-mediated fibrin formation in post-viral syndromes. A better definition of these interactions in preclinical and clinical settings will be crucial for the translation of new therapeutic concepts in chronic thromboinflammatory diseases .’ ❂ 📖 (18 Jan 2024 ~ Science) Immune damage in Long Covid ➤ © 2024 Wolfram Ruf / Science .

❦ I met a nice lady – a ward patient – yesterday who, seeing my respirator [high-filtration mask] , promptly put on her surgical mask. So instead of diving straight in to asking what was most concerning her and how I could help, I opened up a bit about infection control in hospitals. I explained how, because of a lack of respirators, March 2020 saw NHS leaders downgrade PPE for all non-ICU staff. ❂ PPE : Personal Protective Equipment. I then reminded her of the amazing DHSC 2020 and 2021 campaigns on airborne transmission of SARS2 (the green-and-black smoke ones) – and I had to point out that every IPC Lead Nurse had since had to switch off their brain and forget what they knew – and while at work, to only protect ICU staff. ❂ DHSC : Department of Health and Social Care (UK). ❂ IPC : Infection Prevention and Control. I explained that the individuals responsible for the original IPC downgrade were now authors of the national manual on IPC (NIPCM), which sets the standard for infection control in hospitals, and this manual states that airborne transmission is ‘not a thing’ for SARS2 (AGP only). ❂ NIPCM : The UK’s National Infection Prevention and Control Manual. ❂ AGP : Aerosol-Generating Procedure, ie. intubation. So hospitals are destined to be unsafe spaces thanks to the NIPCM, and the surgical mask that she was wearing was OK (ish) to help protect me – but did very little to reduce her risk of SARS2 inhalation. However, she was in a single room (an extra, and not meant as a ward-bed space – but you know, >100% occupancy forever means that you need to use your imagination) – and she already had the window open. She was appalled at what healthcare workers were being put through. She was appalled at the on-going lies. She was appalled at the possible level of harm to patients and staff from such lies. She then went on to tell me how a weekend visitor of hers had just tested positive for Covid. She was worried that they had hugged and chatted, and that she might have got infected. She’s a switched on lady, too. Lives with a medic who has the windows open all the time (“It’s freezing at home”). So I explained about the CleanAirStars.com site. About HEPA filtration being a low energy and low-cost way to remove all airborne pathogens, and to make home a safer place for... • Covid • Flu • RSV • Norovirus • Fungi Etc., etc. The list goes on and on. — “Wow, that’s like magic!” We had a very nice chat. And then we talked about her heart. I just wish I could have this same conversation with each and every NHS CEO and IPC Lead Nurse. I’d ask some questions. I’d want to know why they aren’t protecting staff as they should. I’d want to know why they aren’t protecting patients as they should. I’d want them to know that they are in breach of UK legislation. And I’d want to look them in the eye and ask them to show compassion to the powerless: to staff, and patients. Help us please. Do whatever you can to counter the lies, and to help protect the NHS. Thank-you. ❂ © 2024 Dr. David Tomlinson, NHS Consultant Cardiologist ➲ .

❦ ‘Alzheimer’s disease (AD) is acknowledged by the World Health Organisation (WHO) as a global public health concern. AD is the primary cause of dementia and accounts for 50–70% of cases. SARS-CoV-2 can damage the peripheral and the central nervous system (CNS) through both direct and indirect pathways, potentially leaving COVID-19 patients at higher risks for neurological difficulties, including depression, Parkinson’s disease, AD, etc., after recovering from severe symptoms. Patients who recovered from severe COVID-19 infection are more likely to acquire stable neuropsychiatric and neurocognitive conditions like depression, obsessive-compulsive disorder, psychosis, Parkinson’s disease, and Alzheimer’s disease. SARS-CoV-2 infection causes immune system dysfunction, which can lead to suppression of neurogenesis, synaptic damage, and neuronal death, all of which are associated with the aetiology of Alzheimer’s disease. Severe systemic inflammation caused by SARS-CoV-2 is predicted to have long-term negative consequences, such as cognitive impairment. Research has demonstrated that SARS-CoV-2-infected AD patients had a higher mortality rate. In a study from the Department of Neuroscience at the University of Madrid, 204 participants with Frontotemporal Dementia (FTD) and Alzheimer’s disease (AD) were enrolled. According to the study, 15.2% of these individuals had COVID-19 infection, and sadly, 41.9% of those who had the virus died as a result of their illness. COVID-19 causes a secondary effect on underlying brain pathologies, as SARS-CoV-2 has been shown to trigger or accelerate neurodegeneration processes that possibly explain long-term neurodegenerative effects in the elderly population. In response to the impact of COVID-19 in 2020, governments worldwide acted promptly by implementing various public health measures. During this period, people with cognitive impairments such as dementia or AD may have experienced greater stress and anxiety due to sudden changes in the environment and people’s behaviour. It is also significantly harder for AD patients to comprehend and execute defensive measures such as wearing face masks and sanitising frequently. ❂ COVID-19 has generated a worldwide outbreak, resulting in a slew of issues for humans, particularly those suffering from Alzheimer’s disease. Its ability to invade the central nervous system through the hematogenous and neural routes, besides attacking the respiratory system, has the potential to worsen cognitive decline in Alzheimer’s disease patients. The severity of this issue must be highlighted.’ ❂ 📖 (8 Jan 2024 ~ Frontiers in Aging Neuroscience) Unravelling the connection between COVID-19 and Alzheimer’s disease: a comprehensive review ➤ © 2024 Shajahan et al / Frontiers in Aging Neuroscience .

❦ Q . Why is it important for me to know if I have a COVID-19 infection? ❦ A . If you don’t recover well, it can help your doctor to know if you’ve had a COVID-19 infection – so that they can more effectively treat any of your on-going symptoms. It also helps you to be conscious of the fact that contact with other people might hurt, permanently damage, or kill them.

❦ Person puts hand in flame. Gets burnt. Knows fire burns flesh. Has a fear of getting burnt in the future, because fire and flesh create undesirable pain. Lives in a permanent state of fear of fire for rest of life? No. Becomes cautious of fire, and takes precautions to not be burnt again. If anybody accuses you of ‘living in fear’ for taking precautions to avoid catching SARS-CoV-2 (Covid-19) again and again, know that you are, in fact, ‘living with sensible caution’ – as you know that the headaches and heart attacks and strokes and plaque build-up in arteries and the killing of one’s own parents and the reduction of your children’s IQ and your daily fatigue and your memory disorders and immune dysregulation and your new-onset susceptibility to other opportunistic viral, bacterial and fungal infections, and your high blood pressure, and your aggressive, new-onset or recurrence of cancer and the rapid, aggressive, new-onset dementia – are all things you should rightly be afraid of. For yourself, and for other people. But SARS2 is clever. You often only feel the burn weeks or months later, and you don’t make the connection between the time you stuck your hand in a fire and the now-septic wound that has worked its way into the gristle of your fingers. SARS2 isn’t stupid, you know, and it has had four years of mutating repeatedly inside several billion humans and animals to hone its game while we sit on the lawn and watch our house burn down. ❂ © 2023 C19.Life .

❦ Ms Amanda Pritchard Chief Executive Officer NHS England Sent via email 22 December 2023 Dear Ms Pritchard, Re: Need for revisions to the IPC guidance to protect healthcare workers from COVID-19 Recently, we have been hearing increasing concerns from across our respective memberships about the protection of healthcare workers and patients from COVID-19 , particularly in light of the rise in cases, hospitalisations and deaths that occurred in September and October [2023] . While it was positive to see a reduction in cases and hospitalisations in November which hopefully reflected a reduction in prevalence as well as the effect of the autumn booster programme, we are starting to see early signs that hospitalisations and cases are starting to rise again. There is no room for complacency, particularly as we deal with winter with an NHS under serious strain. In any case, suppressing the virus remains crucial to reduce the risk of new variants of concern . Moreover, the consequences of infection for some individuals remain serious. We have heard from a range of multidisciplinary clinicians from across primary and secondary care express concern about the lack of availability of even the most basic protections in many settings when they are treating patients with confirmed or suspected COVID-19 . Additionally, the BMA’s Patient Liaison Group has shared information about vulnerable patients not attending healthcare settings due to the fear of a possible COVID-19 infection . These are patients, who remain more susceptible to severe disease from COVID-19 and those for whom vaccines are less effective. As we have routinely highlighted, we believe that the existing Infection Prevention Control ( IPC ) Manual for England , and the specific IPC guidance for COVID-19 which preceded it, have contributed to the lack of protection many of our members experience. The manual does appear to recognise that COVID-19 is airborne . It states that Respiratory Protective Equipment ( RPE ), (i.e. a ( FFP ) respirator ) must be considered when treating a patient with a virus spread wholly or partly by the airborne route (2.4). However, it then makes an unclear distinction between viruses spread wholly or partly by the airborne route , and those spread wholly or partly by the airborne or droplet route where RPE is only recommended for so called “Aerosol Generating Procedures” (AGPs) – an outdated concept based on very poor evidence . Specifically , in Appendix 11, it states that a fluid resistant surgical mask ( FRSM ) is adequate protection for the routine care of COVID-19 positive patients (appendix 11), directly contradicting the statement in 2.4. It also seems very odd to make a distinction between viruses that spread only via the airborne route and those spreading via the airborne or droplet route; staff need protection from an airborne virus in both cases , in one they also need to take droplet-based precautions. The HSE’s own research from 2008 confirms a lack of respiratory protection from a FRSM . It is accepted that COVID-19 can be and is spread by the airborne route . The recent evidence given at the UK COVID-19 Inquiry clearly shows that aerosol transmission is a significant , and almost certainly the dominant, route of transmission for COVID-19 . The current guidance is therefore, at the very least, confusing and, at the worst , is recommending inadequate protection for healthcare workers treating COVID-19 patients . This continues to put them and their patients at risk of infection and, in some cases, Long Covid. We are concerned that there has been a lack of stakeholder engagement in recent months to inform updates the IPC Manual. The latest update on 25 October 2023 does not change the recommended PPE for routine care of a patient with COVID-19, although does include a new footnote seven which concerns patients with undiagnosed respiratory illness where coughing and sneezing are significant features but does not mention COVID-19 or provide guidance on recommended PPE or RPE. Stakeholders, including the signatories to this letter are seeking clarity from you about how we can engage with this process to help inform future revisions of the manual and ensure the guidance is clear and recommends adequate protection for healthcare workers. Employers ultimately have the responsibility for the safety of their workforce , under Health and Safety Law , and the IPC Manual for England references the need for risk assessments and the need to follow the hierarchy of controls. Ensuring the protection , so far as reasonably practicable, of staff who are vulnerable through exposure to the virus and any staff or patients who are individually susceptible and at risk of serious illness if they catch COVID-19 , remains a paramount legal obligation . However, the IPC guidance issued by UKHSA is mandatory in all NHS settings and settings where NHS services are provided. This makes it makes it very difficult for NHS Trusts to reconcile the confusing IPC guidance with their statutory duties as employers under health and safety legislation to provide HSE-approved RPE for protection against airborne hazards . This is especially the case as the HSE has opted not to produce its own guidance on the subject. As we deal with winter, when pressure in the NHS intensifies alongside rising flu and other seasonal respiratory viruses, as well as COVID-19, ensuring there are enough staff across the NHS is more important than ever. COVID-19 is likely to still cause significant staff absence , particularly if cases continue to rise in the coming weeks and months. Providing clear and adequate IPC guidance , including on the need for RPE and adequate ventilation , will help protect healthcare workers and patients and reduce staff absence this winter. Providing staff with adequate protection will also better protect patients and will help reassure vulnerable patients they can safely access healthcare . We would appreciate your reassurance that our concerns will be addressed and the relevant IPC guidance will be urgently updated to reflect this, as well as routinely reviewed. We are of course willing to work with your colleagues and the Chief Nursing Officer on IPC guidance. Yours sincerely, Professor Phil Banfield. BMA, Chair of Council. Dr Barry Jones. Chair of Covid Airborne Protection Alliance (CAPA). ❂ 📖 (22 Dec 2023 ~ The British Medical Association & Covid Airborne Protection Alliance) Need for revisions to the IPC guidance to protect healthcare workers from COVID-19 ➤

❦ We’ve contacted chief nursing officers in all four UK countries and the UKHSA to find out what action will be taken in response to WHO’s statement on a new COVID-19 variant of interest. The RCN is asking for a revision to current guidelines , to introduce universal implementation of the two measures advised by the World Health Organization (WHO) to help protect healthcare staff against COVID-19. Earlier this week, in light of the new COVID JN.1 variant, WHO advised healthcare workers and health facilities to: implement universal masking in health facilities , as well as appropriate masking , respirators and other personal protective equipment for health workers caring for suspected and confirmed COVID-19 patients ; improve ventilation in health facilities . The existing national infection prevention and control manuals don’t require standardised masking for COVID-19, and decisions on respiratory protective equipment are left to local risk assessments. This is now inconsistent with WHO’s latest advice . We also have concerns about the adequacy of ventilation in general ward and outpatient areas within hospital buildings and believe that action must be taken to assess and improve this. Although evidence suggests that the global public health risks from the new variant are low, WHO has warned that onset of winter could increase the burden of respiratory infections in the Northern hemisphere. This comes when there are already unsustainable pressures on the health service. Figures show that there has been a rise in COVID-19 cases and hospitalisations , and the RCN argues that without proper protections , ill health could continue to rise in nursing staff and impact their ability to deliver safe and effective patient care . WHO has advised that it is continuously monitoring the evidence and will update the JN.1 risk evaluation as needed. The RCN is urging health care employers to assess the risk posed by COVID-19 and put appropriate safeguards in place for patients and staff . Our COVID-19 workplace risk assessment toolkit aims to help assess and manage the risks associated with respiratory infections such as COVID-19, highlights the duties of nursing staff in specific roles (such as health and safety reps), has advice for employers and leaders, and provides the latest information on risk assessment. ❂ 📖 (21 Dec 2023 ~ Royal College of Nursing / RCN Magazine) COVID JN.1 variant: RCN seeks assurance on new PPE advice ➤ © 2023 Royal College of Nursing (RCN).

❦ ‘Due to its rapidly increasing spread , WHO is classifying the variant JN.1 as a separate variant of interest ( VOI ) from the parent lineage BA.2.86 . It was previously classified as VOI as part of BA.2.86 sublineages. Based on the available evidence, the additional global public health risk posed by JN.1 is currently evaluated as low. Despite this, with the onset of winter in the Northern Hemisphere, JN.1 could increase the burden of respiratory infections in many countries. ➲ Read the risk evaluation: https://www.who.int/activities/tracking-SARS-CoV-2-variants WHO is continuously monitoring the evidence and will update the JN.1 risk evaluation as needed. Current vaccines continue to protect against severe disease and death from JN.1 and other circulating variants of SARS-CoV-2, the virus that causes COVID-19. COVID-19 is not the only respiratory disease circulating. Influenza, RSV and common childhood pneumonia are on the rise. ➲ WHO advises people to take measures to prevent infections and severe disease using all available tools . These include: • Wear a mask when in crowded, enclosed, or poorly ventilated areas, and keep a safe distance from others, as feasible. • Improve ventilation . • Practise respiratory etiquette – covering coughs and sneezes. • Clean your hands regularly. • Stay up-to-date with vaccinations against COVID-19 and influenza, especially if you are at high risk for severe disease. • Stay home if you are sick . • Get tested if you have symptoms, or if you might have been exposed to someone with COVID-19 or influenza. ✻ ➲ For health workers and health facilities , WHO advises : • Universal masking in health facilities , as well as appropriate masking , respirators and other PPE for health workers caring for suspected and confirmed COVID-19 patients . • Improve ventilation in health facilities. Note : Updated 19 Dec 2023 with additional information for health workers and facilities. ’ ❂ 📖 (19 Jan 2023 ~ WHO / World Health Organization) World Health Organization (WHO) Media Advisory for the COVID-19 variant of interest (VOI) JN.1 ➤ © 2023 WHO / World Health Organization. ❦ Date accessed : 11 Jan 2024 .

❦ I am now absolutely convinced that unless we reduce the transmission of Covid-19 through societal non-pharmaceutical interventions (such as cleaning indoor air) and/or the deployment and uptake of second-generation vaccines, attrition of healthcare will reach a tipping point. This tipping point – which may well happen within the next year – will lead to a global decrease in quality of available healthcare services, which in turn will lead to increased morbidity and mortality from all causes. Every government needs to reduce transmission. The denial of this problem will not change the outcome. Policymakers need to understand this. ❂ © 2023 Conor Browne ➲

❦ ‘Al-Aly’s study undertook a comparative analysis of 94 pre-specified health outcomes and found that over 18 months of follow-up, COVID was associated with a “ significantly increased risk ” for 64 of them, or nearly 70% . The disease’s enhanced risk list includes everything from cardiac arrest , stroke , chronic kidney disease , and cognitive impairment to mental health and fatigue , characteristics often associated with long COVID. By comparison, the seasonal flu was associated with increased risk in only 6 of the 94 conditions specified. Further, while COVID increased the risks for almost all the organ systems studied, the flu heightened risk primarily for the pulmonary ( lung ) system . Those findings, Al-Aly says, suggest that “ COVID is really a multi-systemic disease , and flu is more a respiratory virus ”.’ ❂ 📖 (14 Dec 2023 ~ Fortune) COVID-19 v. Flu: A ‘much more serious threat,’ new study into long-term risks concludes ➤ 📖 (14 Dec 2023 ~ The Lancet) Long-term outcomes following hospital admission for COVID-19 versus seasonal influenza: a cohort study ➤ © 2023 Carolyn Barber / Fortune .

❦ Coughing into one’s sleeve while in shared air is like peeing into one’s swimsuit while in shared water. ❂ © 2023 Malgorzata Gasperowicz . ➲

❦ Covid Conscious friend’s 40-year-old partying brother gave Covid to their 80-year-old parents. Mother: spent three weeks in the hospital. Father: went into hospice, and died this morning. Forty-year-old brother never went to hospital nor hospice to visit, because “they’re old”, and “what can I do anyway?” He remains maskless. Co-worker who got Covid along with her father at the family reunion... Covid+ father passed out and was found unconscious in his home. Suffered an acute kidney injury; wears a catheter because he can’t ever urinate on his own again; is now in Palliative Care. Co-worker suddenly can’t remember being sick with Covid, nor her father having had Covid and passing out... and is now telling people that he suffered a kidney injury from a slip and a fall. Colleague says on a virtual call: — “Now that the pandemic is over and people have recovered...” She’s been coughing non-stop since July, and can’t figure out “what I’m allergic to”. Friend posts a picture of a box of KN95s [ear-loop FFP2 respirators] that she purchased online with the caption, “Going back to masking. Got them ready. People protect yourself.” Then for the next three weeks posts maskless pictures at a Patti Labelle concert, a wedding, a birthday dinner, a congressional party... I asked her when she’s going to start using the masks that she posted on Facebook. — “When the president mandates us to.” How many people have you talked to about Covid that have had an “Aha moment”, and immediately starts wearing a well-fitted mask and adjusts their behavior long term? The part of the brain that controls emotions like empathy is damaged. The part of the brain that controls cognitive thinking is damaged. Troll behaviour is at an all-time high because people are triggered by you protecting yourself and them. How incredibly bizarre is this behaviour, and almost everyone who is living in this world at this time! ❂ © 2024 Lady Chuan . ➲

❦ As a consequence of their occupation, doctors and other healthcare workers were at higher risk of contracting coronavirus disease 2019 (COVID-19), and more likely to experience severe disease compared to the general population. Post-acute COVID (Long COVID) in UK doctors is a substantial burden. Insufficient respiratory protection could have contributed to occupational disease, with COVID-19 being contracted in the workplace , and resultant post-COVID complications. Although it may be too late to address the perceived determinants of inadequate protection for those already suffering with Long COVID, more investment is needed in rehabilitation and support of those afflicted . ❂ 📖 (11 Dec 2023 ~ Occupational Medicine) Post-acute COVID-19 complications in UK doctors: results of a cross-sectional survey ➤

❦ I’ve often wondered if Covid, a.k.a. SARS-CoV-2, has its own marketing firm. Over the years, we’ve seen annual “campaigns”, if you will. ❊ 2020 : Hide your elderly and disabled! ❦ Covid still kills and disables children , athletes , and working-age adults . ❊ 2021 : Vax and relax! ❦ You can still transmit COVID if vaccinated; the vaccines wane much more quickly than promised; and lack of masking means faster viral evolution via on-going transmission chains. The vaccines only prevent some severe outcomes some of the time . ❊ 2022 : Back to normal, rise and grind! ❦ Forcing a return to offices and schools without proper mitigations in place – such as ventilation , accurate testing and masking – continues to spread Covid. People wonder why “no-one wants to work anymore”. It’s because they’re out sick. ❊ 2023 : Some folks will fall by the wayside. ❦ Anthony Fauci said this in mid-2023. It is intended to normalize continued higher-than-normal rates of death and disability . Please recall that Fauci had to be pushed hard by Larry Kramer to repurpose meds for HIV while he was at the NIH (USA’s National Institutes of Health). ❊ 2024 : There was no way we could have known. ❦ As rates of global disability climb with no long-term antiviral combination therapy approved, the press and the public start to vent frustrations . We absolutely did know – thanks to the basics of exponential functions and mounds of research. ❊ 2025 : Have you considered MAID? ❦ Due to Canadian efforts at successfully delaying care and benefits to living people while pushing medically-assisted intentional death (MAID), Western governments widely adopt the practice as a way of cutting costs. Influencers suggest 65 is “too old”. ❊ 2026 : Your disease, your responsibility. ❦ Government officials assert that it’s your fault if you didn’t wear an N95 [FFP2 respirator] because there was that one time the CDC (USA’s Centers for Disease Control and Prevention) director barely got the word “mask” out on a video in early December 2023. They use it as a reason for blanket denials of benefits . ❊ 2027 : Get adequate rest! ❦ Campaigns designed to educate the public on the benefits of sleep hygiene are ramped up in the face of increased disability. People are encouraged to work fewer hours if they aren’t feeling well, while their employers demand even more. People are tired. ❊ 2028 : Do your homework, kids! ❦ As PISA studies (Programme for International Student Assessment) continue to show global decline in student performance , education officials ignore the cognitive harms of COVID and instead decry cell-phones and “laziness”. Teen suicides increase due to more pressure, but social media is blamed. ❊ I could go on. A different future is possible, but it’s going to require big changes. Ignore the propaganda. Look at the data. Wear an N95 everywhere where people and air mix – and carry extra masks for others if you can. ❂ © 2023 Chalis Montgomery ➲

❦ The reason why most people aren’t taking Covid-19 seriously is because they simply can’t imagine that their Public Health body would abandon protections and let an incredibly disabling and airborne virus spread wildly. They will be very angry when it becomes clear to them that that’s exactly what has happened. ❂ © 2023 Dr. David Keegan ➲

❦ Always Covid+ Colleague: — “One of the medical groups. One of the groups. One of the groups...” Moderator: — “Is there something you want to share?” Always Covid+ Colleague: — “I was asked something. I don’t know. It has something to do with something.” This is what Covid is doing to the brain. Unfortunately this is not an isolated incident – but something I’m witnessing all day long throughout the company. ❂ © 2023 Lady Chuan ➲

✻ Accessed: 4 Dec 2023. ➲ Date published: 9 May 2023. ➲ Date last updated : 2 Oct 2023 . ❦ Executive summary Ventilation * is an important line of defence for infection control in the healthcare environment . Its design and operation are described in Health Technical Memorandum (HTM-03-01) . The current focus on ventilation has highlighted areas of high risk due to poorly performing and inadequate ventilation in hospitals and other healthcare settings. This may be due to change of room use, age, condition of air handling plant, lack of maintenance, challenges with effective use of natural ventilation or other. It is therefore important to bring these facilities up to the minimum specification of current standards , particularly recognising the challenges of COVID-19 and other infections . Local HEPA filter-based air cleaners (also know as air scrubbers) are one option for improving and supplementing ventilation. The installation of a high efficiency particulate air (HEPA) filter air cleaner can reduce the risk of airborne transmission . This guidance has been written as an interim specification to set the basic standard required for HEPA filter devices to be utilised in healthcare and patient-related settings . This edition is primarily aimed at portable and semi-fixed (wall-mounted) devices. Devices relying on ultraviolet light (UVC) are the subject of a separate guidance document: Application of ultraviolet (UVC) devices for air cleaning in occupied healthcare spaces . * Ventilation is the process by which ‘fresh’ air (normally outdoor air) is intentionally provided to a space and stale air is removed. This may be achieved by mechanical systems using ducts and fans, or natural ventilation most commonly provided through opening windows. The local redistribution of air may also be construed as ventilation. 1. Introduction Ventilation is an important feature in the control of airborne infection . However, the emergence of SARS-CoV-2 as a highly contagious virus has demanded new and innovative solutions to safeguard patients , staff and visitors . Health Technical Memorandum 03-01 Specialised Ventilation for Healthcare Premises (HTM-03-01) is a robust standard for ventilation of higher risk clinical spaces based on high air-change rates using outdoor air to continually flush indoor spaces. The COVID-19 pandemic has shown that greater attention must be paid to the improvement and maintenance of ventilation in healthcare settings . The focus on ventilation has also highlighted areas of high risk due to poorly performing and inadequate ventilation , particularly in older hospitals and other healthcare settings such as primary care and dental suites, which increase risks of nosocomial infections. In cases, where current ventilation does not meet HTM-03-01 standards, this may be due to age, condition of air handling plant, lack of maintenance or other design or operational issues. In the case of naturally ventilated spaces, there is a reliance on staff or patients opening windows. Weather conditions, external noise and air pollution and restricted window openings for safety affect the ability to open windows and means that ventilation in some settings can fall below recommended rates. Local HEPA filter air cleaners are one option for improving and supplementing ventilation . The correct installation and operation of a HEPA filter air cleaner can reduce the risk of airborne transmission . Healthcare trusts are under pressure to improve ventilation and in the meantime are considering options including filter-based air cleaning. This standard will assist trusts in selecting and implementing good quality, reliable equipment. There is substantial evidence from laboratory studies and real-world settings that filtration is an effective technology for reducing airborne pathogens within room air and HVAC systems. A number of research studies have been carried out which indicate that measured levels of micro-organisms in air are greatly reduced by air filters [R1-R5, R7] . There is also evidence which directly associates use of filter-based air cleaners with reductions in infection rates of environmentally-derived aspergillus [R8] . The potential of air scrubbers employing UVC or HEPA technology to mitigate SAR-CoV-2 risks is the subject of a rapid review (September 2022) [R.9] . Filter-based air cleaners also remove other particulate matter and so can also reduce exposure to other air pollutants. However, air cleaners should not be used as a reason to reduce ventilation and care must be taken to ensure sufficient fresh air changes are provided for the dilution of medical gases and noxious odours, and the maintenance of appropriate oxygen and carbon dioxide levels to satisfy the Building Regulations Part F. This document aims to serve as interim guidance and regulatory reference point for the design and correctly engineered deployment of HEPA filter devices in real-world settings with regard to effectivity and safety. It focuses on HEPA filter-based devices which can be positioned locally within a room; the document does not cover HEPA filters used within HVAC ducts. Local filter-based devices require fan-assisted circulation to introduce the room air into the device, pass it through the filters and then to reintroduce the processed air into the room. An important consideration regards the flow of the air which is induced, processed and distributed by the device external to the device itself. The design and placement of the device should promote efficient air distribution in the room space and avoid short-circuiting of air circulation relative to furniture, obstructions, and occupancy. 2. HEPA filter technology HEPA filters comprise a porous structure of fibres or membrane which remove particles carried in an air stream. The mechanism by which particles are removed depends on the size of the particle. Larger particles are removed by impaction onto the filter while smaller particles <1 μm are removed through interception and diffusion. Interception occurs where the particle makes physical contact with the media fibres because particle inertia is not strong enough to enable the particle movement to continue. Diffusion is where random motion (Brownian motion) of the particle enables it to contact the media. These effects are enhanced by the electrostatic charges present on filters. 2.1 Selection of filters Filter efficiency defines the fraction of particles removed and varies by size of particle. The most difficult size of particles to remove, known as the most penetrating particle size (MPPS), for the majority of filters is around 0.3 μm; particles larger or smaller than this size are captured more effectively. For healthcare applications it is recommended that devices should contain filters classified as High Efficiency Particulate Air Filters (HEPA) under BS EN 1822-1 or ISO 29463-1 . HEPA filters have a filter efficiency of at least 99.95% (H13 filter) or 99.995% (H14 filter) for the MPPS, however the performance in situ is sometimes lower depending on the filter and device design and the air flow rate ( section 5.1 ). Micro-organisms range in size from around 0.1 μm for the smallest viruses to several μm in diameter for larger bacteria and fungi . Some fungi and bacteria may be dispersed independent of other material, however, many pathogens will be released on or within another material and therefore the size of the particle that needs to be captured is larger than the pathogen itself. For example, respiratory and gastroenterology viruses will be released within liquid media that contains proteins, salts, surfactants, etc and evaporates to form particles that are larger than the virus itself. Similarly, many skin associated bacteria are released on skin squame which are larger than the bacteria. Some filter-based air cleaning devices contain lower grades of filter. These devices may be appropriate in non-clinical areas, but as the filters have a lower performance for particles relevant to the size of airborne pathogens they are not recommended in settings with vulnerable patients. It is common for HEPA filter-based devices to incorporate a coarse grade of filter (typically ISO ePM10 >50% under ISO 16890-1 ) to act as a dust filter. Some also include a carbon filter to manage odours and volatile organic compounds. Some devices contain several separate filters, while others incorporate the different stage filters into a single cartridge type unit. 2.2 Inclusion of other technologies Devices which include germicidal ultraviolet (UVC) light alongside HEPA filters are likely to be effective [R4] . Where these devices are considered, this standard takes precedence in terms of clean air performance if the UVC lamp is located after the HEPA filter (i.e. the HEPA filter is the primary device for microbial removal). However, all the safety requirements pertaining to the UVC within that standard should also be complied with. Devices which incorporate ionisation, photocatalytic oxidation, electrostatic precipitation or other similar technologies alongside filters are not currently recommended for healthcare use unless there is clear evidence for both effectiveness and safety. These devices can sometimes introduce, or create through secondary reactions, chemical by-products into a room which may themselves have an adverse health effect [R4, R11] . The independent research evidence that these products are any more effective at safely reducing microbial loads in air is still emerging. 3. Applications and sizing Stand-alone, floor-mounted devices can be positioned at any suitable location in a room . These devices are plugged into a standard electrical socket so do not require any installation, although location is important as detailed in sections 8.2 and 8.3. Fixed devices are semi-permanently mounted to a wall or ceiling. These devices will normally be permanently wired into the room electrical systems rather than plugged into a wall socket. Some manufacturers offer local systems that can be interfaced with the ventilation system and are able to offer pressure differential control in a room. In rooms without natural or mechanical ventilation , or where the ventilation falls short of statutory requirements or regulatory advice , auxiliary devices may be deployed to enhance the equivalent air changes. The installation of HEPA filter-based air cleaners can be considered to contribute additional ‘equivalent’ air changes (eACH). For example, a treatment room with 6 ACH could achieve the equivalent of 10 ACH by installing a local filtration unit which recirculated and cleaned the equivalent of 4 eACH. Hence, to meet the requirements that comply with HTM-03-01 , the number of devices required will be dictated by the existing background levels of ventilation. The high filter efficiency of HEPA filters means that the single pass efficiency of an air cleaning device for the MPPS should result in at least a 99% (2 log) reduction in the concentration of particles, including microorganisms, that pass through the device when in normal operation. However, the performance within a room depends on both the flow rate through the device and how it distributes the air in a room. The performance of filter-based devices is described by some manufacturers in terms of a Clean Air Delivery Rate (CADR) which is usually expressed in metres cubed per hour (m 3 h -1 ) (some devices quote the CADR in cubic feet per minute, cfm). Where a CADR is given it should be derived from measurements of how well the device removes a defined size of particles in a test room environment; CADR is usually measured using particles rather than microorganisms. CADR is a function of the airflow rate through the device, the quality of the filter and the way the device distributes air in the test room. Other manufacturers adopt different metrics such as the time to reduce particle concentrations in a room by a specific percentage. The CADR or other metrics can be used, with care, for design purposes as they express how the device will perform in a standardised test room. However, it is important to note that the actual performance will depend on the particular location and operation of the device, including the room size, layout, background ventilation, device design and maintenance ( section 8 ). It is not recommended to use an air cleaning device with a lower grade of filter even if the quoted CADR is high, as the device may be less effective against the smallest pathogen-carrying particles. The CADR used for design purposes should be the rate applicable to the device setting at which the device is most likely to be operated and where the noise level is during operation is at a level of ≤50 dB measured at 3 m (dB 3m ) ( section 5.3 ). ❂ Bibliography Laboratory chamber studies demonstrating effectiveness of HEPA filter devices against particles and microorganisms [R1] Miller-Leiden S, Lohascio C, Nazaroff WW, Macher JM (1996) Effectiveness of in-room air filtration and dilution ventilation for tuberculosis infection control. Journal of the Air & Waste Management Association 46: 869–882. doi:10.1080/10473289.1996.10467523 [R2] Offermann FJ. et al (1985) Control of respirable particles in indoor air with portable air cleaners. Atmospheric Environment 19: 1761–1771. doi:10.1016/0004-6981(85)90003-4 [R3] Ueki H, Ujie M, Komori Y, Kato T, Imai M, Kawaoka Y (2022) Effectiveness of HEPA filters at removing infectious SARS-CoV-2 from the air. mSphere 7(4):e0008622. doi:10.1128/msphere.00086-22. [R4] Beswick A, Brookes J, Rosa I et al. 2022. Room based assessment of mobile air cleaning devices using a bioaerosol challenge. Applied Biosafety Journal. Published online Dec 2022. doi:10.1089/apb.2022.0028 [R5] Lindsley WG et al (2021) Efficacy of portable air cleaners and masking for reducing indoor exposure to simulated exhaled SARS-CoV-2 Aerosols — United States, 2021. Morbidity and Mortality Weekly Report (MMWR) 70: 972—976. doi:10.15585/mmwr.mm7027e1 Testing approach for Clean Air Delivery Rate [R6] Foarde KK, Myers EA, Hanley JT, Ensor DS, Roessler PF (1999) Methodology to perform clean air delivery rate type determinations with microbiological aerosols. Aerosol Science and Technology 30: 235–245. doi:10.1080/713834074 Application of HEPA devices in healthcare setttings [R7] Conway Morris A, Sharrocks K, Bousfield R, et al, The Removal of Airborne Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and Other Microbial Bioaerosols by Air Filtration on Coronavirus Disease 2019 (COVID-19) Surge Units. Clinical Infectious Diseases, Volume 75, Issue 1, 1 July 2022, Pages e97–e101, doi:10.1093/cid/ciab933 [R8] Abdul Salam ZH, Karlin RB, Ling ML, Yang KS. The impact of portable high-efficiency particulate air filters on the incidence of invasive aspergillosis in a large acute tertiary-care hospital. American Journal of Infection Control. 2010 May;38(4):e1-7. doi:10.1016/j.ajic.2009.09.014 . [R9] Bowles C, et al. A rapid review of supplementary air filtration systems in health service settings. September 2022. doi:10.1101/2022.10.25.22281493 medrxiv preprint. Wider reading on air cleaning applications [R10] Medical Advisory Secretariat. Air cleaning technologies: an evidence-based analysis. Ontario health technology assessment series vol. 5 (2005) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3382390/ [R11] SAGE-EMG: Potential application of air cleaning devices and personal decontamination to manage transmission of COVID-19, 4 November 2020 . https://www.gov.uk/government/publications/emg-potential-application-of-air-cleaning-devices-and-personal-decontamination-to-manage-transmission-of-covid-19-4-november-2020 ❂ 📖 (2 Oct 2023 ~ NHS England) NHS Estates Technical Bulletin (NETB 2023/01A): application of HEPA filter devices for air cleaning in healthcare spaces: guidance and standards ➤ ✻ Accessed: 4 Dec 2023. ➲ Date published: 9 May 2023. ➲ Date last updated : 2 Oct 2023 . © 2023 NHS England.

✻ Accessed: 4 Dec 2023. ➲ Date published: 9 May 2023 . ➲ Date last updated : 2 Oct 2023 . ❦ Applicability ‘This NETB applies to all healthcare spaces with ventilation requirements. Objective To provide additional technical guidance and standards on the use of UVC devices for air cleaning in healthcare spaces. Status The document represents advice for consideration by all NHS bodies . It is to be read alongside Health Technical Memorandum 03-01 Specialised Ventilation for Healthcare Premises (HTM 03-01) . Executive summary Ventilation * is a key line of defence for infection control in the healthcare environment . Its design and operation are described in Health Technical Memorandum (HTM-03-01) . The current focus on ventilation has highlighted areas of high risk due to poorly performing and inadequate ventilation in hospitals and other healthcare settings due to age, condition of air handling plant, lack of maintenance, challenges with effective use of natural ventilation or other creates areas of high risk. It is therefore important to bring these facilities up to the minimum specification of current standards, particularly recognising the challenges of COVID-19 and other respiratory infections . Ultraviolet (UVC) air cleaners (also known as air scrubbers) using ultraviolet light are one option for improving and upgrading ventilation. The installation of a UVC air cleaner can reduce the risk of airborne transmission . This document has been written as an interim specification to set the basic standard required for UVC devices to be utilised in healthcare and patient related settings. This edition is primarily aimed at portable and semi fixed (wall-mounted) devices. The series will extend to in-duct and upper room devices in future iterations. Devices relying on HEPA filters or similar filter-based technology can have similar benefits to UVC devices but are not considered in this document. The potential of air scrubbers employing UVC or HEPA technology is the subject of a rapid review (September 2022) . * Ventilation is the process by which ‘fresh’ air (normally outdoor air) is intentionally provided to a space and stale air is removed. This may be achieved by mechanical systems using ducts and fans, or natural ventilation most commonly provided through opening windows. The local redistribution of air may also be construed as ventilation. 1. Introduction Ventilation is a critical feature in the control of airborne infection . However, the emergence of SARS-CoV-2 as a highly contagious virus has demanded new and innovative solutions to safeguard patients , staff and visitors . Health Technical Memorandum 03-01 Specialised Ventilation for Healthcare Premises (HTM-03-01) is a robust standard for ventilation of higher risk clinical spaces based on high air change rates using outdoor air to continually flush indoor spaces. The emergence of COVID-19 has shown that greater attention must be paid to the removal or deactivation of airborne pathogens in areas where ventilation rates are lower. The focus on ventilation has also highlighted areas of high risk due to poorly performing and inadequate ventilation , particularly in older hospitals and other healthcare settings such as primary care and dental, which increase risks of infection spread viz nosocomial infections . In cases, where current ventilation does not meet HTM-03-01 standards, this may be due to age, condition of air handling plant, lack of maintenance or other design or operational issues. In the case of naturally ventilated spaces, there is a reliance on staff or patients opening windows. Weather conditions, external noise and air pollution and restricted window openings for safety affect the ability to open windows and means that ventilation in some settings can fall below recommended rates. UVC air cleaners using ultraviolet light are one option for improving and upgrading ventilation. The correct installation and operation of a UVC air cleaner can effectively reduce the risk of airborne transmission. NHS trusts are under pressure to improve ventilation and are considering options including UVC air cleaning. This standard will assist trusts in selecting and implementing good quality, reliable equipment. There is substantial evidence from laboratory studies and real-world settings that UVC is an effective technology for reducing airborne pathogens within room air and HVAC systems. A number of trial ‘case studies’ have been carried out which indicate that measured levels of micro-organisms in air are greatly reduced and infection rates have decreased. These trials have also shown that UVC within HVAC systems safely allows some levels of air recirculation and can achieve substantial energy reductions compared to the normal 100% fresh air approach set out in HTM-03-01. For example, a scheme with 50% fresh air and 50% recirculated air would reduce heat demand by 50%. However, care must be taken to ensure sufficient fresh air changes are provided for the dilution of medical gases and noxious odours, and the maintenance of appropriate oxygen and carbon dioxide levels. This document aims to serve as interim guidance and regulatory reference point for the design and correctly engineered deployment of germicidal UVC devices in real-world settings with regard to effectivity and safety. 2. UVC germicidal effects There are a wide range of UVC devices which aim to inactivate microorganisms in the air and/or on surfaces. This document focuses on contained UVC devices which can be positioned locally within a room or within an HVAC duct. These devices usually require fan-assisted circulation to introduce the room air into the device, expose it to ultraviolet light and then to reintroduce the processed air into the room. Therefore, aerodynamics internal to the device together with the lamp specification determines the air and microbial particle UVC exposure time and hence the radiation dose. These devices are known as active UVC air cleaning devices . Not considered in this document are passive UVC devices, aka upper room devices, which rely on the natural air currents within rooms. An important consideration regards the flow of the air which is induced, processed and distributed by the device external to the device itself. The design and placement of the device should promote efficient air circulation in the room space and avoid short-circuiting of air circulation relative to furniture, obstructions, and occupancy. The ultraviolet-C (UVC) spectrum lies in the interval [200…280] nm. UVC irradiation as a means of microbial inactivation has been used for over 100 years in multiple sectors including medical, scientific, water disinfection, manufacturing and agricultural. UVC germicidal activity inactivates microorganisms rendering them unable to replicate. Most commonly, germicidal activity is generated by mercury ionisation lamps with the major spectral line at 254 nm wavelength. This is sometimes also known as germicidal ultraviolet (GUV) or ultraviolet germicidal irradiation (UVGI) . This standard uses the term UVC . Recent studies suggest that devices based on far-UV (222 nm wavelength) may also be effective ; however, these are not covered here. The photo-toxicity risks associated with UVC is universally recognised. The design, specification and implementation of germicidal UVC solutions currently lacks rigorous governance and the requirement for regulatory change is recognised. The purpose of this standard therefore is to establish the key criteria for successful and reliable long-term application of UVC air cleaning while avoiding the potential safety hazards and operational pitfalls, particularly when equipment is used in spaces occupied by non-technical people. 3. Applications This standard covers the types of UVC air cleaners used as standalone or in-duct units where the principal active element is UVC at the nominal wavelength of 254 nm. In rooms without natural or mechanical ventilation, or where the ventilation falls short of local requirements or regulatory advice , auxiliary devices may be deployed to enhance the effective air changes. The installation of UVC air cleaners can be considered to contribute additional ‘equivalent’ air changes (eACH). For example, a treatment room with only 2 ACH could achieve the equivalent of 10 ACH by installing a UVC unit which recirculated and cleaned the equivalent of 8 ACH (eACH) for the micro-organisms of concern. Hence, to meet the requirements that comply with HTM-03-01, the number of devices required will be dictated by the existing background levels of ventilation. In-duct HVAC systems In buildings with existing HVAC systems which have recirculation of air, it can be effective to install UVC lamps directly into the ducts, placing them downstream of pre-existing particulate filters. This allows for the treatment of all rooms in the building covered by the HVAC system or within branch ducts serving various zones and the rooms within those zones. Due to the lamps being contained within the ducts, the risk of direct exposure to UVC is low. However, maintenance can be carried out; safely shut-down interlocks should be fitted and hazard notices compliant with BS EN ISO 7010 prominently displayed. 254 nm devices covered in this standard ❂ In-duct UVC: UVC lamps are installed directly into the HVAC system or are contained within a locally installed ventilation device which is connected into the HVAC system, similar to a fan-coil unit. Devices may use the fans and filters within the existing HVAC system or, in some cases, may have local fans and filters to provide the recirculation. Significant modelling and design are required to implement such systems. ❂ Floor standing UVC ‘mobile’ devices: UVC lamps are contained within a standalone floor mounted device that can be positioned at any suitable location in a room. These devices provide local air cleaning within a room and are plugged into a standard electrical socket so do not require any installation. The device contains lamps, dust filters and a fan to draw room air through the device. Devices are portable and so can be easily moved. ❂ Fixed UVC devices – wall or ceiling mounted: Similar to floor standing units but fixed to a wall or ceiling. These devices will normally be permanently wired into the room electrical system rather than plugged into a wall socket. UVC devices not covered in this standard ❂ Decontamination UVC devices: High intensity open-field UVC devices that are designed for periodic surface decontamination in unoccupied spaces. These devices are sometimes known as UVC robots. ❂ Upper-room UVC devices: UVC devices which utilise an open UV field within the room above the heads of occupants. These are passive devices which rely on the general circulation of room air and are sometimes assisted by ceiling fans. ❂ Devices based on other parts of the UV spectrum: The devices covered in this standard are based on 254 nm wavelength lamps. There are a number of other UV technologies including Far UV (222 nm) which has early data showing it is likely to be effective. ❂ Devices that incorporate other technologies alongside UVC: There are a number of devices which use UVC alongside other technologies such as titanium dioxide catalysts or ionisers. These devices often emit by-products into the room, either intentionally or deliberately. The health impacts of any emissions must be carefully considered.’ ❂ * Additional info. Source Sans Pro Normal 21/18. 1st row, 4th Colour. ❂ 📖 (2 Oct 2023 ~ NHS England NHS Estates Technical Bulletin (NETB 2023/01B): application of ultraviolet (UVC) devices for air cleaning in occupied healthcare spaces: guidance and standards ➤ ✻ Accessed: 4 Dec 2023. ➲ Date published: 9 May 2023. ➲ Date last updated: 2 Oct 2023 . © 2023 NHS England.

✻ Accessed: 4 Dec 2023. ➲ Date published: 24 Jan 2023. ➲ Date last updated: 2 Feb 2023. ❦ The UKHSA’s definition of ‘ Airborne ’, and how it applies to SARS-CoV-2 / COVID-19 : ➲ ‘ Airborne (droplet or aerosol) transmission : This occurs when an infected person coughs, sneezes, or talks (droplets) containing the infectious agent are expelled into the air and inhaled by someone nearby OR when an infectious agent is suspended in the air and inhaled by someone (aerosol) because the infectious particles are much smaller and can remain suspended in the air for long periods of time . For example flu, RSV, COVID-19 , TB, measles, C. diphtheria, Strep pneumoniae.’ ❂ ➲ [C19.Life Note ] : The accepted scientific definition of ‘airborne aerosol transmission’ most certainly also includes the act of breathing . While the UKHSA admits to close-range SARS-CoV-2 transmission via droplet (and aerosol), it neglects to emphasise far-range transmission via infectious aerosols. ❂ 📖 (24 Jan 2023 / Updated 2 Feb 2023 / Accessed 4 Dec 2023 ~ UK Health Security Agency) UKHSA Advisory Board: preparedness for infectious disease threats ~ Airborne (droplet or aerosol) transmission ➤ © 2023 UKHSA .

✻ Accessed: 4 Dec 2023. ➲ Date published: 1 May 2010. ➲ Date last updated: 1 Jan 2024. ❦ Notifiable diseases and causative organisms: How to report ‘Notifications of infectious diseases (NOIDs) and reportable causative organisms: legal duties of laboratories and medical practitioners. ➲ List of notifiable organisms (causative agents) Causative agents notifiable to UKHSA under the Health Protection (Notification) Regulations 2010 : · Bacillus anthracis · Bacillus cereus (only if associated with food poisoning) · Bordetella pertussis · Borrelia spp · Brucella spp · Burkholderia mallei · Burkholderia pseudomallei · Campylobacter spp · Carbapenemase-producing Gram-negative bacteria · Chikungunya virus · Chlamydophila psittaci · Clostridium botulinum · Clostridium perfringens (only if associated with food poisoning) · Clostridium tetani · Corynebacterium diphtheriae · Corynebacterium ulcerans · Coxiella burnetii · Crimean-Congo haemorrhagic fever virus · Cryptosporidium spp · Dengue virus · Ebola virus · Entamoeba histolytica · Francisella tularensis · Giardia lamblia · Guanarito virus · Haemophilus influenzae (invasive) · Hanta virus · Hepatitis A, B, C, delta, and E viruses · Influenza virus · Junin virus · Kyasanur Forest disease virus · Lassa virus · Legionella spp · Leptospira interrogans · Listeria monocytogenes · Machupo virus · Marburg virus · Measles virus · Monkeypox virus · Mumps virus · Mycobacterium tuberculosis complex · Neisseria meningitidis · Omsk haemorrhagic fever virus · Plasmodium falciparum, vivax, ovale, malariae, knowlesi · Polio virus (wild or vaccine types) · Rabies virus (classical rabies and rabies-related lyssaviruses) · Rickettsia spp · Rift Valley fever virus · Rubella virus · Sabia virus · Salmonella spp ➤ SARS-CoV-2 · Shigella spp · Streptococcus pneumoniae (invasive) · Streptococcus pyogenes (invasive) · Varicella zoster virus · Variola virus · Verocytotoxigenic Escherichia coli (including E.coli O157) · Vibrio cholerae · West Nile Virus · Yellow fever virus · Yersinia pestis ❂ ➲ Reporting of SARS-CoV-2 test results to UKHSA All laboratories in England performing a primary diagnostic role must notify UKHSA of specified causative agents (organisms), in accordance with the Health Protection (Notification) Regulations 2010. ❂ SARS -CoV-2 is the notifiable causative agent for COVID-19 . ❂ All registered medical practitioners in England must notify the proper officer of the relevant local authority or the local UKHSA health protection team of specified infectious diseases , in accordance with the Public Health (Control of Disease) Act 1984 and the Health Protection (Notification) Regulations 2010 . All proper officers must disclose the entire notification to UKHSA . ❂ COVID-19 is a notifiable infectious disease .’ ❂ 📖 (1 May 2010 / Updated 1 Jan 2024 / Accessed 4 Dec 2023 ~ UK Health Security Agency) UKHSA / Notifiable diseases and causative organisms: How to report ➤ © 2024 UKSHA.

✻ Accessed: 4 Dec 2023. ❦ The Health & Safety At Work Act (1974) [Abridged]. ‘The law imposes a responsibility on the employer to ensure safety at work for all their employees. Much of the law regarding safety in the work place can be found in the Health & Safety At Work Act 1974 . ➲ Employers have to take reasonable steps to ensure the health , safety and welfare of their employees at work. Failure to do so could result in a criminal prosecution in the Magistrates Court or a Crown Court. Failure to ensure safe working practices could also lead to an employee suing for personal injury or in some cases the employer being prosecuted for corporate manslaughter . As well as this legal responsibility, the employer also has an implied responsibility to take reasonable steps as far as they are able to ensure the health and safety of their employees are not put at risk . So an employer might be found liable for his actions or failure to act even if these are not written in law. The employer’s responsibility to the employee might include a duty to provide safe plant and machinery and safe premises , a safe system of work and competent trained and supervised staff . ➲ Workplace (Health, Safety and Welfare) Regulations 1992: This deals with any modification, extension or conversion of an existing workplace. The requirements include control of temperature, lighting, ventilation , cleanliness, room dimensions etc . ➲ Personal Protective Equipment Work Regulations 1992 ( PPE ): Deals with protective clothing or equipment which must be worn or held by an employee to protect against health and safety risks . It also covers maintenance and storage of such equipment . Employers cannot charge for such clothing or equipment which must carry the “CE” marking. ➲ The employer may also have a responsibility to customers or visitors who use the work place. It is always advisable for employers to have a written code of conduct, rules regarding training and supervision, and rules on safety procedures. This should include information on basic health and safety requirements. Leaflets and posters giving warnings of hazards are always advisable. Also, the management of Health & Safety At Work Regulations 1992 requires an employer to carry out a risk assessment of the work place and put in place appropriate control measures . ➲ The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 & 2013 ( RIDDOR ): Employers must notify the Health and Safety Executive or local authority about work accidents resulting in death , personal injury or sickness where an employee is off work for more than 3 days . Records must be kept of all such accidents at the workplace for at least 3 years. Accident books must be kept where an employer employs ten or more persons on the same premises. ➲ Employers Liability (Compulsory Insurance) Regulations 1998 Employers must insure against liability for injury or disease sustained by an employee in the course of their employment. The sum to be insured is not less than £5 million .’ ❂ 📖 (Accessed 4 Dec 2023 ~ Compact Law) Compact Law ~ Health & Safety At Work (Health & Safety At Work Act 1974) ➤ © 2023 Compact Law.

❦ 'For middle-aged adults ( 50–64 ) in this period [June 2022 – June 2023 ], the relative excess for almost all causes of death examined was higher than that seen for all ages .' ➲ ‘Since July 2020, the Office for Health Improvement and Disparities (OHID) has published estimates of excess mortality. In the period from week ending 3rd June 2022 to 30th June 2023 , excess deaths for all causes were relatively greatest for 50–64 year olds ( 15% higher than expected ), compared with 11% higher for 25–49 and < 25 year olds , and about 9% higher for over 65 year old groups. Several causes, including cardiovascular diseases , show a relative excess greater than that seen in deaths from all-causes ( 9% ) over the same period (week ending 3rd June 2022–30th June 2023), namely: all cardiovascular diseases ( 12% ), heart failure ( 20% ), ischaemic heart diseases ( 15% ), liver diseases ( 19%) , acute respiratory infections ( 14% ), and diabetes ( 13% ). For middle-aged adults (50–64) in this 13-month period, the relative excess for almost all causes of death examined was higher than that seen for all ages . Deaths involving cardiovascular diseases were 33% higher than expected, while for specific cardiovascular diseases, deaths involving ischaemic heart diseases were 44% higher , cerebrovascular diseases 40% higher and heart failure 39% higher . Deaths involving acute respiratory infections were 43% higher than expected and for diabetes , deaths were 35% higher . Deaths involving liver diseases were 19% higher than expected for those aged 50–64 , the same as for deaths at all ages. Looking at place of death, from 3rd June 2022 to 30th June 2023 there were 22% more deaths in private homes than expected compared with 10% more in hospitals . The greatest numbers of excess deaths in the acute phase of the pandemic were in older adults. The pattern now is one of persisting excess deaths which are most prominent in relative terms in middle-aged and younger adults , with deaths from CVD [cardiovascular] causes and deaths in private homes being most affected.’ ❂ ➲ [C19.Life Note ] : Considering their findings and conclusion, I’m not sure why the authors would choose to use the term ‘post-pandemic’ in this title – when their evidence points to an on-going pandemic, fueled by continuing high rates of infection, that is now simply killing younger age-groups than previously seen.] ❂ 📖 (1 Dec 2023 ~ The Lancet (Regional Health Europe) Excess mortality in England post Covid-19 pandemic: implications for secondary prevention ➤ © 2023 Pearson-Stuttard et al / The Lancet (Regional Health Europe) .

❦ SARS-CoV-2 infection precipitates a molecular cascade that reactivates latent viral agents. Infection doesn’t just pass through the body’s defenses but rather reprograms them. It reactivates dormant pathogens and perpetuates a cycle of chronic immune activation. Long COVID sufferers are burdened with a significantly higher prevalence of immune responses to certain DNA viruses – namely, Epstein-Barr Virus (EBV)* and Parvovirus B19 – than those in good health. * Epstein-Barr Virus (EBV) is a common human virus that spreads primarily through saliva. It is a member of the herpes virus family and is found all over the world. Most people will get infected with EBV in their lifetime and will not have any symptoms. Elevated levels of antibodies against these viruses in Long COVID patients not only signal potential viral reactivations. It also suggests a reality where SARS-CoV-2 may be inciting a smoldering activation of chronic viral infections. ❂ 📖 (9 Nov 2023 ~ European Heart Journal) Sequential activation of DNA viruses by the RNA virus SARS-CoV-2 in patients with long COVID syndrome ➤ © 2023 Outbreak Updates ➲

❦ Chris Whitty, from the Covid Inquiry: “The one situation... that you would ever aim to achieve herd immunity is by vaccination . That is the only situation that is a rational policy response.” And yet... the UK is no longer offering vaccines to the vast majority of its working-age population. According to the JCVI member Dr Adam Finn, the UK’s strategy going forward is that: “... most under 65’s will now end up boosting their immunity not through vaccination, but through catching Covid many times .” ➲ (24 Sep 2023 ~ BBC) What you need to know about Covid as new variant rises ➤ Let me translate: The stated aim is to get infected over and over and over again... to protect against being infected over and over and over again! How does this make any sense at all? The government has decided that it is not good “value for money” to actually give the boosters out – even for the age groups who have already had Covid vaccine doses purchased for them (for example, the 50-65 year olds) – so millions of doses [8.5 million] are now destined to be binned, rather than being used. ➲ ‘COVID VACCINE: COST EFFECTIVENESS ASSESSMENT. For the first time ever, the UK government has used a ‘bespoke, non-standard cost-effectiveness assessment’ to decide who would be eligible for the Covid booster this Autumn. In this thread, I explore how this assessment was undertaken…’ ➤ Meanwhile, in many other countries, the booster is open to anyone who wants it . No strict eligibility criteria. Just step forward and get protected. Let’s take a look at a few: 1. THE USA : Covid booster available to EVERYONE aged 6 months and older. The CDC (USA’s Centers for Disease Control ) recommends that everyone ages 6 months and upwards get the updated COVID-19 booster to protect against serious illness. The new vaccine targets the most common circulating variants, and should be available later this week. The full details are here ➤ . 2. CANADA : Covid booster available to EVERYONE aged 6 months and older. Full details are here ➤ . 3. FRANCE : Covid booster available to EVERYONE. Full details are here ➤ . 4. BELGIUM : Covid booster available to EVERYONE. Full details are here ➤ . 5. JAPAN : Covid booster available to EVERYONE aged 6 months and older. Full details are here ➤ . Why is the UK falling so far out of step with so many other countries on their Covid vaccine strategy? How can they justify binning millions of purchased vaccine doses when there are many people who would gladly take them? ➲ ‘So what’s going to happen to the millions of purchased doses which now won’t be used? Well, here’s the real kicker... it seems they’re destined for the bin. A number of alternative uses have been considered, but the conclusion is: “THESE DOSES HAVE NO FEASIBLE ALTERNATIVE USE”. ’ ➤ If the UK government won’t fund deployment of the Covid jab to EVERYONE (as so many other countries do), then why isn’t there at least an option to buy it privately? This model already exists with the flu jab – why is there not the same option for Covid? © 2023 Cat in the Hat ➲

❦ On 23rd November 2021, a colleague said to me: — “I don’t want to be afraid anymore,” and gave up caring about catching or spreading Covid. Last week they brought it home from a conference for their partner, who has been admitted to hospital this afternoon with complications. You shouldn’t be afraid of fear. Fear is your friend. Fear may stop you killing your husband. © 2023 Tern, a Priest in England ➲

❦ These stats hit different. They’re not just cold data. They’re real stories of how SARS-CoV-2 has left people’s lives flipped upside down, with their “normal” now just a throwback, and their future a big question mark. SARS-CoV-2 ruthlessly hijacks lives into a chronic state of debilitating fatigue and diminished function. In this study, Long COVID patients – a group predominantly in their mid-forties – are facing a grim reality. These individuals are trapped in a vicious cycle where their functional status is severely compromised, with 95 percent facing severe limitations. Physical activity levels have plummeted, with a staggering 79.3% reporting a low activity status – a stark contrast to their pre-COVID state. Quality of life has nosedived for 54.1% of these patients, and fatigue has worsened alarmingly in 94.7% of cases – meeting the criteria for Chronic Fatigue Syndrome in an overwhelming 92.4% of cases. ❂ 📖 (14 Nov 2023 ~ Nature: Scientific Reports) Functionality, physical activity, fatigue and quality of life in patients with acute COVID-19 and Long COVID infection ➤ © 2023 Outbreak Updates ➲

❦ For folks with Chronic Obstructive Pulmonary Disease (COPD) who beat their initial SARS-CoV-2 infection, the road ahead is brutal. At discharge, they’re not in the clear. They’re actually in worse shape and more likely to end up back in the hospital, gasping for air. COPD patients hit by COVID are more likely to have other health problems, and don’t tend to live as long. This study* puts a spotlight on these survivors as extra vulnerable. COPD patients who’ve had a severe bout of COVID are walking a tightrope; their odds of ending up back in the hospital are tripled. Plus, these COPD patients are dying at higher rates within a year compared to those without lung issues. It’s a loud wake-up call that beating the virus in the short-term doesn’t mean the danger is over. The COPD crowd needs a solid game-plan after leaving the hospital to stand a fighting chance. ❂ * 📖 (7 Nov 2023 ~ International Journal of Chronic Obstructive Pulmonary Disease) Persistent Respiratory Failure and Re-Admission in Patients with Chronic Obstructive Pulmonary Disease Following Hospitalization for COVID-19 ➤ © 2023 Outbreak Updates ➲

❦ I believe Covid is the first disease in recorded history that humans have deliberately chosen to “live with”. Because that’s an empty slogan, it deliberately disguises two fundamentally different meanings. We have, of course, had to endure some diseases because they’re hard to control – or have no treatments. Colds, flu, dengue fever, TB, cancer, malaria, heart disease… But we’ve constantly worked to control spread of these diseases, and tried to develop treatments and preventions for them. That’s what “living with” has historically meant. Enduring something while trying to prevent, control and treat it. But the “living with” slogan for Covid means something fundamentally and historically different. It means to do nothing. Just infect, repeatedly. It’s not a fight against the disease. It’s a fight against public health itself. Funded by the same vested interests who have been assaulting everything with ‘public’ in its name, or with a public focus. It’s an assault upon the concept of public itself. And again, no matter how much these vested interests deny it, this is also an open, declared campaign. And has been for over 70 years. It’s right there: ‘personal responsibility’ to replace anything public. — “There is no such thing as society: there are individual men and women, and there are families.” (Margaret Thatcher) Never before has this lunacy extended to disease. But it does now. I don’t think enough have registered yet that once you remove all of the infrastructure of society in this way, all that’s left that binds people together are slogans. We live in a sloganocracy. “Living with Covid” sits atop an ocean of slogans; we’re neck-deep in them. Slogans are the only interpersonal social life that is now permitted to exist. “Stop the Boats.” Spend time listing them. It’s eye-opening. © 2023 Henry Madison . ➲ ❂ — “It is what it is.” — (“Covid is what Covid is.”) — (“It isn’t what it isn’t.”) — “Levelling up.” — “Get Brexit Done.” — “What doesn’t kill you makes you stronger.” — “Eat out to help out.” — “Mask if it makes you feel more comfortable.” — “I’ve moved on.” — “Live your best life.” — “Life is for living...” A thought-terminating cliché (also known as a semantic stop-sign , a thought-stopper , bumper-sticker logic , or clichéd thinking ) is a form of loaded language, often passing as folk wisdom, intended to end an argument and quell cognitive dissonance.

❦ ‘It is now well established that post-COVID syndrome ( PCS ) represents a serious complication in a substantial number of patients following SARS-CoV-2 infection. PCS is diagnosed when COVID-19-related symptoms persist for more than 3 months. It can occur even after an initially mild to moderate course of infection , and comprise a large variety of symptoms . Around 30% of PCS patients show neurological and neuropsychiatric sequelae , such as fatigue , depressive symptoms , and cognitive dysfunction . These are experienced as particularly debilitating, as they have detrimental effects on daily functioning in PCS patients and hamper a successful return to their jobs. Fatigue is a frequent and one of the most debilitating symptoms in post-COVID syndrome (PCS). Recently, we proposed that fatigue is caused by hypoactivity of the brain’s arousal network and reflected by a reduction of cognitive processing speed . Eighty-eight PCS patients with cognitive complaints and 50 matched healthy controls underwent neuropsychological assessment. Seventy-seven patients were subsequently assessed at 6-month follow-up. Patients showed cognitive slowing indicated by longer reaction times compared to control participants in a simple-response tonic alertness task and in all more complex tasks requiring speeded performance . Reduced alertness correlated with higher fatigue . Alertness dysfunction remained unchanged at 6-month follow-up and the same was true for most attention tasks and cognitive domains .’ ❂ 📖 (7 Nov 2023 ~ Journal of Neurology) Persistent cognitive slowing in post-COVID patients: longitudinal study over 6 months ➤ © 2023 Journal of Neurology .

❦ I accept that school boards ultimately do not care about the safety of their students and staff. But a HEPA air purifier costs less than a few days of sub coverage. Add a $1 mask/day x 180 school days, and that’s another day of sub coverage. You don’t incur the disruption to education delivery that happens when a sub comes in. You’re not potentially permanently disabling education workers. The “school boards are cash-strapped” excuse makes no sense when the solution to constant sickness is: “We’ve got more subs!” © 2023 Amanda Hu . ➲

➲ A layperson-level overview from New Atlas on how all variants of SARS-CoV-2 – the virus that causes COVID-19 – are ‘neuroinvasive’ , meaning that all can infect or enter the brain and the nervous system . ❂ ❦ ‘... We know COVID is associated with a variety of neurological symptoms , both short- and long-term, but it still isn’t entirely clear whether these cognitive issues are the result of the virus directly infecting brain cells or simply due to a broader systemic inflammatory response. Studies looking at human brain tissue have yielded contradictory results. Some have found direct traces of SARS-CoV-2 , while others report only inflammatory damage . Animal models certainly demonstrate it is possible for the virus to infect the brain, but human tissue samples are obviously taken after a patient dies – meaning researchers can only hypothesize what happens during an acute infection. Using a hamster model, the research compared infection with the original SARS-CoV-2 virus from 2020 to several subsequent variants including Gamma, Delta and Omicron/BA.1 variants. Interestingly, the findings confirmed epidemiological observations showing acute disease severity is reduced in Omicron infections – however, all [SARS-CoV-2] variants demonstrated similar neuroinvasive capabilities. And, most strikingly, all variants infected the brain’s olfactory regions regardless of whether symptoms of anosmia (the loss of sense of smell) were present or not. “This suggests that anosmia and neuronal infection are two unrelated phenomena. If we follow this line of reasoning, it is quite possible that even an asymptomatic infection is characterized by the spread of the virus in the nervous system.” The researchers conclude this suggests all SARS-CoV-2 variants have the capacity to infect the brain, via the olfactory pathway, regardless of clinical disease presentations. This means it is possible even mild infections can lead to the virus infiltrating the brain. “The next step will be to understand... whether the virus is able to persist in the brain beyond the acute [initial, short-term] phase of infection, and whether the presence of the virus can induce persistent inflammation and the symptoms described in cases of long COVID, such as anxiety, depression and brain fog” [brain damage].’ © 2023 Rich Haridy / New Atlas. ➲ Source © 2023 Institut Pasteur .

❦ Two million people living in this country have Long Covid, and there have been over 230,000 deaths due to Covid. That’s why masks are now commonplace, and people want to help protect each other ❤️. It’s why hospitals across the NHS are striving to do all they can to limit the spread of nosocomial Covid, recognising the increased risk of death it carries, wanting to limit Long Covid, as well as protect their staff in work ❤️. It’s why your workplaces and schools have introduced safer ventilation and clear policies to reduce outbreaks, to clearly communicate what’s happening, and protect generations of the future from a multi-system, vascular-driven illness ❤️. It’s why, instead of ignoring Covid, society has gathered together as one to help limit the devastating damage we have all witnessed, and why it has collectively said “no” to any further preventable death or disability from this pandemic by all taking simple, effective mitigations ❤️. © 2023 NHS Medical Consultant . ➲

❦ Your brain is a vast city. The roads (myelin) in this city let cars move efficiently. Oligodendrocytes are the construction workers who maintain these roads. As we age, these workers slow down, causing traffic jams and slower thoughts. Enter SARS-CoV-2, the destructive rioter. It doesn’t just disrupt traffic; it damages the roads and chases away the construction crews. Weeks after the riot, the city still struggles to function, with long-lasting road damages and traffic jams. This is the ‘brain fog’ of post-COVID life. ❂ 📖 (24 Sep 2023 ~ Aging and Disease) Role of Microglia, Decreased Neurogenesis and Oligodendrocyte Depletion in Long COVID-Mediated Brain Impairments ➤ © 2023 Outbreak Updates ➲

❦ When SARS-CoV-2 infects a cell, it takes over the cell’s machinery for its own benefit. Imagine a factory that produces cars. Each section of the factory has a specific job: some parts assemble the engine, some the body, and others paint and finish the car. Now, imagine if a group of saboteurs entered this factory. Instead of letting the factory produce cars, these saboteurs force the machinery to produce something entirely different, like bicycles. Not only does the factory stop producing cars, but it’s also now churning out bicycles at a rapid pace, which then exit the factory and convince other factories to do the same. Once SARS-CoV-2 enters a cell by binding to the ACE2 receptor*, it releases its RNA into the cell. * The ACE2 receptor acts as a cellular doorway for SARS-CoV-2 to hook into and infect a wide range of human cells. ACE2 receptors are highly expressed in the heart, kidneys, and lungs. The widespread nature of this receptor – found, for example, in the oral and nasal mucosa, the nasopharynx, stomach, small intestine, colon, skin, testes, lymph nodes, thymus, bone marrow, spleen, liver, kidney and brain – explains why so many organs can be affected by SARS-CoV-2. ACE2 = Angiotensin-converting enzyme 2. This viral RNA then heads to the cell’s machinery (ribosomes) and essentially tricks it into making viral proteins instead of the cell’s own proteins. As a result, the cell starts producing components of new virus particles. Once these components are assembled into new viruses, they exit the cell and go on to infect other cells, repeating the cycle. Over time, this hijacking leads to cell damage and death, contributing to the tissue and organ damage observed in COVID-19. © 2023 Outbreak Updates ➲

❦ Your lungs are balloons made of the finest silk, allowing them to expand and contract effortlessly with each breath. SARS-CoV-2 is as a needle, puncturing and tearing this delicate fabric. In an attempt to heal, the body patches up the punctures, but instead of the original silk, it uses rough patches. These patches – scarring or fibrosis – make parts of the lung rigid, restricting its once flawless expansion. With each subsequent infection, more patches appear, further suffocating the lung’s true function. The virus doesn’t just infect. It sabotages the very essence of our breath. ❂ 📖 (6 Apr 2022 ~ Annals of Medicine and Surgery) Post COVID-19 pulmonary fibrosis; a meta-analysis study ➤ © 2023 Outbreak Updates ➲

❦ ‘The emergence of [new SARS-CoV-2 Variant of Interest] BA.2.86 meant a decision was made to bring forward the autumn Covid booster to better protect the most vulnerable this winter. But the new jabs are only available to people over 65 years old – it was the over-50s last year – and those with certain health conditions. That is a tactical decision , says Dr. Adam Finn, Professor of Paediatrics at the University of Bristol. He explained: “When younger people who’ve already had infections and vaccines get Covid [again], they get a cold and a cough and might be off work for a few days. There’s no real value in investing a lot of time and effort immunising them again when there are so many other things for the Health Service to be doing.” [ ❦ Note : Can a 62-year-old be defined as a ‘ younger person ’? Yes, at a pinch, if Mr. Finn compares them to a 78-year-old. What age-group do these ‘ younger people ’ belong to who don’t need vaccinating, and who instead need to be continually reinfected with a highly pathogenic Biohazard-Level 3 virus? Could it be a 32-year-old man or woman hoping to have a baby ? Or the 0 to 19-year-olds , who are the academic professor’s strong suit? ] ‘The reality is then that most under-65s will now end up boosting their immunity not through vaccination , but through catching Covid many times . In general, Prof Finn says each new infection should feel milder with the length of time you are sick reduced [sic] . “Each time you catch it, your immunity gets stronger and broader ,” he adds. ’ ❂ [ Note : This is simply not true, and is staggeringly dangerous. ] ❂ 📖 (24 Sep 2023 ~ Jim Reed, Health Reporter / BBC online) What you need to know about Covid as new variant [BA.2.86] rises ➤ © 2023 BBC .

❦ ‘The most common causes of acquired lymphocytopenia include: ➲ Protein-energy undernutrition. ➲ HIV infection. ➲ COVID-19 . ➲ Certain other viral infections. Patients with HIV infection routinely have lymphocytopenia, which arises from destruction of CD4+ T cells infected with the HIV virus. Patients with COVID-19 also frequently have lymphocytopenia ( 35% to 83% of patients ) . Lower lymphocyte counts portend a poor prognosis and an increased likelihood of requiring ICU admission and of dying from the disease. The cause of the lymphocytopenia is not completely understood, but COVID-19 can directly infect lymphocytes, and a cytokine-related apoptosis of the cells is likely. ➲ Lymphocytopenia is most often due to AIDS , and recently COVID-19 , or undernutrition, but it also may be inherited or caused by various infections, drugs, or autoimmune disorders. ➲ Patients have recurrent viral , bacterial , fungal , or parasitic infections .’ ❂ 📖 (Accessed 16 Sep 2023 ~ Merck & Co.) Entry for 'Lymphocytopenia' in Merck Manual ➤ © 2023 Merck & Co .